Mejia v. American Cas. Co., 99-P-2043.

• Decision Date: 18 July 2002
• Docket Number: No. 99-P-2043.,99-P-2043.
• Citation: 55 Mass. App. Ct. 461,771 N.E.2d 811
• Court: Appeals Court of Massachusetts
• Parties: Melissa MEJIA & another<SMALL><SUP>1</SUP></SMALL> v. AMERICAN CASUALTY COMPANY.

771 N.E.2d 811

55 Mass. App. Ct. 461

Melissa MEJIA & another¹ v. AMERICAN CASUALTY COMPANY.

No. 99-P-2043.

Appeals Court of Massachusetts, Essex.

Argued January 14, 2002.

Decided July 18, 2002.

Peter A. Callahan for the plaintiffs.

John P. Graceffa for the defendant.

Present: BROWN, KASS, & KANTROWITZ, JJ.

KANTROWITZ, J.

The plaintiffs, Melissa Mejia and Niurka Santana, appeal from a Superior Court judge's grant of summary judgment in favor of the defendant, American Casualty Company (American). Mejia and Santana, who were injured in an automobile accident, each submitted and were reimbursed for the first $2,000 of their medical bills by American under the compulsory personal injury protection (PIP) benefits section of a standard Massachusetts automobile policy issued by Americn to Mejia's mother. Thereafter, Mejia and Santana submitted additional medical bills to American for payment under the optional medical payments (MEDPAY) part of the policy. American informed them that they were required to submit these bills to their health insurers and that further coverage under the automobile policy would only be considered for payment by American if and when the health insurers did not pay their bills.

At issue on appeal is whether the motion judge was correct in ruling that the plaintiffs were required to submit their additional medical bills first to their health insurance providers, rather than bypassing them and making a claim initially and directly to the motor vehicle insurer under the MEDPAY section. We conclude that, under the terms of the policy, the plaintiffs were first required to submit their bills to their health insurers, but if the health insurers declined to pay them, the plaintiffs were then entitled to be reimbursed under the MEDPAY coverage of American's policy if these expenses were not payable under PIP.

Background. On November 11, 1995, the plaintiffs were injured in an automobile accident in Woburn. Mejia was driving at the time of the accident and Santana was a passenger. The vehicle was registered to Mejia's mother, Sylvia Mejia, and was insured by the defendant, American. Coverage under the policy included part 2, PIP, with a maximum amount of $8,000 per claimant and part 6, MEDPAY, in the amount of $5,000 per claimant. Both plaintiffs had private health insurance coverage in effect at the time of the accident.

From approximately November 28, 1995, through November, 1996, the plaintiffs submitted applications for PIP benefits to American. Mejia's medical bills and lost wages arising out of the accident came to $6,504, and Santana's came to $2,777.30. American made PIP payments for medical expenses totaling $2,000 to Mejia and $2,208 to Santana.² American also made further payments from the PIP coverage to Mejia and Santana for medical payments submitted to and denied by their private health insurance providers.³

On January 7, 1997, American received a demand letter from the plaintiffs pursuant to G.L. c. 93A, c. 176D, and c. 90, § 34M, requesting that American pay further accident-related medical bills under the MEDPAY provision of the policy.⁴ The plaintiffs had not submitted these bills to their private health insurance providers prior to submitting them to American. American responded on January 30, 1997, by requesting documentation that these bills had been first submitted to, and denied by, the plaintiffs' private health insurance providers. American also advised the plaintiffs' counsel that, to the extent coverage for these bills was not provided by the health insurers, they would be considered for payment under the PIP coverage section of the policy.⁵ When the plaintiffs did not provide the requested documentation, American denied payment, stating that its obligation to pay medical bills in excess of $2,000 was governed by the PIP (not MEDPAY) provision of the policy, prequiring a denial of benefits from the health insurance providers prior to payment.

On May 13, 1997, the plaintiffs filed a complaint in Superior Court seeking a declaration pursuant to G.L. c. 231A that American was responsible for all of the plaintiffs' outstanding medical expenses in excess of $2,000 under the MEDPAY provision of the policy and that the plaintiffs need not submit those claims to their health insurance providers first. The complaint alleged that American's refusal to pay was a breach of contract and in violation of G.L. c. 93A, c. 176D, and c. 90, § 34M. The plaintiffs also claimed reasonable attorney's fees and costs and expenses of litigation. On July 1, 1997, American filed a counterclaim seeking a declaratory judgment that the plaintiffs were not entitled to the requested payment.

The plaintiffs moved for partial summary judgment on their claims for declaratory relief, breach of contract, and breach of G.L. c. 90, § 34M. American opposed the plaintiffs' motion and moved for summary judgment on its counterclaim. After hearing the cross motions, the judge granted summary judgment in favor of American and against the plaintiffs, who appealed.

Discussion. Summary judgment is appropriate where there are no genuine issues as to any material fact and where the moving party is entitled to judgment as matter of law. See Cassesso v. Commissioner of Correction, 390 Mass. 419, 422, 456 N.E.2d 1123 (1983); Mass.R.Civ.P. 56(c), 365 Mass. 824 (1974). Here, both parties agreed that there were no genuine issues of material fact, and both argued that they were entitled to judgment as matter of law. We begin our analysis by interpreting the language of the insurance contract. See Freelander v. G. & K Realty Corp., 357 Mass. 512, 516, 258 N.E.2d 786 (1970).

Part 2 of the policy at issue, "Personal Injury Protection" (PIP), provides for payment of medical expenses, lost wages, and replacement services and states in pertinent part:

"Some people have a policy of health, sickness, or disability insurance or a contract or agreement with a group, organization, partnership or corporation to provide, pay for, or reimburse the cost of medical expenses. If so, we will pay up to $2,000 of medical expenses for any injured person. We will also pay medical expenses in excess of $2,000 for such injured person which will not be paid by a medical expense provider. In either case, our total payment for medical expenses, lost wages and replacement services will not exceed $8,000.

. . .

"If anyone is entitled to PIP benefits and also to benefits under another Part of this policy, we will pay from this Part first." (Emphases supplied.)

Part 6 of the policy, "Medical Payments" (MEDPAY), states in pertinent part:

"Under this Part, we will pay reasonable expenses for necessary medical and funeral services incurred as a result of an accident.

"We will pay for expenses resulting from bodily injuries to anyone occupying your auto at the time of the accident [emphasis omitted]....

. . .

"We will not pay under this Part for any expenses that are payable or would have been payable except for a deductible under the PIP coverage of this policy or any other Massachusetts auto policy" (emphases supplied).

When the words of the contract are not ambiguous, the contract will be enforced according to its terms. Schwanbeck v. Federal-Mogul Corp., 412 Mass. 703, 706, 592 N.E.2d 1289 (1992), citing Freelander v. G. & K Realty Corp., 357 Mass. at 516, 258...