CERTIFICATION FROM THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WASHINGTON IN BRETT DURANT, on behalf of himself and all others similarly situated, Plaintiff,
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, a foreign automobile insurance company, Defendant.
case concerns a class action insurance claim suit pending in
federal court. The federal district court has asked this
court to answer two certified questions concerning whether an
insurer's use of a "maximum medical
improvement" (MM) provision violates WAC 284-30-395(1).
case began with an auto policy claim by plaintiff Brett
Durant. Durant has been a policyholder with State Farm Mutual
Automobile Insurance Company since 1995 and carried $35, 000
in personal injury protection (PIP) coverage. On July 21,
2012, Durant was injured in a motor vehicle accident. He
opened a PIP claim with State Farm. State Farm then sent him
a "coverage letter" that stated:
The policy provides coverage for reasonable and necessary
medical expenses that are incurred within three (3) years of
the accident. Medical services must also be essential in
achieving maximum medical improvement for the injury you
sustained in the accident.
Docket (Dkt.) #30 (Decl. of Brett Durant) at 2 & Ex. C
sought treatment with chiropractor Harold Rasmussen, DC, who
diagnosed injuries including sprains to the neck, back,
pelvis, and right shoulder. After a shoulder MRI (magnetic
resonance imaging) showed a ligament sprain and "a
possible small type I SLAP [(superior labral
anteroposterior)] tear, " Durant was referred to an
orthopedic surgeon who diagnosed "mild
bursitis/tendinitis, " which was treated with physical
therapy and cortisone injections. Id. at 2.
months after the accident, State Farm sent Dr. Rasmussen a
form letter with blanks to fill in inquiring about
Durant's progress. The letter was directed toward State
Farm's MMI standard, asking, "Has the patient
reached maximum medical improvement?" and "If the
patient has not reached maximum medical improvement, what is
your target maximum medical improvement date?"
Id. at 2 & Ex. D. Dr. Rasmussen responded that
Durant was not at MMI but his target date was
"2-1-13." Id. at Ex. D.
injuries were not resolved by that date, and he continued to
receive chiropractic and massage therapy. State Farm then
sent another letter to Dr. Rasmussen, which inquired,
"You have treated Brett past his given MM[I] date of
2/1/2013. Please explain." Dkt. #32 (Decl. of Tyler
Firkins), Ex. Q at 11 of 13. Dr. Rasmussen replied,
"Patient was not stable and needed treatment to
continued to have back, shoulder, and pelvic issues and
continued to receive care. His care providers billed his PIP
claim as before, but State Farm denied each bill on the basis
that, "[s]ervices are not covered, as your provider
advised us you previously reached maximum medical
improvement." Dkt. #30, Ex. F.
retained an attorney who wrote to State Farm asking them to
pay the outstanding medical bills. The attorney explained
that State Farm must use the standard authorized by WAC
284-30-395(1); that whether Durant had reached MMI was
irrelevant; and that unless State Farm had a competent
medical opinion that Durant's treatment was not
reasonable, necessary, or related, State Farm must pay the
attorney provided State Farm a letter from Dr. Rasmussen
explaining that Durant's continuing injuries meant that
he would require periodic care for his spinal and pelvic
dysfunction and that during periods of exacerbation, Durant
should receive treatment to restore movement and to reduce
his pain. The State Farm claim representative ignored Dr.
Rasmussen's opinion and authored a letter that reiterated
the previous denial, noted that Durant had previously reached
MMI, and stated that the Office of the Insurance Commissioner
(OIC) "thoroughly reviews and approves policy language
proposed by insurance companies." Dkt. #30, Ex. H.
Durant's attorney responded by letter that Durant needed
medical treatment from time to time due to exacerbations in
order to maintain his recovery and that this treatment should
be considered reasonable, necessary, and related under WAC
284-30-395(1). By that time, Durant had unpaid medical bills
of more than $1, 000 that had been denied by State Farm, but
State Farm stood by its decision and continued to deny
payment based on its MMI standard.
filed this action in King County Superior Court in 2015,
alleging that State Farm's use of the MMI standard
violates its duty of good faith, breaches the insurance
contract, violates the Insurance Fair Conduct Act, RCW
48.30.010-.015, and violates the Consumer Protection Act,
chapter 19.86 RCW. State Farm removed the case to federal
court. The United States District Court granted Durant's
motion to certify a class of plaintiffs. State Farm moved for
reconsideration. In denying the motion for reconsideration,
the district court also granted Durant's motion to
certify the following two questions to this court:
1. Does an insurer violate WAC 284-30-395(1)(a) or (b) if
that insurer denies, limits, or terminates an insured's
medical or hospital benefits claim based on a finding of
"maximum medical improvement?"
2. Is the term "maximum medical improvement"
consistent with the definition of "reasonable" or
"necessary" as those terms appear in WAC
Certified Question: Does State Farm's limitation of
medical claims based on its MMI provision violate WAC
284-30-395(1)(a) or (b)?
contends that the plain language of the regulation in
question answers the first certified question. We agree.
questions from federal court are questions of law that this
court reviews de novo." Brady v. Autozone Stores,
Inc., 188 Wn.2d 576, 580, 397 P.3d 120 (2017) (citing
Carlsen v. Glob. Client Sols., LLC, 171 Wn.2d 486,
493, 256 P.3d 321 (2011)). "This court may reformulate
the certified question." Id. (citing Allen
v. Dameron, 187 Wn.2d 692, 701, 389 P.3d 487 (2017)).
Further, the meaning of a statute is a question of law that
is reviewed de novo. State v. J.M., 144 Wn.2d 472,
480, 28 P.3d 720 (2001). This court's fundamental
objective in determining what a statute means is to ascertain
and carry out the legislature's intent. Id. If
the statute's meaning is plain on its face, then courts
must give effect to its plain meaning as an expression of
what the legislature intended. Id. A statute that is
clear on its face is not subject to judicial construction.
court interprets regulations under the rules of statutory
construction. Mader v. Health Care Auth., 149 Wn.2d
458, 472, 70 P.3d 931 (2003). It construes the act as a
whole, giving effect to all of the language used.
Id. If a regulation is unambiguous, intent can be
determined from the language alone, and the court will not
look beyond the plain meaning of the words of the regulation.
Id. at 473.
begin with the plain language of the regulation. WAC
284-30-395(1) provides in relevant part:
(1) Within a reasonable time after receipt of actual notice
of an insured's intent to file a personal injury
protection medical and hospital benefits claim, and in every
case prior to denying, limiting, or terminating an
insured's medical and hospital benefits, an insurer shall
provide an insured with a written explanation of the coverage
provided by the policy, including a notice that the insurer