Court Opinion

ID: 4580018
Source: CourtListenerOpinion
Date Created: 2020-10-23 14:05:48.30861+00
Date Added: 2024-06-11T13:40:49.958171
License: Public Domain

RENDERED: OCTOBER 16, 2020; 10:00 A.M.
                        NOT TO BE PUBLISHED

                 Commonwealth of Kentucky
                           Court of Appeals

                              NO. 2019-CA-1432-MR

JEROME PEEPLES AND
RASHAD LEE                                                           APPELLANTS

                 APPEAL FROM JEFFERSON CIRCUIT COURT
v.                  HONORABLE MITCH PERRY, JUDGE
                         ACTION NO. 19-CI-004056

ALLSTATE PROPERTY AND CASUALTY
INSURANCE COMPANY                                                        APPELLEE

                                     OPINION
                                    VACATING

                                   ** ** ** ** **

BEFORE: CALDWELL, MAZE, AND MCNEILL, JUDGES.

MAZE, JUDGE: Jerome Peeples and Rashad Lee appeal from orders of the

Jefferson Circuit Court granting the petition by Allstate Property and Casualty

Insurance Company (Allstate) to appear for medical examinations by a physician

of its choice as a part of its investigation of their insurance claims. Peeples and
Lee argue that Allstate failed to present any evidence showing “good cause” in

support of that order, as required by KRS1 304.39-270(1). We agree, finding that

Allstate presented no evidence meeting its burden of proof under the statute.

Hence, we vacate the orders requiring Peeples and Lee to appear for the

examinations.

                On November 23, 2018, Peeples and Lee were involved in a motor

vehicle accident in Jefferson County, Kentucky. The accident occurred when

another vehicle collided with their vehicle in a parking lot. Both vehicles incurred

minor damage, the police were not called, and no accident report was filed.

                Shortly after the accident, Peeples and Lee began receiving

chiropractic treatment. They asserted claims against Allstate, the insurer of the

vehicle which they occupied, for payment of medical expenses and any coverage

available under Allstate’s policy for basic reparations benefits (BRB). In response,

Allstate initiated an investigation of the claims. Allstate asserts that the injuries are

inconsistent with the minor nature of the accident, that the medical records are

inconsistent, and that Peeples previously made a claim asserting similar injuries.

                During its investigation, Allstate asked Peeples and Lee to submit to

medical examination by a physician of its choice to confirm the claims. After

1
    Kentucky Revised Statutes.

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Peeples and Lee declined to do so, Allstate filed a petition pursuant to KRS

304.39-270(1) to require them to submit to an independent medical examination

(IME).2 Allstate’s petition stated that no decision had been made regarding

Peeples’ claims and that it needed the IME to complete its investigation of the

claim.

                 The trial court held a hearing on the petition, at which Allstate’s

counsel summarized the allegations in the petition. Counsel for Peeples and Lee

objected, arguing that the representations were not evidence and could not meet the

“good cause” standard required by KRS 304.39-270(1). Nevertheless, the trial

court entered Allstate’s tendered order directing Peeples and Lee to appear for an

IME “at a mutually convenient date and time no later than thirty days from the

entry of this Order. . . .” After the parties could not agree on a date, the trial court

subsequently entered an order directing Peeples and Lee to appear for the IME on

September 10, 2019.3 Peeples and Lee now appeal from these orders.

2
 KRS 304.39-270(1) refers to a “mental or physical examination by a physician.” Previous
cases interpreting this section have referred to such an examination as an “independent medical
examination” or “IME.” That term has a specialized meaning, particularly within the field of
workers’ compensation law. But in the interest of consistency, we will continue to use that term
here. In so doing, however, we do not suggest that the results of such an examination should be
afforded any presumption of credibility. Rather, the results of such an examination are simply
evidence, the credibility of which must be decided by the ultimate finder of fact.
3
    The parties do not indicate whether the IMEs were ever conducted.

                                                -3-
             Peeples and Lee sought coverage under the BRB provisions of

Allstate’s policy. That coverage must be construed in accord with the provisions

of the Motor Vehicle Reparations Act (MVRA), KRS 304.39-010, et seq. See

Countryway Ins. Co. v. United Fin. Cas. Ins. Co., 496 S.W.3d 424, 434 (Ky. 2016).

In pertinent part, KRS 304.39-210 requires Allstate to conduct a reasonable

investigation and to pay claims timely after receiving proof of the fact and amount

of loss realized. As part of the insurer’s investigation, KRS 304.39-270(1)

provides that:

             If the mental or physical condition of a person is material
             to a claim for past or future basic or added reparation
             benefits, the reparation obligor may petition the circuit
             court for an order directing the person to submit to a
             mental or physical examination by a physician. Upon
             notice to the person to be examined and all persons
             having an interest, the court may make the order for good
             cause shown. The order shall specify the time, place,
             manner, conditions, scope of the examination, and the
             physician by whom it is to be made.

This statute expressly permits an insurer to require a claimant to submit to a

medical examination to evaluate BRB claims. However, the insurer cannot compel

its insured to submit to an IME simply upon demand without a showing of “good

cause.”

             The pivotal case interpreting the “good cause” provision is Miller v.

United States Fidelity & Guaranty Company, 909 S.W.2d 339 (Ky. App. 1995).

The Court in Miller held that an insurer must employ a case-by-case analysis, and

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that the insurer must affirmatively demonstrate that such cause exists for a medical

examination to be conducted. Id. at 342. The Court further held that “good cause”

is more than a mere suspicion that the insured’s treatments were unnecessary or

unreasonable. Rather, the insurer must present some proof that it has taken

measures to determine the validity or extent of the insured’s injuries less intrusive

than an unwanted independent medical examination. Id.

             In Miller, the insurer submitted an affidavit by its adjuster setting out

its general suspicions about the claim. This Court concluded that the affidavit, by

itself, was insufficient to show good cause to require an IME. Id. The Court in

Miller concluded that the insurer failed to show either good cause or that less

intrusive measures were insufficient. In the absence of any specific evidence

supporting these suspicions, the Court concluded that the insurer failed to establish

good cause to require a medical examination. Id. at 343.

             On the other hand, in White v. Allstate Insurance Co., 265 S.W.3d 254

(Ky. App. 2007), this Court held that the insurer had shown good cause to require

its insured to submit to an IME. In White, the insurer retained a medical expert to

perform a peer review of the insureds’ medical records. The expert concluded that

the medical records failed to indicate a nexus between the treatments and the motor

vehicle accident, failed to document the medical necessity of the treatments, and

failed to provide a treatment plan. Id. at 255. This Court concluded that the

                                          -5-
expert’s report was sufficient to establish good cause to require the insured to

attend the IME. Id. at 256.

             Allstate argues that the holdings in Miller and White have been

modified by the decision of the Kentucky Supreme Court in Government

Employees Insurance Co. v. Sanders, 569 S.W.3d 923 (Ky. 2018). But in Sanders,

the Court merely held that a reparations obligor may not rely solely on a medical-

records review to deny or terminate an insured’s benefits. Id. at 925. The Court

expressly distinguished that situation from the proof necessary for an insurer to

establish good cause under KRS 304.39-270(1). Id.

             In Miller, this Court set out the type of evidence which an insurer

must submit to justify an IME: (1) peer review of the insured’s medical records by

an independent health care provider; (2) evidence disputing the credentials of the

insured’s treating physician; (3) a showing that the treating physician failed to

provide further documentation or to answer any specific concerns; (4) an

explanation how another examination could be expected to satisfy the company’s

misgivings; and (5) specific reasons supporting the company’s doubts about the

necessity for treatment were provided. 909 S.W.2d at 342. The Court held that the

insurer is not required to make a showing on all these factors. Id. at 342-43. As

noted above, a peer review of the insured’s medical records by an independent

                                         -6-
health provider may be sufficient to establish good cause. White, 265 S.W.3d at

255.

             KRS 304.39-270(1) clearly places the burden on the reparations

obligor to demonstrate affirmative proof that “good cause” exists for an IME to be

conducted. Miller, 909 S.W.2d at 342. Until such good cause is shown, the

MVRA creates a statutory presumption of reasonableness of medical bills as

submitted. Id. In the current case, Allstate’s petition merely alleged that

“Respondents’ medical injuries are inconsistent with regard to the severity and

location of pain.” Allstate also alleged that it had concerns about the claims due to

the minor nature of the accident and because “Respondents have a history of motor

vehicle accidents wherein they alleged similar injuries to what they are claiming

resulted from the subject accident . . . .”

             The petition was not accompanied by an affidavit supporting these

allegations. Moreover, Allstate’s allegations in its petition are not proof. See

Educ. Training Sys., Inc. v. Monroe Guar. Ins. Co., 129 S.W.3d 850, 853 (Ky.

App. 2003). Likewise, arguments and representations by Allstate’s counsel are not

evidence. Mason v. Commonwealth, 331 S.W.3d 610, 624-25 (Ky. 2011). At the

hearing, Allstate presented no evidence to establish good cause. In fact, the only

proof offered by Allstate consists of the photographs showing the damage to each

of the vehicles. But even that material is questionable because Allstate offered no

                                              -7-
foundation to support its admission as evidence. Counsel only presented his

representations of Allstate’s general suspicions that the treatments received by

Peeples and Lee were unnecessary.

             Under the circumstances, Allstate failed to satisfy its burden of proof

for an IME under KRS 304.39-270(1). In the absence of any proof by Allstate, the

trial court had no basis for the entry of an order. Therefore, we conclude that the

trial court clearly erred by granting Allstate’s petition. Nothing in this Opinion

precludes Allstate from filing a new petition which the trial court would consider

in light of the evidence presented.

             Accordingly, we vacate the orders of the Jefferson Circuit Court

directing Peeples and Lee to appear for an independent medical examination.

             ALL CONCUR.

BRIEFS FOR APPELLANTS:                     BRIEF FOR APPELLEE:

Aaron Michael Murphy                       Eric C. Rice
Louisville, Kentucky                       Daniel S. Gumm
                                           Megan L. Adkins
                                           Louisville, Kentucky

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