§431:10C-304  Obligation to pay personalinjury protection benefits.  For purposes of this section, the term"personal injury protection insurer" includes personal injuryprotection self-insurers.  Every personal injury protection insurer shallprovide personal injury protection benefits for accidental harm as follows:

(1)  Except as otherwise provided in section431:10C-305(d), in the case of injury arising out of a motor vehicle accident,the insurer shall pay, without regard to fault, to the provider of services onbehalf of the following persons who sustain accidental harm as a result of theoperation, maintenance, or use of the vehicle, an amount equal to the personalinjury protection benefits as defined in section 431:10C-103.5(a) payable forexpenses to that person as a result of the injury:

(A)  Any person, including the owner, operator,occupant, or user of the insured motor vehicle;

(B)  Any pedestrian (including a bicyclist); or

(C)  Any user or operator of a moped as definedin section 249-1;

provided that this paragraph shall not apply inthe case of injury to or death of any operator or passenger of a motorcycle ormotor scooter as defined in section 286-2 arising out of a motor vehicleaccident, unless expressly provided for in the motor vehicle policy;

(2)  Payment of personal injury protection benefitsshall be made as the benefits accrue, except that in the case of death, paymentof benefits under section 431:10C-302(a)(5) may be made immediately in a lumpsum payment, at the option of the beneficiary;

(3)  (A)  Payment of personal injury protectionbenefits shall be made within thirty days after the insurer has receivedreasonable proof of the fact and amount of benefits accrued, and demand forpayment thereof. All providers must produce descriptions of the serviceprovided in conformity with applicable fee schedule codes;

(B)  If the insurer elects to deny a claim forbenefits in whole or in part, the insurer shall, within thirty days, notify theclaimant in writing of the denial and the reasons for the denial.  The denialnotice shall be prepared and mailed by the insurer in triplicate copies and bein a format approved by the commissioner.  In the case of benefits for servicesspecified in section 431:10C-103.5(a) the insurer shall also mail a copy of thedenial to the provider; and

(C)  If the insurer cannot pay or deny theclaim for benefits because additional information or loss documentation isneeded, the insurer shall, within the thirty days, forward to the claimant anitemized list of all the required documents.  In the case of benefits forservices specified in section 431:10C-103.5(a) the insurer shall also forwardthe list to the service provider;

(4)  Amounts of benefits which are unpaid thirty daysafter the insurer has received reasonable proof of the fact and the amount ofbenefits accrued, and demand for payment thereof, after the expiration of thethirty days, shall bear interest at the rate of one and one-half per cent permonth;

(5)  No part of personal injury protection benefitspaid shall be applied in any manner as attorney's fees in the case of injury ordeath for which the benefits are paid.  The insurer shall pay, subject tosection 431:10C-211, in addition to the personal injury protection benefitsdue, all attorney's fees and costs of settlement or suit necessary to effectthe payment of any or all personal injury protection benefits found due underthe contract.  Any contract in violation of this provision shall be illegal andunenforceable.  It shall constitute an unlawful and unethical act for anyattorney to solicit, enter into, or knowingly accept benefits under anycontract;

(6)  Disputes between the provider and the insurerover the amount of a charge or the correct fee or procedure code to be usedunder the workers' compensation supplemental medical fee schedule shall begoverned by section 431:10C-308.5; and

(7)  Any insurer who violates this section shall besubject to section 431:10C-117(b) and (c). [L 1987, c 347, pt of §2; am L 1992,c 124, §11; am L 1993, c 6, §20 and c 205, §27; am L 1997, c 251, §41; am L1998, c 275, §21; am L 2000, c 138, §1]

 

Case Notes

 

  Section entitles motorcycle passenger to claim no-faultbenefits against automobile driver's policy for passenger's injuries receivedin accident between driver's vehicle and motorcycle.  81 H. 302, 916 P.2d 1203.

  Term "any person" in paragraph (1)(A)(i) includesmotorcycle passengers.  81 H. 302, 916 P.2d 1203.

  In light of the unambiguous mandatory language of paragraph(3)(B), an insurer is required to provide written notice of its denial--inwhole or in part--of the claim for benefits; written notice to the claimant isrequired where the denial or partial denial relates to the treatment serviceand/or the charges therefor; where the denial or partial denial involvestreatment services, the insurer must also provide written notice to theprovider.  109 H. 185, 124 P.3d 930.

  Where insurer's denial of plaintiff's claim for no-faultbenefits was based upon an open question of law--whether "the reasons"as used in paragraph (3)(B) means "all reasons"--there was no badfaith on the part of insurer for not having stated all the reasons for itsdenial of plaintiff's claim.  109 H. 537, 128 P.3d 850.

  Hawaii's no-fault legislative scheme did not establishdoctor's status as a third party beneficiary as a matter of law.  116 H. 159,172 P.3d 471.

  Paragraph (1)(B) (1987) created a statutory right tosurvivors' loss benefits.  88 H. 345 (App.), 966 P.2d 1071.

  Pursuant to paragraph (1)(B) (1987) and §431:10C-103(10)(B)(1987), upon the death of an insured, the insurer is obligated to provide theinsured's survivor a survivor's loss benefit of up to either (1) $15,000 wherethe insured has purchased only the basic no-fault coverage, or (2) the expandedlimits of no-fault benefits where the insured has contracted for it under anoptional additional coverage.  88 H. 345 (App.), 966 P.2d 1071.

  The plain language of paragraph (1) requires a causalconnection between a motor vehicle accident and any injury for which a claimfor no-fault insurance benefits is made.  101 H. 21 (App.), 61 P.3d 532.

  Insurer violated the time requirements of paragraph (3)(C)(1993) when it delayed granting or denying insured's claim for no-faultbenefits pending (1) receipt of answers from insured's treating physicians toinsurer's questions regarding the underlying cause of the medical conditionthat required insured to undergo bypass surgery a few days after a motorvehicle accident, and (2) insured's undergoing two independent medicalexaminations; however, the commissioner wrongly concluded that insurer'sviolation of these time requirements procedurally barred insurer fromcontesting the substantive merits of insured's claim.  101 H. 311 (App.), 67P.3d 810.

  Under paragraph (5), an award of attorney's fees and costs ismandatory if a claimant prevails in a settlement or suit for no-fault benefits;and under §431:10C-211(a), an award of attorney's fees and costs may, in theexercise of a court's or the commissioner's discretion, be awarded to anonprevailing claimant, as long as the claim is not determined to beunreasonable, fraudulent, excessive, or frivolous.  104 H. 375 (App.), 90 P.3d267.

  Paragraph (3)(B) (1993) applies to billing disputes and thissection's notice requirement is triggered by a partial denial of claims in theform of reduced or partial payments by an insurer; thus, trial court erred infinding that insurer was not required to issue a formal notice of denial ofbenefits pursuant to paragraph (3)(B) (1993) after it made both reduced andpartial payments on physician's claims.  117 H. 477 (App.), 184 P.3d 792.

  Paragraph (4) (1993) is applicable when a payment due isdelayed in conjunction with a billing dispute; thus, physician was entitled tointerest on the balance withheld by insurer thirty days after physiciansubmitted physician's billing statements and demand for payment; insurer wasnot permitted to withhold payment for an indeterminate period of time, withoutinterest, while it sought additional information from physician.  117 H. 477(App.), 184 P.3d 792.

  The doctrine of equitable tolling cannot be applied to expandthe two-year statute of limitations period in §431:10C-315 (1993) based solelyon an issuer's failure to provide a formal notice of denial required pursuantto paragraph (3) (1993) in conjunction with a reduced or partial payment.  117H. 502 (App.), 184 P.3d 817.