REPORT TITLE:
Insurance

DESCRIPTION:
Requires IMEs to be performed by a provider agreed to by the
parties in a workers' compensation or motor vehicle insurance
case.  In the event the parties cannot agree to a provider, the
selection may be submitted to the commissioner, arbitration, or
circuit court.  Standardizes references to the fee schedule in
the motor vehicle law.  (CD1)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                                        2476
HOUSE OF REPRESENTATIVES                H.B. NO.           H.D. 1
TWENTIETH LEGISLATURE, 2000                                S.D. 2
STATE OF HAWAII                                            C.D. 1
                                                             
________________________________________________________________
________________________________________________________________


                   A  BILL  FOR  AN  ACT

RELATING TO INSURANCE.



BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:

 1      SECTION 1.  Section 431:10C-304, Hawaii Revised Statutes, is
 
 2 amended to read as follows:
 
 3      "431:10C-304  Obligation to pay personal injury protection
 
 4 benefits.  For purposes of this section, the term "personal
 
 5 injury protection insurer" includes personal injury protection
 
 6 self-insurers.  Every personal injury protection insurer shall
 
 7 provide personal injury protection benefits for accidental harm
 
 8 as follows:
 
 9      (1)  Except as otherwise provided in section 431:10C-305(d),
 
10           in the case of injury arising out of a motor vehicle
 
11           accident, the insurer shall pay, without regard to
 
12           fault, to the provider of services on behalf of the
 
13           following persons who sustain accidental harm as a
 
14           result of the operation, maintenance, or use of the
 
15           vehicle, an amount equal to the personal injury
 
16           protection benefits as defined in section 431:10C-
 
17           103.5(a) payable for expenses to that person as a
 
18           result of the injury:
 
19           (A)  Any person, including the owner, operator,
 
20                occupant, or user of the insured motor vehicle;
 

 
Page 2                                                     2476
                                     H.B. NO.           H.D. 1
                                                        S.D. 2
                                                        C.D. 1

 
 1           (B)  Any pedestrian (including a bicyclist); or
 
 2           (C)  Any user or operator of a moped as defined in
 
 3                section 249-1;
 
 4           provided that this paragraph shall not apply in the
 
 5           case of injury to or death of any operator or passenger
 
 6           of a motorcycle or motor scooter as defined in section
 
 7           286-2 arising out of a motor vehicle accident, unless
 
 8           expressly provided for in the motor vehicle policy;
 
 9      (2)  Payment of personal injury protection benefits shall be
 
10           made as the benefits accrue, except that in the case of
 
11           death, payment of benefits under section 431:10C-
 
12           302(a)(5) may be made immediately in a lump sum
 
13           payment, at the option of the beneficiary;
 
14      (3)  (A)  Payment of personal injury protection benefits
 
15                shall be made within thirty days after the insurer
 
16                has received reasonable proof of the fact and
 
17                amount of benefits accrued, and demand for payment
 
18                thereof. All providers must produce descriptions
 
19                of the service provided in conformity with
 
20                applicable fee schedule codes;
 
21           (B)  If the insurer elects to deny a claim for benefits
 
22                in whole or in part, the insurer shall, within
 
23                thirty days, notify the claimant in writing of the
 

 
Page 3                                                     2476
                                     H.B. NO.           H.D. 1
                                                        S.D. 2
                                                        C.D. 1

 
 1                denial and the reasons for the denial.  The denial
 
 2                notice shall be prepared and mailed by the insurer
 
 3                in triplicate copies and be in a format approved
 
 4                by the commissioner.  In the case of benefits for
 
 5                services specified in section 431:10C-103.5(a) the
 
 6                insurer shall also mail a copy of the denial to
 
 7                the provider; and
 
 8           (C)  If the insurer cannot pay or deny the claim for
 
 9                benefits because additional information or loss
 
10                documentation is needed, the insurer shall, within
 
11                the thirty days, forward to the claimant an
 
12                itemized list of all the required documents.  In
 
13                the case of benefits for services specified in
 
14                section 431:10C-103.5(a) the insurer shall also
 
15                forward the list to the service provider;
 
16      (4)  Amounts of benefits which are unpaid thirty days after
 
17           the insurer has received reasonable proof of the fact
 
18           and the amount of benefits accrued, and demand for
 
19           payment thereof, after the expiration of the thirty
 
20           days, shall bear interest at the rate of one and one-
 
21           half per cent per month;
 
22      (5)  No part of personal injury protection benefits paid
 
23           shall be applied in any manner as attorney's fees in
 

 
Page 4                                                     2476
                                     H.B. NO.           H.D. 1
                                                        S.D. 2
                                                        C.D. 1

 
 1           the case of injury or death for which the benefits are
 
 2           paid.  The insurer shall pay, subject to section
 
 3           431:10C-211, in addition to the personal injury
 
 4           protection benefits due, all attorney's fees and costs
 
 5           of settlement or suit necessary to effect the payment
 
 6           of any or all personal injury protection benefits found
 
 7           due under the contract.  Any contract in violation of
 
 8           this provision shall be illegal and unenforceable.  It
 
 9           shall constitute an unlawful and unethical act for any
 
10           attorney to solicit, enter into, or knowingly accept
 
11           benefits under any contract; [and
 
12      (6)  Any insurer who violates this section shall be subject
 
13           to section 431:10C-117(b) and (c).]
 
14      (6)  Disputes between the provider and the insurer over the
 
15           amount of a charge or the correct fee or procedure code
 
16           to be used under the workers' compensation supplemental
 
17           medical fee schedule shall be governed by section
 
18           431:10C-308.5; and
 
19      (7)  Any insurer who violates this section shall be subject
 
20           to section 431:10C-117(b) and (c)."
 
21      SECTION 2.  Section 431:10C-308.5, Hawaii Revised Statutes,
 
22 is amended to read as follows:
 
23      "431:10C-308.5  Limitation on charges.  (a)  As used in
 

 
Page 5                                                     2476
                                     H.B. NO.           H.D. 1
                                                        S.D. 2
                                                        C.D. 1

 
 1 this article, the term ["workers' compensation schedules"]
 
 2 "workers' compensation supplemental medical fee schedule" means
 
 3 the [schedules] schedule adopted and as may be amended by the
 
 4 director of labor and industrial relations for workers'
 
 5 compensation cases under chapter 386, establishing fees and
 
 6 frequency of treatment guidelines[, and contained in sections 12-
 
 7 13-30, 12-13-35, 12-13-38, 12-13-39, 12-13-45, 12-13-85 through
 
 8 92, and 12-13-94, Hawaii administrative rules].  References in
 
 9 the workers' compensation [schedules] supplemental medical fee
 
10 schedule to "the employer", "the director", and "the industrial
 
11 injury", shall be respectively construed as references to "the
 
12 insurer", "the commissioner", and "the injury covered by personal
 
13 injury protection benefits" for purposes of this article.
 
14      (b)  The charges and frequency of treatment for services
 
15 specified in section 431:10C-103.5(a), except for emergency
 
16 services provided within seventy-two hours following a motor
 
17 vehicle accident resulting in injury, shall not exceed the
 
18 charges and frequency of treatment permissible under the workers'
 
19 compensation [schedules.] supplemental medical fee schedule.
 
20 Charges for independent medical examinations, including record
 
21 reviews, physical examinations, history taking, and reports, to
 
22 be conducted by a licensed Hawaii provider unless the insured
 
23 consents to an out-of-state provider, shall not exceed the
 

 
Page 6                                                     2476
                                     H.B. NO.           H.D. 1
                                                        S.D. 2
                                                        C.D. 1

 
 1 charges permissible under the [workers' compensation schedules
 
 2 for consultation for a complex medical problem.] appropriate
 
 3 codes in the workers' compensation supplemental fee schedule.
 
 4 The workers' compensation [schedules] supplemental medical fee
 
 5 schedule shall not apply to independent medical examinations
 
 6 conducted by out-of-state providers[; provided that] if the
 
 7 charges for the examination are reasonable.  The independent
 
 8 medical examiner shall be selected by mutual agreement between
 
 9 insurer and claimant; provided that if no agreement is reached,
 
10 the selection may be submitted to the commissioner, arbitration
 
11 or circuit court.  The independent medical examiner shall be of
 
12 the same specialty as the provider whose treatment is being
 
13 reviewed, unless otherwise agreed by the insurer and claimant.
 
14 All records and charges relating to an independent medical
 
15 examination shall be made available to the claimant upon request.
 
16 The commissioner may adopt administrative rules relating to fees
 
17 or frequency of treatment for injuries covered by personal injury
 
18 protection benefits.  If adopted, these administrative rules
 
19 shall prevail to the extent that they are inconsistent with the
 
20 workers' compensation [schedules.] supplemental medical fee
 
21 schedule.
 
22      (c)  Charges for services for which no fee is set by the
 
23 workers' compensation [schedules] supplemental medical fee
 

 
Page 7                                                     2476
                                     H.B. NO.           H.D. 1
                                                        S.D. 2
                                                        C.D. 1

 
 1 schedule or other administrative rules adopted by the
 
 2 commissioner shall be limited to eighty per cent of the
 
 3 provider's usual and customary charges for these services.
 
 4      (d)  Services for which no frequency of treatment guidelines
 
 5 are set forth in the workers' compensation [schedules]
 
 6 supplemental medical fee schedule or other administrative rules
 
 7 adopted by the commissioner shall be deemed appropriate and
 
 8 reasonable expenses necessarily incurred if so determined by a
 
 9 provider.
 
10      (e)  In the event of a dispute between the provider and the
 
11 insurer over the amount of a charge or the correct fee or
 
12 procedure code to be used under the workers' compensation
 
13 supplemental medical fee schedule, the insurer shall:
 
14      (1)  Pay all undisputed charges within thirty days after the
 
15           insurer has received reasonable proof of the fact and
 
16           amount of benefits accrued and demand for payment
 
17           thereof; and
 
18      (2)  Negotiate in good faith with the provider on the
 
19           disputed charges for a period up to sixty days after
 
20           the insurer has received reasonable proof of the fact
 
21           and amount of benefits accrued and demand for payment
 
22           thereof.
 
23 If the provider and the insurer are unable to resolve the
 

 
Page 8                                                     2476
                                     H.B. NO.           H.D. 1
                                                        S.D. 2
                                                        C.D. 1

 
 1 dispute, the provider, insurer, or claimant may submit the
 
 2 dispute to the commissioner, arbitration, or court of competent
 
 3 jurisdiction.  The parties shall include documentation of the
 
 4 efforts of the insurer and the provider to reach a negotiated
 
 5 resolution of the dispute.
 
 6      [(e)] (f)  The provider of services described in section
 
 7 431:10C-103.5(a) shall not bill the insured directly for those
 
 8 services but shall bill the insurer for a determination of the
 
 9 amount payable.  The provider shall not bill or otherwise attempt
 
10 to collect from the insured the difference between the provider's
 
11 full charge and the amount paid by the insurer.
 
12      [(f)] (g)  A health care provider shall be compensated by
 
13 the insurer for preparing reports documenting the need for
 
14 treatments which exceed the [schedules] workers' compensation
 
15 supplemental medical fee schedule in accordance with the fee
 
16 schedule for special reports.  The health care provider may
 
17 assess the cost of preparing a report to the insurer at no more
 
18 than $20 per page up to a maximum of $75 for each report."
 
19      SECTION 3.  Statutory material to be repealed is bracketed.
 
20 New statutory material is underscored.
 
21      SECTION 4.  This Act shall take effect upon its approval.