SPINA, J.
In this proceeding we consider whether a claimant may seek medical expense benefits under the "medical payments" coverage (MedPay) of a standard Massachusetts automobile insurance policy (auto policy) where she has already recovered for those expenses under a separate policy of health insurance. Diane Golchin filed suit against Liberty Mutual Insurance Company (Liberty Mutual), both personally and on behalf of a putative class of similarly situated individuals, alleging that
1. Standard of review. The motion judge dismissed Golchin's complaint pursuant to Mass. R. Civ. P. 12 (b) (6), 365 Mass. 754 (1974), for failure to state a claim on which relief can be granted. In reviewing the sufficiency of a complaint under rule 12 (b) (6), "[w]e take as true `the allegations of the complaint, as well as such inferences as may be drawn therefrom in the plaintiff's favor....' Blank v. Chelmsford Ob/Gyn, P.C., 420 Mass. 404, 407 (1995)." Marram v. Kobrick Offshore Fund, Ltd., 442 Mass. 43, 45 (2004), quoting Warner-Lambert Co. v. Execuquest Corp., 427 Mass. 46, 47 (1998). "What is required at the pleading stage are factual `allegations plausibly suggesting (not merely consistent with)' an entitlement to relief...." Iannacchino v. Ford Motor Co., 451 Mass. 623, 636 (2008), quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 557 (2007). "Factual allegations must be enough to raise a right to relief above the speculative level ... [based] on the assumption that all the allegations in the complaint are true (even if doubtful in fact)...." Iannacchino v. Ford Motor Co., supra at 636, quoting Bell Atl. Corp. v. Twombly, supra at 555.
As a result of imprecise pleading, however, it is not immediately clear that this is the proper standard of review. The motion judge ruled on what Liberty Mutual captioned as "Defendant, Liberty Mutual Insurance Company's, Motion to Dismiss Plaintiff's Complaint." In that motion, however, Liberty Mutual asserts at least one fact — that Golchin refused to provide Liberty Mutual with a copy of her health insurance policy — that does not appear on the face of the pleading. In addition,
Liberty Mutual's motion can be interpreted only as a motion to dismiss Golchin's complaint pursuant to rule 12 (b) (6), for failure to state a claim on which relief can be granted. However, under rule 12 (b), "[i]f, on any motion asserting the defense numbered (6), ... matters outside the pleading are presented to and not excluded by the court, the motion shall be treated as one for summary judgment" rather than as one to dismiss. See J.W. Smith & H.B. Zobel, Rules Practice § 12.7, at 199 (2d ed. 2006). Conversion of the motion into one for summary judgment may therefore have been appropriate because Liberty Mutual's motion relies on facts and documents outside the complaint that were not excluded by the motion judge.
Conversion, however, is not an absolute requirement because "[w]here ... the plaintiff had notice of [the extrinsic] documents and relied on them in framing the complaint, the attachment of such documents to a motion to dismiss does not convert the motion to one for summary judgment...." Marram v. Kobrick Offshore Fund, Ltd., supra at 45 n.4. See J.W. Smith & H.B. Zobel, Rules Practice, supra at § 12.15, at 216. The standard Massachusetts auto policy attached by Liberty Mutual to its motion clearly falls within this category. See Marram v. Kobrick Offshore Fund, Ltd., supra. Further, the G. L. c. 93A demand letter and Liberty Mutual's response obviously were available to Golchin before she brought this action and were necessarily relied on by her in drafting the complaint. See id. It was thus unnecessary to convert Liberty Mutual's motion from one to dismiss under rule 12 (b) into one for summary judgment under Mass. R. Civ. P. 56, as amended, 436 Mass. 1404 (2002). Accordingly, we apply the standard of review laid out above.
On September 14, 2006, Golchin was involved in a motor vehicle accident while she was an occupant of her husband's car. The car was insured under a Massachusetts auto policy issued by Liberty Mutual that included optional MedPay benefits of up to $25,000. Golchin sustained significant personal injuries and, as a result of those injuries, incurred medical expenses in excess of $100,000. At the time of the accident, Golchin also was covered under a health insurance policy issued by Blue Cross and Blue Shield of Massachusetts (Blue Cross).
Liberty Mutual paid $2,000 in personal injury protection (PIP) benefits to Golchin as a result of the accident. Golchin also submitted to Liberty Mutual documentation of additional medical expenses and requested payment pursuant to the MedPay coverage provided by the Liberty Mutual policy. Liberty Mutual refused to pay these benefits, citing the fact that they already had been paid by Blue Cross under the health insurance policy.
3. Analysis. Golchin seeks benefits under a standard Massachusetts auto policy. "We interpret the words of the standard policy in light of their plain meaning, ... giving full effect to the document as a whole[,] ... consider[ing] `what an objectively reasonable insured, reading the relevant policy language, would expect to be covered' ... [and] interpret[ing] the provision of the standard policy in a manner consistent with the statutory and regulatory scheme that governs such policies." (Citations omitted.) Given v. Commerce Ins. Co., 440 Mass. 207, 209 (2003), quoting Hazen Paper Co. v. United States Fid. & Guar. Co., 407 Mass. 689, 700 (1990). "Finally, because the approved wording of the standard policy is controlled by the Commissioner of Insurance and not by any insurer (see G. L. c. 175, § 113A), we do not construe ambiguities against the insurer." Given v. Commerce Ins. Co., supra at 210.
The standard policy contains two coverages implicated by Golchin's claim. First, the policy provides a maximum of
Under the terms of the standard policy, if PIP benefits are available under any Massachusetts auto policy they are always paid first.
The order in which PIP and MedPay benefits are triggered is relevant to Golchin's claim because the portion of the standard policy addressing PIP states:
This language is required by statute. G. L. c. 90, § 34A. Following an accident, therefore, the first $2,000 in benefits are paid by PIP with benefits above that threshold being payable by health insurance. After the $2,000 threshold has been reached, the standard policy provides that any medical expenses "which will not be paid by a health plan" are payable by PIP and will erode its $8,000 limit of liability. Only after PIP benefits have been exhausted or where they are unavailable does the standard policy provide that MedPay benefits are due. See Mejia, supra at 465-466. The standard Massachusetts auto policy therefore contains language expressly precluding the simultaneous payment of health insurance and MedPay benefits at least until the $8,000 limit of PIP benefits has been reached.
Golchin makes no argument that the plain meaning of these policy terms is unclear or that an objectively reasonable insured would conclude that MedPay benefits are payable before PIP benefits have been exhausted. See Given v. Commerce Ins. Co., supra at 209. Further, this interpretation is precisely the one adopted by the Commissioner of Insurance (commissioner) in Bulletin 2008-12 (bulletin), which provides examples of coordination of benefits between PIP, health insurance, and MedPay coverage. Considering that the commissioner controls the language of the policy, see id. at 210, the bulletin's interpretation of the policy and its interaction with other regulations is highly persuasive. See Metropolitan, supra at 397 (such bulletins are not binding but nevertheless "useful in our effort to interpret ambiguous statutory provisions relevant to the agency's area of expertise"). Further, other Massachusetts decisions addressing the interplay of PIP and MedPay coverages have reached a similar conclusion.
In the Mejia case, the Appeals Court concluded that "payment under PIP is to precede any payments under [MedPay]," and that, after the $2,000 cap to exclusive PIP benefits has been reached, "[t]he availability of PIP in turn depends upon whether the claimant has health insurance for the medical service that
We considered a slightly different circumstance in the Metropolitan case. There, a claimant was injured while a passenger in a vehicle insured by Metropolitan, which paid the first $2,000 in PIP benefits and directed him to his health insurer for payment of the balance. Id. The health insurer refused coverage, citing a clause in its policy rendering its coverage excess of any MedPay coverage. Id. at 390-391. Metropolitan sought declaratory relief, arguing that the provisions of G. L. c. 90, § 34A, precluded payment of the MedPay benefit. Id. We disagreed, holding that the statute "only prohibits a health insurer from denying coverage because of the existence of PIP [rather than MedPay] benefits." Id. at 394. As a result, we held that the health insurer's deferral language did not violate the letter or spirit of the statute. Id. at 394-395. Further, we concluded that the effect of the health insurance policy's "other insurance" clause was similar to the effect resulting from the Dominguez and Mejia cases — PIP benefits were unavailable, but MedPay benefits were not. Metropolitan, supra at 394-395 & n.8, citing Dominguez, supra at 112-113, and Mejia, supra at 466.
This analysis would be sufficient to dispose of Golchin's complaint if further facts had not been introduced to the record. Golchin has not alleged that PIP benefits have been exhausted or are unavailable, so factual prerequisites for triggering MedPay
As discussed above, the provisions of the standard Massachusetts auto policy link MedPay and health coverage only to the extent that, after $2,000 in PIP benefits, PIP is secondary to health insurance and MedPay is available only where PIP benefits are exhausted or unavailable. See note 3, supra. If PIP benefits are exhausted, there is no further language in the standard auto policy that links health insurance and MedPay benefits, so, under the terms of the policy, MedPay benefits are payable. Golchin requested payment of MedPay benefits after the PIP benefits were exhausted, Liberty Mutual refused, and Golchin now seeks relief on the theories set forth in her complaint. Without more, therefore, the alleged facts before us indicate that Golchin's right to relief rises above the speculative level. See Iannacchino v. Ford Motor Co., 451 Mass. 623, 636 (2008). In opposition to this conclusion, however, Liberty Mutual argues that various statutes and regulations are controlling and preclude payment of MedPay benefits in these circumstances. See Given v. Commerce Ins. Co., 440 Mass. 207, 209-210 (2003). Liberty Mutual's arguments are unpersuasive.
Liberty Mutual's principal argument is based on the bulletin, which addresses the coordination of benefits among PIP, health
As an initial matter, we note that Liberty Mutual bases much of its argument on the assertion that the bulletin is "binding on the [c]ourt with the force and effect of a statute." Liberty Mutual's argument on this point, however, falls short. Briefly paraphrased, Liberty Mutual asserts that because the commissioner possesses authority to issue cost control regulations and because the coordination of benefits discussed in the bulletin would control costs, the bulletin is a regulation having the force of law. Assuming, without deciding, that the first two propositions are correct, Liberty Mutual's conclusion does not follow. Merely because the commissioner is possessed of authority regarding a particular topic does not render his every pronouncement regarding that topic a regulation possessing the full force and effect of a statute. See Global NAPs, Inc. v. Awiszus, 457 Mass. 489, 496-497 (2010) (distinguishing "[g]uidelines issued by an administrative agency" from "regulations adopted pursuant to the Administrative Procedures Act"). Further, there are a number of considerations regarding the status of the bulletin that Liberty Mutual does not address and that do not weigh in its favor.
First, our precedent has treated the commissioner's previous bulletin on this topic as a persuasive interpretation of statutes and policy language but not as an "official agency action" controlling on the court. Metropolitan, supra at 396-397. Liberty Mutual does not acknowledge this precedent or explain why a different conclusion is appropriate regarding the bulletin presently under consideration. Second, the bulletin notes that our
Read in its entirety, the document's clear purpose is to provide insurers with procedural guidance in light of confusing and potentially conflicting provisions in auto policies (requiring that MedPay benefits be excess of PIP), health policies (potentially requiring that health insurance be excess of MedPay), statutes (requiring that health insurance be excess of PIP after the first $2,000 in benefits), and case law (concluding that, depending on policy language, health insurance may be excess of MedPay though PIP has not been exhausted). See G. L. c. 90, § 34A; Metropolitan, supra at 395; Mejia, supra. Considering these sources, the bulletin advises insurers that, where a health insurer has denied benefits, the auto insurer's determination whether MedPay or PIP benefits are available turns on the health insurer's stated reasons for the denial.
The bulletin does not advise insurers regarding proper procedures where a claimant receives complete recovery from his or her health insurer and nevertheless seeks MedPay benefits for the same expenses. Indeed, the bulletin does not even consider the possibility that such a claim might be filed. Liberty Mutual
Liberty Mutual also makes a number of arguments that regulations promulgated by the division of insurance with regard to the coordination of benefits, 211 Code Mass. Regs. §§ 38.00 (1995), require the dismissal of Golchin's complaint. First, Liberty Mutual notes that the regulation precludes Blue Cross from establishing a plan that is "always secondary," see 211 Code Mass. Regs. § 38.06(2), and argues that the terms of the Blue Cross plan, therefore, must be examined to determine "which benefit, Blue Cross or MedPay, Golchin would be entitled to [receive]." Because Golchin refuses to produce the Blue Cross policy, Liberty Mutual argues that dismissal is necessary. Similarly, and in the alternative, Liberty Mutual cites a provision in the regulation stating that "a plan which pays for or provides more benefits than it should have ... may recover the excess from ... [other] insurance companies." 211 Code Mass. Regs. § 38.08. Liberty Mutual argues that, without reviewing the Blue Cross policy, it cannot determine whether Blue Cross has "provided more benefits than [it] should have"
Regarding the first two arguments, which rest on Golchin's failure to produce the Blue Cross policy, it is notable that Liberty Mutual fails to address the scope and applicability of the regulation, which provides:
211 Code Mass. Regs. § 38.02. There is no question but that MedPay coverage and health insurance are both "plans" within the meaning of the regulation. See 211 Code Mass. Regs. § 38.03. It is similarly clear that the standard Massachusetts auto policy contains no language that might be described as a "coordination of benefits provision." See 211 Code Mass. Regs. § 38.02; 211 Code Mass. Regs. § 38.03 (defining coordination of benefits as "a provision establishing the order in which plans pay their claims"). Pursuant to 211 Code Mass.
Liberty Mutual's third argument based on 211 Code Mass. Regs. §§ 38.00 is similarly unpersuasive. Liberty Mutual begins by noting that a "secondary plan" may "reduce its benefits so that the total benefits paid or provided by all plans . . . are not more than total allowable expense." 211 Code Mass. Regs. § 38.07. Liberty Mutual does not argue, however, that the standard auto policy is a "secondary plan" entitled to reduce its benefits pursuant to 211 Code Mass. Regs. § 38.07.
In Liberty Mutual's opinion, the language of the NAIC's model regulation "emphasize[s]" the existence of a "double payment prohibition." See II NAIC Model Laws, Regulations and Guidelines 120-1 (2005) (coordination of benefits model regulation). In support of this point, Liberty Mutual asserts that "[t]his prohibition [on double recovery] is established in the
Liberty Mutual may be correct regarding the model regulation. Liberty Mutual's brief fails to acknowledge, however, the fact that 211 Code Mass. Regs. §§ 38.00 is not a wholesale adoption of the NAIC model regulation and that, in promulgating the Massachusetts regulation, the commissioner made substantial changes to the NAIC's model. Compare 211 Code Mass. Regs. §§ 38.00 with II NAIC Model Laws, Regulations, and Guidelines 120-1 (coordination of benefits model regulation). Most crucial, neither of the passages quoted by Liberty Mutual appears in the regulations actually adopted in Massachusetts. Specifically, the purposes of the Massachusetts regulation do not include any reference to the reduction of duplicate benefits, see 211 Code Mass. Regs. § 38.02, and the definition of "[c]oordination of [b]enefits" contained at 211 Code Mass. Regs. § 38.03 omits the particular phrase of the model regulation on which Liberty Mutual's brief places emphasis.
We are thus left to consider that, in regulating the coordination of benefits in Massachusetts, the commissioner was presented with draft language supporting Liberty Mutual's position and decided to exclude it from the regulation actually promulgated. While the model regulation might contain a blanket prohibition on double recoveries (we express no view on the subject), the Massachusetts regulation does not. Comparison of the NAIC model regulations and 211 Code Mass. Regs. §§ 38.00 thus supports a conclusion that is precisely opposite to the one advocated by Liberty Mutual. We therefore hold that, although the Massachusetts coordination of benefits regulation does contain individual sections regarding double recoveries, see, e.g., 211 Code Mass. Regs. § 38.07, those sections are inapplicable here and do not constitute a general ban on duplicative recoveries.
4. Conclusion. Taken together, Golchin's complaint and the
So ordered.
Massachusetts, however, does not necessarily adopt this view of medical insurance. See Frost, supra at 430 ("we recognize the indemnity character of medical and hospital expense benefits"); 16 S. Williston, Contracts, supra at 53 ("many different types of insurance have been correctly described as contracts of indemnity, including ... that portion of an automobile policy that provides for the payment of medical expenses"). But see Allstate Ins. Co. v. Bearce, 412 Mass. 442, 448-449 (1992) (citing Frost case to distinguish MedPay coverage from property insurance). It is therefore possible (although consideration of the matter requires addressing a thicket of policy considerations and the impact of the medical lien statute, G. L. c. 111, § 70A) that indemnity principles precluding double recovery may apply to benefits sought under MedPay. See, e.g., Koppers Co. v. Aetna Cas. & Sur. Co., 98 F.3d 1440, 1452 (3d Cir.1996) ("We begin with the principle of indemnity, a fundamental principle of insurance law which prohibits insurance contracts from conferring a benefit greater than the insured's loss ..."); 15 G. Couch, Insurance, supra at § 217:1, at 217-5 to 217-6 ("as a general rule, the fact that the insured has double coverage does not mean that he or she is entitled to recover twice for the same loss"); 3 J.E. Thomas & F.J. Mootz, New Appleman on Insurance § 22.05, 22-35 to 22-40 (2010) (addressing offsets and credits of payments of other insurers, allocation amongst insurers, and prohibitions on double recovery).