Court Opinion

ID: 5645345
Source: CourtListenerOpinion
Date Created: 2022-01-11 06:44:11.836604+00
Date Added: 2024-06-11T08:38:21.105180
License: Public Domain

Pope, Judge,
concurring in part and dissenting in part.
1. The majority has reversed the trial court’s order granting summary judgment to plaintiff on her claim against State Farm for reimbursement of medical expenses in the amount of $2,983.95. Yet the majority’s opinion fails to address the issue raised by State Farm in this appeal as to whether a no-fault insurer is liable for medical expenses incurred by an insured at an HMO. (The majority states they are “inclined to think that an HMO membership for which the insured or her employer pays a premium is not different in principle from an ordinary medical insurance policy for which a premium is paid,” but this dicta falls short of answering the issue raised by State Farm in its appeal.) This issue must be addressed before this case is remanded for trial.
State Farm relies on United States v. Travelers Indem. Co., 253 Ga. 328 (320 SE2d 164) (1984) to support its assertion that no-fault carriers are not liable for the reasonable value of medical services incurred by an insured at an HMO. In Travelers, the United States attempted to recover from the no-fault carriers of insured servicemen the reasonable value of medical care provided the servicemen and their families after they had been treated in military hospitals following motor vehicle accidents. The Supreme Court concluded that the legislature intended a no-fault carrier to be required to pay only those expenses which are “incurred” by an insured. Thereafter, the Supreme court provided a definition of “incurred,” by stating: “In order for an insured to incur medical expenses which would trigger the no-fault carrier’s duty to pay, he must have either paid them or have become liable for them. [Cits.]” Id. at 329. Because the United States provided medical treatment to the insured servicemen and their families without any cost to the servicemen, the court concluded the insured servicemen had not “incurred” expenses within the meaning of OCGA § 33-34-1 et seq. Thus, the no-fault carriers in Travelers were not liable for the payment of no-fault benefits under these circumstances.
State Farm argues that just as servicemen are not liable for payment of medical expenses provided by United States military hospitals, HMO members are similarly not liable for payment of medical expenses provided by HMOs. However, this argument clearly ignores the fact that HMO members must pay monthly premium payments for their membership and, in certain circumstances, co-payments at the time medical services are provided. Because medical services are not provided without any cost to HMO members, it simply does not follow that medical services provided by HMOs are received free of cost by members. An HMO member’s premium payments are sufficient to meet the requirement set forth in Travelers that an insured “incur” expenses within the meaning of OCGA § 33-34-1 et seq. State *183Farm is therefore liable to plaintiff for the reasonable value of medical services provided by her HMO, and a question of fact remains only as to the amount of State Farm’s liability. To the extent the majority’s opinion may be interpreted by State Farm as a determination that it is not liable for any of plaintiff’s medical expenses incurred at the HMO, I must dissent.
2. I also disagree with the majority’s conclusion that State Farm refused to pay plaintiff’s claims because plaintiff failed to provide reasonable proof of medical expenses (i.e., her claims are “confused, multiplicitous and mingled with expenses which were as easily attributable prima facie to Jinks’ other collisions in 1985 and 1987”). The exhibits attached to plaintiff’s claim were medical records and forms prepared by plaintiff’s HMO. Although the HMO documents do contain some charges pertaining to services and medications provided plaintiff prior to the 1986 accident, the record contains letters from plaintiff’s attorney providing State Farm with the clarifications and explanations State Farm requested. Most importantly, however, the record reveals State Farm refused to pay any of the medical claims submitted by plaintiff, even those clearly pertaining to the 1986 accident. OCGA § 33-34-6 (b) provides, that “[i]f reasonable proof is not supplied as to the entire claim, the amount supported by reasonable proof is overdue if not paid within 30 days after proof is received by the insurer.” “Thus, [State Farm] may have been justified in denying or delaying payment for any bills which purported to be for treatment attributable to the [1985 or 1987 accident], but it was not necessarily justified in denying or delaying payment for any other bills which purported to be for treatment attributable to the [August 1986 accident], [Cit.]” Baker v. J. C. Penney Cas. Ins. Co., 192 Ga. App. 134, 137 (2) (384 SE2d 233) (1989). Since State Farm denied all of plaintiff’s medical claims, it is my opinion it must have done so because of its misplaced reliance on Travelers, rather than because the claim forms were confusing. However, I must agree with the majority’s conclusion that the issue of State Farm’s good faith in its refusal to pay plaintiff’s medical claims based upon its reliance on Travelers is one for jury resolution.
3. I must also dissent to Division 2 of the majority opinion determining that State Farm was entitled to summary judgment on plaintiff’s claim for lost wages. The majority contends that because plaintiff could not provide a disability statement from her treating physician as requested by State Farm, her claim for lost wages, as a matter of law, was not supported by reasonable proof. However, “OCGA § 33-34-6 (b) ‘does not require a claimant to submit proof of loss of such exactitude as would verify the claim in and of itself. The proof of loss submitted need only be such as would enable the insurer to verify the basic components of the claim through the exercise of *184reasonable diligence. (Cit.)’ [Cit.]” Baker v. J. C. Penney Cas. Ins. Co., supra at 136. Plaintiff, therefore, need only have submitted reasonable proof of the fact and amount of her loss sustained, not the exact proof requested by State Farm. Plaintiff having alleged in support of her motion for summary judgment that she submitted reasonable proof to State Farm of her claim for lost wages, the burden shifted to State Farm to establish why the physician’s disability statement was crucial to its consideration of her claim, especially in light of the evidence showing State Farm’s payment of a portion of plaintiff’s lost wage claim (38 hours of lost wages) without the benefit of the requested disability statement. State Farm having failed to meet its burden, a question of fact remains as to whether reasonable proof of plaintiff’s claim for lost wages was properly submitted to State Farm. Accordingly, the trial court did not err in denying plaintiff’s and defendant’s motions for summary judgment on the claim for lost wages.
Decided March 4, 1992.
Harper, Waldon & Craig, Thomas D. Harper, Frank Boucek III, for appellant.
Van Gerpen, Hoffman & Harris, Frank P. Harris, for appellee.
I am authorized to state that Presiding Judge Carley and Judge Johnson join in this opinion.