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GEICO’s “paper review” of basic insurance benefits may run afoul of Kentucky law

 

insurance benefitsIn Kentucky, basic reparations benefits (BRB) are typically available without regard to fault in an automobile accident case, up to the insured’s policy limits for such benefits.

Recently, the state’s appellate court was called upon to review the procedures of a particular insurance company that had made it a practice to terminate such benefits based solely on “paper reviews” of its insured’s medical records.

Facts of the Case

In the recent case of Houchens v. Government Employees Insurance Company (known to most as GEICO), the plaintiffs filed suit in the Jefferson Circuit Court, seeking redress both individually and as class representatives for the defendant insurance company’s allegedly wrongful unilateral termination of certain payments based on its self-generated “paper review.” As grounds for relief, the plaintiffs averred in their complaint that they had been injured in an automobile accident in 2011, that they had sought chiropractic treatment for their injuries, that they had submitted their bills to the defendant insurance company under the BRB section of their policies, and that their no-fault benefits had been terminated after the defendant paid approximately half of the amount owed. The plaintiffs sought to recover the outstanding no-fault benefits, interest on the overdue benefits, and attorney fees.

The matter was removed to federal court but ultimately returned to the state circuit court, which granted summary judgment to the defendant on the basis that there was nothing in the Kentucky Motor Vehicle Reparations Act that prohibited a reparations obligor from basing a benefits decision solely on the review of an insured’s medical records.

Decision of the Kentucky Court of Appeals

The appellate court reversed the lower court’s entry of summary judgment for the insurance company and remanded the case for further proceedings. According to the court, the sole issue to be decided was whether a reparations obligor such as the defendant was entitled to use “paper reviews” not tendered to nor reviewed by a court as the sole basis for terminating or denying the no-fault benefits of an insured. In ruling for the plaintiffs on appeal, the appellate court determined that the trial court had misconstrued certain prior case law as supporting the insurance company’s position.

According to the court, the Kentucky Legislature enacted Kentucky Revised Statute § 304.29-270(1) as a safeguard against the misuse of independent medical examinations (IMEs). Thus, the court reasoned that the legislature would not place considerable oversight on the use of IMEs while condoning an insurance company’s practice of denying or terminating benefits solely on the basis of a unilateral paper review of the insured’s medical records. To do so would essentially make the insurer “judge, jury, and executioner,” which the court found unacceptable.

To Talk to a Lawyer about a Car or Truck Accident

If you have been hurt or lost a loved one due to a negligent driver, the experienced Kentucky car accident attorneys at English, Lucas, Priest & Owsley are here to help you seek justice against the responsible party. Call us at (270) 781-6500 to set up a free case consultation. We serve all of Kentucky and Tennessee, including Bowling Green, Hopkinsville, Clarksville, and the surrounding areas.

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