Opinion ID: 1515674
Heading Depth: 1
Heading Rank: 3

Heading: Decision to Grant Judgment as a Matter of Law

Text: In ruling on Liberty Mutual's motion for judgment as a matter of law, the Superior Court found that [T]here is no evidence from which this jury could conclude that the defendant was put on notice, that preapproval of the nerve block procedure was necessary in order for the service to be provided.... [or] that Liberty Mutual would not have paid for such a procedure ultimately upon being submitted a bill for it. Brown argues that the Superior Court improperly granted Liberty Mutual's motion because the court ignored probative evidence that Liberty Mutual was aware that pre-authorization was required to begin treatments and that, without justification, Liberty Mutual refused to authorize the treatments. This Court reviews de novo the Superior Court's decision to grant judgment as a matter of law. [43] To grant judgment as a matter of law on a particular issue, the Superior Court must find that there is no legally sufficient evidentiary basis for a reasonable jury to find for that party on that issue. [44] On appeal, this Court must determine `whether the evidence and all reasonable inferences that can be drawn therefrom, taken in a light most favorable to the non-moving party, raise an issue of material fact.' [45] To survive Liberty Mutual's motion for judgment as a matter of law on her claim alleging a breach of the implied covenant of good faith and fair dealing, Brown must present sufficient evidence from which a jury may reasonably infer (1) that Liberty Mutual knew that pre-approval was required for the nerve block treatments and (2) that Liberty Mutual denied pre-authorization for the treatments (3) without reasonable justification. [46] Excluding Dr. DuShuttle's notation and his supporting hearsay testimony, the sum of Brown's admissible evidence appears to be: (1) that Liberty Mutual was aware of the RSD diagnosis and the accompanying recommendation of nerve block treatments, (2) that Liberty Mutual was also aware of the rapid, predicted deterioration of Brown's condition in the absence of the nerve block treatments, and (3) that doctors customarily require pre-authorization before proceeding. On the notice issue, Brown raised a genuine issue of material fact concerning the existence of a custom among doctors to require pre-approval before proceeding with a new course of treatment. Specifically, Dr. DuShuttle agreed that it is customary in the medical profession to get pre-authorization before conducting a procedure. In contrast, a Liberty Mutual employee testified that, with some limited exceptions, Liberty Mutual ordinarily does not pre-authorize procedures over the telephone. Resolving this dispute in a manner most favorable to Brown, a reasonable jury could infer that it is a general custom in the medical community to require such pre-authorization before treatment. Nevertheless, Brown has presented no competent evidence to support her contention that Liberty Mutual was aware of this requirement or that the billing clerk in Dr. DuShuttle's office notified Liberty Mutual of the requirement. Indeed, Brown did not even present evidence that Dr. Godfrey always requires pre-approval before administering nerve block treatments. [47] Brown suggests that the jury could infer Liberty Mutual's knowledge of the pre-authorization requirement from the testimony of Liberty Mutual's employees that Liberty Mutual pre-authorizes expensive procedures in some situations. Contrary to Brown's contentions, however, we find that this testimony does not support a reasonable inference that Liberty Mutual normally or routinely requires pre-authorization or that it knew of a pre-authorization requirement among physicians. Absent evidence that Liberty Mutual knew that Brown would not receive treatment because of its alleged denial of pre-approval, Brown's claim that Liberty Mutual unreasonably refused payment must fail as a matter of law. [48] As the Superior Court observed, there is also no evidence that Liberty Mutual would have refused to pay (or unreasonably delayed payment) for the nerve block treatments if it had been requested to do so. Of course, as Brown argues, an insurer's denial of pre-authorization may well be the functional equivalent of a refusal to pay the claim altogether if physicians are unwilling to proceed without guaranteed payment. Brown's argument thus raises the question whether an insurer may breach the implied covenant of good faith and fair dealing by denying pre-approval for necessary treatment where pre-approval is not required by the insurance contract but the insurer knows that pre-approval is required before a doctor will administer the treatment. Because we have concluded that Brown has presented no evidence that Liberty Mutual was aware that pre-approval was required, there is no need to decide this issue here.