WHIPPLE, C.J.
This writ application is before us on remand from the Louisiana Supreme Court. The issue presented on remand of defendant/relator's application for supervisory writs is whether "expenses incurred," as stated in the medical payment provision of plaintiff's automobile liability policy, means the full amount of the medical expenses charged by a treating hospital in connection with plaintiff's automobile accident, or the reduced amount of medical expenses accepted by the hospital due to a contractual agreement with plaintiff's health insurer. We conclude that "expenses incurred" constitutes the full amount of medical expenses charged by the treating hospital and that the trial court properly denied the automobile insurer's motion for summary judgment. Thus, we again deny the insurer's writ application.
Plaintiff Ashley Hoffman was injured in an automobile accident on June 24, 2010, and sought treatment at Baton Rouge General Medical Center's emergency room ("Baton Rouge General"). At the time of the accident, Ms. Hoffman was insured under at least two different insurance policies, i.e., an automobile liability policy with uninsured/underinsured motorist coverage and a medical payments provision issued by Travelers Indemnity Company of America ("Travelers") to her parents and a health insurance policy issued by AETNA.
On August 17, 2010, Ms. Hoffman, through her attorney, submitted a medical bill to Travelers in the amount of $485.29 from Baton Rouge General, incurred for her treatment in the emergency room after the accident. According to Travelers, the submitted "account summary" did not contain an itemization of the medical treatment provided to Ms. Hoffman and, therefore, precluded Travelers from analyzing the claim for medical payment or making a payment. The Travelers' claim handler then contacted Baton Rouge General directly and requested an itemized bill of Ms. Hoffman's account purportedly so that she could process and pay the claim. In response to the request, Baton Rouge General provided Travelers with an itemized invoice in the amount of $713.67 on September 3, 2010. Travelers reviewed the itemized bill and then issued payment on September 22, 2010 in the amount of $674.73 to Ms. Hoffman and her attorneys. Travelers' explanation of benefits indicated that a charge of $72.00 for a procedure was reduced to an allowed amount of $33.06 "based on provider charges within the provider's geographic area." Thus, the invoiced amount of $713.67 was reduced to $674.73.
On June 14, 2011, Ms. Hoffman filed a "Class Action Petition for Declaratory Judgment, Injunctive Relief and for Incidental Damages." The petition alleged that Travelers reduced the $72.00 charge to $33.06 with an explanation code that "[t]he amount allowed is based on provider charges within the provider's geographic scope," without any definition of "geographic scope" of the allowed amount, nor
Travelers filed a motion for summary judgment in response to Ms. Hoffman's suit, arguing that Ms. Hoffman's petition should be dismissed because Travelers fully performed under the policy by paying $674.73 for "expenses incurred," when Ms. Hoffman's expenses only totaled $485.29.
On April 30, 2012, the trial court denied Travelers' motion, and Travelers then filed an application for supervisory writs with this court, challenging the trial court's denial of the motion for summary judgment. This court denied Travelers' writ application on September 19, 2012. See Hoffman v. Travelers Indemnity Company of America, 2012-CW-0725 (La.App. 1st Cir.9/19/12) (unpublished writ action). Thereafter, on December 14, 2012, the Louisiana Supreme Court granted Travelers' application for supervisory writs and remanded the matter to this court for briefing, argument, and full opinion. Hoffman v. Travelers Indemnity Company of America, 2012-2271 (La.12/14/12) 104 So.3d 451.
In accordance with the remand order from the Louisiana Supreme Court, we issue the following full opinion on the merits of Travelers' writ application.
The "Medical Payments" provision of the Travelers' policy states that Travelers will pay "reasonable expenses incurred" for necessary medical and funeral services because of `bodily injury' caused by an accident and sustained by an insured. Travelers contends that this policy language is unambiguous and, furthermore, that it is "well-established" in Louisiana that the phrase "expenses incurred" in an insurance policy means "only those expenses that the insured is legally obligated to pay, i.e., the amount that the medical-service providers were willing to accept as full payment for their services — the discounted bill." In support, Travelers cites
In Irby, the plaintiff sought benefits under the medical payments provision of his automobile liability policy for costs associated with treatment at a United States public hospital following an automobile accident. The plaintiff was never charged for the medical and hospital services he received, due to his status as an active member of the United States Coast Guard. The court found the plaintiff did not incur any medical expenses under the automobile liability policy, noting that "plaintiff never was under any obligation to pay the medical and hospital expenses and therefore never `incurred' the same...." Irby, 175 So.2d at 11.
In Brackens, the plaintiff sought benefits under the medical payments provision of his automobile liability policy for costs associated with treatment at a veterans' administration hospital following an automobile accident. As a veteran, the plaintiff was entitled to receive hospital services without payment and no charge was made to plaintiff for the services. The court found the plaintiff did not incur any medical expenses under the automobile policy terms, stating that "[p]laintiff here has never been liable or obligated for payment of the medical services rendered by the VA Hospital, either initially or by reason of the settlement with the tort-feasor's insurer. He has never, therefore, `incurred' any medical expense for which payment is due under the medical payments provision of the insurance contract." Brackens, 339 So.2d at 488.
Likewise, in Drearr, the plaintiff was a war veteran who received medical treatment at a veterans' administration hospital free of charge. The plaintiff sought payment of medical expenses under an insurance policy wherein the insurer contracted to pay plaintiff for medical expenses incurred. The court found that "the plaintiff not having incurred any expenses-indeed, he could not legally do so in a veterans' facility — has no right of recovery under the certificate of insurance issued by defendant." Drearr, 119 So.2d at 153.
In Rigby, the plaintiff was a doctor who sued to recover damages for personal injuries received in an automobile accident, including special damages for medical expenses. However, the physicians and surgeons who treated the plaintiff after the accident did not charge him. The court found that the plaintiff was not entitled to a sum for medical expenses, stating that "[s]ince plaintiff [was] not charged for the services, he could not be damaged in an amount not claimed of him by any one and not charged against him." Rigby, 151 So. at 122.
Unlike Irby, Brackens, Drearr, and Rigby, in the instant case, Baton Rouge General did charge for the services provided to Ms. Hoffman. Thus, these cases differ from the situation herein, where actual expenses were incurred. Moreover, we are not the first court to make this distinction. This exact distinction was noted in Thomas v. Universal Life Ins. Co., 201 So.2d 529 (La.App. 3rd Cir.1967), and Niles v. American Bankers Ins. Co., 229 So.2d 435 (La.App. 3rd Cir.1969) writ refused, 255 La. 479, 231 So.2d 394 (1970).
In Thomas, the plaintiff was insured under a hospital and surgical expense policy, wherein the insurer was obligated to
In Niles, the plaintiff brought suit to recover benefits under a hospitalization policy. The issue was whether the plaintiff "actually incurred" the hospital expenses claimed, as a substantial portion of the expenses were paid by Medicare. The court concluded that the hospital expenses were "actually incurred" by the plaintiff, and that the defendant insurer was liable to the plaintiff for the insurance benefits claimed. In reaching its conclusion, the court distinguished Drearr, Irby and Rigby, stating:
Niles, 229 So.2d at 438.
Applying the rationale of Niles and Thomas to the instant matter, we find that the "expenses incurred" by Ms. Hoffman, within the meaning of that term as used in the Travelers' policy, were $713.67, i.e., the amount reflected on the Baton Rouge General statement as invoiced and billed to plaintiff prior to any discount obtained on account of Ms. Hoffman's health insurance. Baton Rouge General charged her for the services it provided and it was entitled to be paid for the charges. The fact that the charges could ultimately be reduced by virtue of a negotiated rate agreement between the treating hospital and plaintiff's medical insurer is of no moment in determining the amount which Travelers is legally and contractually obligated to pay.
In so concluding, we note that this was not a gratuitous reduction by the treating hospital; rather, premiums were paid by or on behalf of Ms. Hoffman for health insurance to obtain this benefit. Thus, Travelers is not entitled to a windfall based on premiums paid to her health insurer, as there is no evidence that plaintiff's premiums paid to Travelers were reduced on account of her having a separate policy. Absent Ms. Hoffman's decision to collaterally obtain health insurance, she would be responsible for the full sum invoiced, as the "expenses incurred" by her for the hospital charges. Moreover, if Ms. Hoffman's health insurer had failed or refused to pay the hospital charges, she remained responsible for the charges as she signed a treatment authorization form upon being admitted to the hospital which included a contractual obligation that she "assume[s] responsibility for and guarantee] the payment of all Medical Center charges in accordance [with] the Medical Center's then current rate." There is no basis in fact or law to allow Travelers to obtain a windfall for Ms. Hoffman's separately paid health insurance.
Travelers argues that a contrary result is mandated by a footnote of a federal
Accordingly, we find no error in the trial court's denial of Travelers' motion for summary judgment and deny its application for writs.
For the above and foregoing reasons, Travelers' application for supervisory writs, seeking review of the trial court's denial of its motion for summary judgment, is hereby denied at its cost.
HIGGINBOTHAM, J., concurs with reasons.
McCLENDON, J., dissents and assigns reasons.
I respectfully submit that the majority opinion unnecessarily discusses the meaning of the term "expenses incurred" as used in the Travelers' policy, because the meaning of the term is subject to interpretation of the parties' intent, and is therefore, inappropriate for summary judgment.
For these additional reasons, I concur in the result of the majority opinion.
McCLENDON, J., dissents and assigns reasons.
In her petition, Ms. Hoffman alleges that she "received a medical bill for $713.67" from the Baton Rouge General, attaching a copy of the bill to her petition. The attached bill indicates that the "Amount You [Ashley Hoffman] Owe" is $485.29, reflecting an adjusted amount because of a contractual agreement between the hospital and AETNA.
In interpreting a contract, the words of a contract must be given their generally prevailing meaning. LSA-C.C. art. 2047. The Travelers' policy requires it to pay "reasonable expenses incurred" by its insured because of bodily injury caused by an accident. The