Health Insurance
Do accident victims have the right to choose their own medical provider after an accident? Can the defendant demand that accident victims stay within their insurance network because it might cost more if they don’t? In May 2018, a California appellate court ruled that an injured person could not be forced to use their own insurance if they wanted to use a provider outside their plan. In short, the court ruled that the party who committed a civil wrong (caused an accident) cannot force accident victims (the plaintiffs) to choose a medical provider that would save the defendant money. The choice of a medical provider, the court ruled, was the plaintiffs.
Details of the Case
The accident occurred in May 2011, when the plaintiff – Dave Pebley – and his wife were returning home in their recreational vehicle on the 126 Freeway in Ventura. The RV had a flat, and the wife, who was driving, pulled over to the side of the road and activated the vehicle’s hazards. A Kenworth big rig driven by an employee of Santa Clara Organics, LLC, moving at 50 mph and hauling a 40,000-pound load, hit the left rear of the RV, breaking the passenger seat occupied by the plaintiff. Pebley was transported to a hospital with injuries to his face, lower back, and neck. He was treated and released.
Medical Provider Testimony
At first, Pebley was treated by providers within his health insurance plan, Kaiser Permanente. He filed a personal injury lawsuit against the driver and Santa Clara Organics, LLC. Pebley then sought care from an orthopedic specialist who was outside his insurance network. The doctor, Gerald Alexander, performed a fusion of three vertebrae in Pebley’s cervical spine at Olympia Medical Center. Later, the surgeon testified that Pebley would also require additional fusions of the cervical and lumbar spine. He also said that even with spinal fusion surgery the patient often has ongoing issues such as numbness, weakness, and pain.
Cost of Medical Expense Damages
The surgeon testified that his professional charges were usual and reasonable. Since the plaintiff relied on a medical lien to obtain the surgery, he was ultimately responsible for payment, which the doctor said he expected to receive. A medical lien is one where the service is provided and expected to be paid out of the proceeds of a lawsuit or if the lawsuit fails by the plaintiff.
The defendants provided an expert who testified that if the plaintiff’s choice of medical care options had remained within the insurance network, the cost for the medical expense damages would be less than half, excluding professional fees.
Motions in Limine
Prior to the initial trial, both sides filed several motions, called motions in limine, to restrict testimony about recoverable medical expense damages. The trial court evoked another case, Bermudez v. Ciolek. This case involved an uninsured bicyclist hurt in an intersection accident where the total lien amount was allowed if the injured party presented proof of cost and reasonableness. Pebley provided bills showing the amount paid and expert testimony affirming its reasonableness.
Trial Court Decision That Favors Accident Victims
The trial court verdict ruled that the defendants were negligent. It awarded Pebley $269,000 in past medical expenses and future medical costs of $375,000 along with $900,000 in noneconomic damages and $2.1 million in future noneconomic damages. The defendants, who requested a new trial, argued that Pebley should have recovered only the cost of medical expenses that his insurer would have paid. This request was denied, and the defendants filed an appeal.
The Appeal
The court of appeals needed to decide whether Pebley would be considered insured or uninsured according to prior case law. The defendants in the case said it was the responsibility of accident victims to choose medical care options that would mitigate the cost of the accident. Pebley had argued that the surgery was complex and could have disastrous side effects, including paralysis or death or a poor outcome. Choosing an experienced surgeon was essential. The appellate court agreed. The appellate court ruled that it indeed was the accident victim’s right to choose, and for the purposes of the case, he should be treated as uninsured.
Conclusions
In the case, Pebley v. Santa Clara Organics, LLC, the court affirmed the accident victim’s right to be treated by a health care specialist with the experience the situation required, and the defense could not force him to use his own insurance. Rather, the choice was that of the plaintiff. It agreed with the plaintiff’s argument that a health care organization is usually chosen prior to illness and that it might not be the best choice for a specific situation. In short, the plaintiff had the right to choose the best medical care option open to him, and the defendants did not have the right to dissuade him. Pebley, the appellate court ruled, would be considered uninsured and recover the full amount of the charges he owed.
Watch the following video where attorney Ed Smith explains how to choose a personal injury lawyer:
What an Injury Lawyer Can Do For You
After an injury, accident victims may feel they have limited options when seeking medical care. Pressure may be applied by both the insurance company and the legal representatives of the at-fault party. Having an injury attorney at your side to defend your rights and explain your options is invaluable in getting what you need.
Sacramento Personal Injury Lawyer
I’m Ed Smith, a Sacramento personal injury lawyer. Winning your case is dependent on the law. It is important to have an injury lawyer’s insight on legal matters. Call me at (916) 921-6400 or (800) 404-5400 for free and friendly advice. You can reach me online too, using my convenient contact form.
I’ve helped numerous Sacramento and Northern California residents obtain the compensation they deserve in all types of car accidents, traumatic brain injury and wrongful death among others.
I am a member of the Million Dollar Advocates. We are a nationwide forum composed of trial attorneys who have won more than $1 million for a client.
Before retaining a lawyer, it is prudent to learn about their practice. You can review comments by former clients and some of my peers as well as see how I resolved prior cases on the following pages:
Photo Attribution: https://pixabay.com/en/justice-statue-lady-justice-2060093/; https://www.youtube.com/watch?v=DLQ8I1W1gR8
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