Durant v. State Farm Mut. Auto. Ins. Co.

FIITE

IN CLERKS OSnCI

This opinion was filed for record

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SUSAN L. CARLSON

SUPREME COURT CLERK

IN THE SUPREME COURT OF THE STATE OF WASHINGTON

CERTIFICATION FROM THE UNITED

STATES DISTRICT COURT FOR THE No. 94771-6

WESTERN DISTRICT OF WASHINGTON

IN

BRETT DURANT,on behalf of himself and

all others similarly situated,

Plaintiff,

En Banc

STATE FARM MUTUAL AUTOMOBILE

INSURANCE COMPANY,a foreign

automobile insuranee company.

Defendant. Filed JUN 0 7 2018

J

MADSEN, J.—This case concerns a class action insurance claim suit pending in

federal court. The federal district court has asked this court to answer two certified

questions concerning whether an insurer's use of a "maximum medical improvement"

(MMI)provision violates WAC 284-30-395(1).

No. 94771-6

FACTS

This case began with an auto poliey claim by plaintiff Brett Durant. Durant has

been a polieyholder with State Farm Mutual Automobile Insurance Company since 1995

and carried $35,000 in personal injury protection (PIP) coverage. On July 21, 2012,

Durant was injured in a motor vehiele accident. He opened a PIP claim with State Farm.

State Farm then sent him a "coverage letter" that stated:

The policy provides coverage for reasonable and neeessary medical

expenses that are ineurred within three(3) years of the aecident. Medical

services must also be essential in achieving maximum medical improvement

for the injury you sustained in the accident.

Docket(Dkt.)#30(Decl. of Brett Durant) at 2 & Ex. C (emphasis added).'

Durant sought treatment with chiropractor Harold Rasmussen, DC, who diagnosed

injuries including sprains to the neck, back, pelvis, and right shoulder. After a shoulder

MRI(magnetic resonance imaging)showed a ligament sprain and "a possible small type

I SLAP [(superior labral anteroposterior)] tear," Durant was referred to an orthopedic

surgeon who diagnosed "mild bursitis/tendinitis," which was treated with physical

therapy and cortisone injections. Id. at 2.

Four months after the accident. State Farm sent Dr. Rasmussen a form letter with

blanks to fill in inquiring about Durant's progress. The letter was directed toward State

Farm's MMI standard, asking,"Has the patient reached maximum medical

improvement?" and "If the patient has not reached maximum medical improvement, what

'Citations are to the certified record as provided by the federal district court unless otherwise

noted. See RCW 2.60.010(4),.030(2).

No. 94771-6

is your target maximum medical improvement date?" Id. at 2 & Ex. D. Dr. Rasmussen

responded that Durant was not at MMI but his target date was "2-1-13." Id. at Ex. D.

Durant's injuries were not resolved by that date, and he continued to receive

chiropractic and massage therapy. State Farm then sent another.letter to Dr. Rasmussen,

which inquired,"You have treated Brett past his given MM[I] date of 2/1/2013. Please

explain." Dkt. #32(Deel. of Tyler Firkins), Ex. Q at 11 of 13. Dr. Rasmussen replied,

"Patient was not stable and needed treatment to 3/27/2013." Id.

Durant continued to have back, shoulder, and pelvic issues and continued to

receive care. His care providers billed his PIP claim as before, but State Farm denied

each bill on the basis that, "[sjervices are not covered, as your provider advised us you

previously reached maximum medical improvement." Dkt. #30, Ex. F.

Durant retained an attorney who wrote to State Farm asking them to pay the

outstanding medical bills. The attorney explained that State Farm must use the standard

authorized by WAC 284-30-395(1); that whether Durant had reached MMI was

irrelevant; and that unless State Farm had a competent medical opinion that Durant's

treatment was not reasonable, necessary, or related. State Farm must pay the bills.

The attorney provided State Farm a letter from Dr. Rasmussen explaining that

Durant's continuing injuries meant that he would require periodic care for his spinal and

pelvic dysfunction and that during periods of exacerbation, Durant should receive

treatment to restore movement and to reduce his pain. The State Farm claim

representative ignored Dr. Rasmussen's opinion and authored a letter that reiterated the

previous denial, noted that Durant had previously reached MMI,and stated that the

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Office of the Insurance Commissioner(QIC)"thoroughly reviews and approves policy

language proposed by insurance companies." Dkt. #30, Ex. H. Durant's attorney

responded by letter that Durant needed medical treatment from time to time due to

exacerbations in order to maintain his recovery and that this treatment should be

considered reasonable, necessary, and related under WAG 284-30-395(1). By that time,

Durant had unpaid medical bills of more than $1,000 that had been denied by State Farm,

but State Farm stood by its decision and continued to deny payment based on its MMI

standard.

Durant filed this action in King County Superior Court in 2015, alleging that State

Farm's use of the MMI standard violates its duty of good faith, breaches the insurance

contract, violates the Insurance Fair Conduct Act, RCW 48.30.0 lO-.015, and violates the

Consumer Protection Act, chapter 19.86 RCW. State Farm removed the case to federal

court. The United States District Court granted Durant's motion to certify a class of

plaintiffs. State Farm moved for reconsideration. In denying the motion for

reconsideration, the district court also granted Durant's motion to certify the following

two questions to this court:

1. Does an insurer violate WAC 284-30-395(l)(a) or(b)if that insurer denies,

limits, or terminates an insured's medical or hospital benefits claim based on a finding of

"maximum medical improvement?"

No. 94771-6

2. Is the term "maximum medical improvement" consistent with the definition of

"reasonable" or "necessary" as those terms appear in WAC 284-30-395(1)?^

ANALYSIS

First Certified Question: Does State Farm's limitation of medical claims based on

its MMI provision violate WAC 284-30-395(l)(a) or (b)?

Durant contends that the plain language of the regulation in question answers the

first certified question. We agree.

"Certified questions from federal court are questions of law that this court reviews

de novo." Brady v. Autozone Stores, Inc., 188 Wn.2d 576, 580, 397 P.3d 120(2017)

(citing Carlsen v. Glob. Client Sols., LLC, 171 Wn.2d 486, 493, 256 P.3d 321 (2011)).

"This court may reformulate the certified question." Id. {citing Allen v. Dameron, 187

Wn.2d 692, 701, 389 P.3d 487 (2017)). Further, the meaning of a statute is a question of

law that is reviewed de novo. State v. J.M., 144 Wn.2d 472, 480, 28 P.3d 720(2001).

This court's fundamental objective in determining what a statute means is to ascertain

and carry out the legislature's intent. Id. If the statute's meaning is plain on its face, then

courts must give effect to its plain meaning as an expression of what the legislature

intended. Id. A statute that is clear on its face is not subject to judicial construction. Id.

This court interprets regulations under the rules of statutory construction. Mader

V. Health Care Auth., 149 Wn.2d 458, 472, 70 P.3d 931 (2003). It construes the act as a

whole, giving effect to all of the language used. Id. If a regulation is unambiguous.

^ Order at 4(July 10, 2017)(granting certified question).

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No. 94771-6

intent can be determined from the language alone, and the court will not look beyond the

plain meaning of the words of the regulation. Id. at 473.

We begin with the plain language of the regulation. WAC 284-30-395(1) provides

in relevant part:

(1) Within a reasonable time after receipt of actual notice of an

insured's intent to file a personal injury protection medical and hospital

benefits claim, and in every case prior to denying, limiting, or terminating

an insured's medical and hospital benefits, an insurer shall provide an

insured with a written explanation ofthe coverage provided by the policy,

including a notice that the insurer may deny, limit, or terminate benefits if

the insurer determines that the medical and hospital services:

(a) Are not reasonable;

(b) Are not necessary;

(e) Are not related to the accident; or

(d) Are not incurred within three years of the automobile accident.

These are the only groundsfor denial, limitation, or termination of

medical and hospital services permitted pursuant to RCW 48.22.005(7),

48.22.095, or 48.22.100.

(Emphasis added.) The final sentence of this regulation is unambiguous: an insurer may

deny PIP benefits "only" for the reasons listed; no other reasons are permitted.

State Farm argues that its MMI language is merely definitional, explaining the

"necessary" provision contained in the regulation. That is unconvincing. First, State

Farm's policy language and its coverage letter present the MMI provision as an

additional criterion that must be met for medical payments. The auto policy provides in

relevant part as follows:

PersonalInjury Protection Benefits mean accident related:

I. Medical and Hospital Benefits, which are payments for reasonable

medical expenses incurred within three years ofthe date of the accident.

No. 94771-6

Reasonable Medical Expenses mean expenses:

2. incurred for necessary:

a. medical, surgical, X-ray, dental, ambulance, hospital, and

professional nursing services, and

b. pharmaceuticals, eyeglasses, hearing aids, and prosthetic devices

that are rendered by or prescribed by a licensed medical provider within the

legally authorized scope of the provider's practice and are essential in

achieving maximum medical improvementfor the bodily injury sustained in

the accident.

Dkt #32, Ex. N at 7 of 24(some emphasis added).

As presented,""Reasonable MedicalExpenses^' are defined as fees "incurred for

necessary" medical services that are rendered by a medical provider "and are essential in

achieving maximum medical improvement for the bodily injury sustained in the

accident." Id.(some emphasis added). Because the MMI provision is stated

conjunctively, it is not a definition of"necessary" but is instead a separate and additional

prerequisite under the policy for payment of medical expenses. Moreover, the policy's

introductory provisions explain that "[djefined words and phrases [contained in the

policy] are printed in boldface italics." Id. at 4 of 24. In the "reasonable medical

expenses" quoted passage,"necessary" is not so designated. Thus, the plain language of

the auto insurance policy does not support State Farm's assertion that its MMI provision

defines the term "necessary."

Further, the coverage letter that Durant received states, in relevant part, as follows:

No. 94771-6

MEDICAL AND HOSPITAL BENEFITS

The policy provides coveragefor reasonable and necessary medical

expenses that are incurred within three (3) years ofthe accident. Medical

services must also be essential in achieving maximum medical improvement

for the injury you sustained in the accident. To assist us in determining

what expenses are reasonable and necessary, we may obtain a second

opinion from a medical provider. We may also have the treatment

reviewed by other medical professionals.

Occasionally there are situations where treatment may not be considered

reasonable, necessary, or related to the accident. Similarly, there may be

cases where the services are not essential in achieving maximum medical

improvementfor the injury sustained in the accident. In such cases, YOUR

PIP COVERAGE MAY NOT PAY FOR ALL OF YOUR EXPENSES.

Dkt. #30, Ex. C.(emphasis added).

As can be seen, the first sentence in the first paragraph identifies three criteria for

receiving medical payments: the medical services must be reasonable, necessary, and

within three years ofthe accident. The second sentence adds a fourth criterion: the

medical services ''must also be essential in achieving maximum medical improvement for

the injury you sustained in the accident." Id.(emphasis added). As presented, the fourth

criterion is an additional requirement and does not refer back to or define any of the

earlier listed criteria.

The second paragraph in the above quoted coverage letter warns that where the

listed criteria are not met, the insured's PIP coverage may not pay for the expenses.

Again, the four criteria are separately noted, indicating their separate status as a basis for

denying coverage. Neither the policy language nor the coverage letter indicates that the

MMI provision is a definition of"necessary" as State Farm contends.

No. 94771-6

In addition, as Durant's circumstance demonstrates, State Farm is using the MMI

standard contained in its auto policy as the primary criterion for limiting the

responsibility it would otherwise have to pay medical claims under the regulation; and it

is doing so by applying a criterion not listed in the regulation. As noted, the regulation's

plain language does not permit such additions. "No insurance contract can contain an

inconsistent or contradictory term to any mandated, standard provision unless it is more

favorable to the insured." Kroeber v. GEICO Ins. Co., 184 Wn.2d 925, 929-30, 366 P.3d

1237(2016)(citing RCW 48.18.130(2)); 5'ee also Liberty Mut. Ins. Co. v. Tripp, 144

Wn.2d 1, 12, 25 P.3d 997(2001)(insurers cannot diminish statutorily mandated coverage

through language in the insurance policy); Britton v. Safeco Ins. Co. ofAm., 104 Wn.2d

518, 531, 707 P.2d 125 (1985)(where legislature has mandated a certain amount and

kind of coverage, insurer cannot avoid that obligation by a policy clause which has not

been authorized by the legislature); Kyrkos v. State Farm Mut. Auto. Ins. Co., 121 Wn.2d

669, 672, 852 P.2d 1078(1993)(exclusions that deny statutory mandated coverage are

void).

Also, since the regulation's terms "reasonable" and "necessary" are not defined,

we use their ordinary (dictionary) meaning. See Boeing Co. v. Aetna Cas. & Sur. Co.,

113 Wn.2d 869, 877, 784 P.2d 507(1990)(undefined terms in insurance contracts

"must" be given their plain, ordinary, and popular meaning, and courts may look to

No. 94771-6

standard English language dictionaries to determine common meaning).^ State Farm's

MMI standard is clearly more restrictive than what would ordinarily be considered

reasonable and necessary medical care. As Durant's case demonstrates, treatment

prescribed by his provider to address his ongoing pain resulting from the car accident

would be permissible under the plain language of the regulation, which permits such

reasonable and necessary treatment. Only State Farm's employment of the more

restrictive MMI standard disallows such treatments and does so in violation ofthe

regulation.''

Finally, State Farm throughout its response brief relies on the assertion that its

auto policy containing the MMI provision has been repeatedly approved by the OIC,^

^ The common meaning of"reasonable" is "not eonflieting with reason : not absurd : not

ridiculous . . . being or remaining within the bounds of reason:not extreme : not excessive."

Webster's Third New International Dictionary 1892(2002).

The common meaning of"necessary" is "of, relating to, or having the character of

something that is logically required or logically inevitable or that cannot be denied without

involving contradiction." Id. at 1510.

While not directly applicable to the present auto insurance policy context, WAC 182-500-0070,

which applies in the medical assistance context, demonstrates that a reasonable view of what

constitutes medically necessary care is far broader than State Farm's restrictive MMI standard.

The noted WAC defines the term "medically necessary" in the medical assistance context as

a term for describing requested service which is reasonably calculated to prevent,

diagnose, correct, cure, alleviate or prevent worsening ofconditions in the client

that endanger life, or cause suffering or pain, or result in an illness or infirmity,

or threaten to cause or aggravate a handicap, or cause physical deformity or

malfunction. There is no other equally effective, more conservative or

substantially less costly course oftreatment available or suitable for the client

requesting the service.

WAC 182-500-0070 (emphasis added).

^ Any past approval by the OIC of State Farm's policy form is not dispositive on the issue of

State Farm's compliance with WAC 284-30-395 in any event. RCW 48.18.510 provides that

"[a]ny insurance policy . . . hereafter issued and otherwise valid, which contains any condition or

provision not in compliance with the requirements of this code, shall not be rendered invalid

thereby, but shall be construed and applied in accordance with such conditions and provisions as

would have applied had such policy ... been in full compliance with this code."

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No. 94771-6

urging that the court should defer to the QIC's expertise on the issue. This court indeed

gives substantial weight to an administrative agency's interpretations in its area of

expertise, see Port ofSeattle v. Pollution Control Hr'gs Bd, 151 Wn.2d 568, 595,90

P.3d 659(2004)(due deference must be given to the specialized knowledge and expertise

of an administrative agency), but the view expressed by the QIC is at odds with State

Farm's assertions.

The QIC has filed an amicus brief forcefully stating that it has told carriers,

including State Farm, that provisions adding criteria to PIP benefit payments violate

WAG 284-30-395(1). The QIC amicus brief states,"The plain language of WAG 284-

30-395 clearly prohibits the use of'maximum medical improvement' as an additional

grounds for the denial, limitation, or termination ofPIP benefits aside from those listed in

WAG 284-30-395(1)." Amicus Guriae Br.(GIG Br.) at 9. Relying on the language of

the underlying statute, RGW 48.22.005(7), which provides that "'[mjedical and hospital

benefits' means payments for all reasonable and necessary expenses incurred by or on

behalf of the insured for injuries sustained as a result of an automobile accident," the GIG

explains,"Nowhere does the statute exclude palliative care, or care to maintain a stable

condition, rather than to improve a person's condition. Rather, the Legislature chose the

phrase 'all reasonable and necessary' as the parameters for determining care that must be

covered." GIG Br. at 10. Accordingly,

A carrier cannot enforce a policy that denies medical and hospital services

that are reasonable, necessary, related to the accident, and incurred within

three years of the accident, but that do not achieve 'maximum medical

improvement.[']

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No. 94771-6

This interpretation of WAC 284-30-395 has been clearly

communicated by the Commissioner, through his staff, to American Family

Insurance in 2010, and again to State Farm in 2015, when taking exception

to the language in their policies. In both instances, the Commissioner has

directed carriers with non-compliant policy forms to submit new policy

forms, with language that reflects the limited grounds available for the

denial, limitation, or termination of medical and hospital benefits found in

WAC 284-30-395(1). At no point has the Commissioner, or his staff,

communicated a contrary interpretation of WAC 284-30-395(1). Based on

the plain language of WAC 284-30-395(1), no carrier can use additional

requirements, including "maximum medical improvement" as a basis for

denying, limiting, or terminating medical and hospital coverage under PIP.

M at 11-12(emphasis added). The OIC amicus brief concluded that the answer to the

first certified question is yes. Mat 12. For the reasons discussed above, we agree.

Second Certified Question: Is the term "maximum medical improvement"

consistent with the definition of"reasonable" or "necessary" as those terms appear in

WAC 284-30-395(1)?

We answer this certified question no. Washington statutes mandate that insurers

writing automobile insurance offer PIP coverage, which includes coverage for payment

of"all reasonable and necessary expenses incurred ... for injuries sustained as a result of

an automobile accident." RCW 48.22.005(7)(emphasis added); see also RCW 48.22.085

(requiring PIP coverage be offered),.095 (setting required minimum PIP coverage

amounts),.100 (setting PIP benefit limits). The statutory requirement to offer PIP

coverage implicates public policy. See Sherry v. Fin. Indem. Co., 160 Wn.2d 611,620-

21, 160 P.3d 31 (2007). As discussed above, WAC 284-30-395(1) provides that the only

permissible bases for denying PIP medical expense payments are if treatment is not

reasonable, not necessary, not related to the accident, or not incurred within three years of

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No. 94771-6

the accident. This regulation and the noted statutes reflect Washington's strong public

policy in favor of the full compensation of medical benefits for victims of road accidents.

By contrast, State Farm's policy language limits payment ofPIP medical benefits

to services "essential in achieving maximum medical improvement." Dkt. #32, Ex. N at

7 of 24. This limitation denies Durant his PIP medical benefits necessary to return him to

his pre-injury state. Excluding payment for palliative care from the reasonable and

necessary medical expenses that are required to be paid under PIP coverage violates the

public policy reflected in the statutory and regulatory scheme underlying PIP coverage,

which is to fully compensate insureds for their actual damages from automobile

accidents. See Sherry, 160 Wn.2d at 620-21 ("Washington State has long favored full

compensation for those injured in automobile accidents."). State Farm's MMI provision

is not consistent with the terms "reasonable" and "necessary" as those terms are used in

RCW 284-30-395(1).

Defendant State Farm does not convincingly argue otherwise. It analogizes its

MMI provision to the industrial insurance context and to maritime law, which are both

distinguishable. State Farm cites a WAC regulation promulgated under Title 51 RCW,

the Industrial Insurance Act(IIA), defining "proper and necessary" health care services,

that states,"Once a worker's condition has reached maximum medical improvement,

treatment that results only in temporary or transient changes is not proper and necessary."

WAC 296-20-01002 "Proper and necessary" subsection (3). State Farm suggests that this

regulatory limitation of payment for health care services by the Department of Labor and

Industries supports its argument that medical services, after an insured reaches maximum

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No. 94771-6

medical improvement, are not "necessary" services under its PIP policy or WAC 284-30-

395(1). Def.'s Resp. Br. at 33-34. This is not an appropriate comparison, as the purposes

in regulating medical services provided to injured workers under Title 51 RCW and in

regulating medical services an insurer is required to pay in PIP coverage under Title 48

RCW are distinct.

Washington's public system of workers' compensation is not the equivalent of

insurance. See Wash. Ins. Guar. Ass'n v. Dep't ofLabor & Indus., 122 Wn.2d 527, 532-

33, 859 P.2d 592(1993). The IIA was the product of a "grand compromise" in 1911, in

which injured workers were ensured a swift, no-fault compensation system for injuries on

the job and employers received immunity from civil suits by workers. Birklid v. Boeing

Co., 127 Wn.2d 853, 859, 904 P.2d 278 (1995). As a result,"employees may receive less

than full tort damages in exchange for the expense and uncertainty of litigation." Minton

V. Ralston Purina Co., 146 Wn.2d 385, 390,47 P.3d 556 (2002).

MMI in Title 51 RCW is related to the concept of fixed impairment, which plays a

key role in the compromise reflected in the IIA. "Maximum medical improvement may

be present though there may be fluctuations in levels of pain and function. . . .

'Maximum medical improvement' is equivalent to 'fixed and stable.'" WAC 296-20-

01002("proper and necessary" subsection (3)). An injured worker is entitled to receive

"proper and necessary" medical services, but once "maximum medical improvement" has

been reached, the Department of Labor and Industries may consider the worker's

condition "fixed and stable" and close the claim, at which point the worker may be

eligible for an award of permanent disability, among other benefits. See Boyd v. City of

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No. 94771-6

Olympia, 1 Wn. App. 2d 17, 27-28, 403 P.3d 956(2017), review denied, 190 Wn.2d 1004

(2018).

MMl functions in two complementary ways in the workers' compensation system.

First, it establishes that an injured worker has a "fixed and stable" impairment, thereby

triggering disability benefits. See id. at 28; see also WAC 296-20-200(4). The disability

benefits awarded constitute compensation for the value ofthe injured worker's permanent

loss of function. See WAC 296-20-19000; see also Tomlinson v. Puget Sound Freight

Lines, Inc., 166 Wn.2d 105, 111, 206 P.3d 657 (2009). Second, establishingMMI

terminates the responsibility of the self-insured employer or department to provide

ongoing medical expenses. See Shafer v. Dep't ofLabor & Indus., 166 Wn.2d 710, 716-

17, 213 P.3d 591 (2009)(closure of claim proper when injured worker's condition has

become fixed and stable).

By establishing an impairment as fixed and stable, a finding of maximum medical

improvement serves a critical role in determining the relative rights and remedies

available under the IIA, facilitating the "compromise" reflected in that unique statutory

scheme.

The restrictive limitation on the definition of"proper and necessary" medical care

set forth in the IIA regulation(WAC 296-20-01002) is not present in the statutes or

regulation governing PIP coverage here. WAC 284-30-395(1) provides that an insurer

may deny, limit, or terminate benefits if it determines medical services are not reasonable

or necessary, without limiting the meaning of reasonable or necessary to services

"essential in achieving maximum medical improvement." Dkt. #32, Ex. N at 7 of 24.

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No. 94771-6

The failure to narrow "reasonable" or "necessary" services underscores that the QIC's

regulation did not adopt the IIA's restrictive definition of"proper and reasonable"

medical services.

Further, maximum medical improvement in workers' compensation under state

law is closely related to the concept of"cure" in the "maintenance and cure" doctrine

applicable to injured seamen under federal maritime law. See Miller v. Arctic Alaska

Fisheries Corp., 133 Wn.2d 250,268, 944 P.2d 1005(1997)(recognizing that

"[mjaintenance and cure is the maritime analog to land-based industrial insurance paying

an injured seaman's medical expenses (cure) and compensation in lieu of wages

(mamtenance)for injuries incurred in service of a ship"); see also Dean v. Fishing Co. of

Alaska, 111 Wn.2d 399,406, 300 P.3d 815 (2013)(noting that a shipowner's duty to pay

maintenance and cure continues until the seaman reaches the point of maximum medical

recovery). State Farm agrees that the "maximum medical cure" standard hi maritime law

is the equivalent of"MMI," and states that "[ujnder the 'maximum medical cure'

standard, a ship owner's obligation to pay an injured seaman's medical bills ends when

he or she has reached a point where 'future treatment will merely relieve pain and

suffering but not otherwise improve the seaman'sphysical condition."'' Def.'s Resp. Br.

at 34-35 (quoting Lee v. Metson Marine Servs., Inc., 2012 WL 5381803, at *2(D. Haw.

Oct. 31,2012)(court order)(emphasis added)). But State Farm points to nothing in

Washington's PIP statutes and regulations, or the underlying public policy, that suggests

that requhed payment for medical services will not include treatment that "'will merely

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No. 94771-6

relieve pain and suffering but not otherwise improve [a patient's] physieal condition.'"

Id. at 35 (quoting Lee, 2012 WL 5381803, at *2).

In sum, State Farm's analogizing to workers' compensation and maritime law is

unconvincing. For the reasons discussed above. State Farm's use of the term "MMI" is

not consistent with the common meaning of"reasonable" and "necessary" as those terms

appear in WAC 284-30-395(1), and we answer the second certified question no.®

CONCLUSION

We answer the first certified question yes. An insurer violates WAC 284-30-

395(l)(a) or(b)if that insurer denies, limits, or terminates an insured's medical or

hospital benefits claim based on a finding of"MMI."

We answer the second certified question as follows: under the

circumstances of this ease, the term "MMI" is not consistent with the terms

"reasonable" or "necessary" as those terms appear in WAC 284-30-395(1).

® Regarding the second certified question, the QIC amicus brief offers a "qualified yes," noting

that the terms "reasonable" and "necessary" are not defined in the regulation, and thus "a carrier

could potentially use a term such as 'maximimi medical improvement' when defining what

'reasonable' and 'necessary' mean under its particular contracts. However, such definitions

cannot add another requirement to the coverage ofmedical and hospital services that does not

already exist in statute or WAC." OIC Br. at 14, 12-13. The OIC does not clearly articulate

what language or conditions might meet these requirements. In any event, "[tjhis court will

consider certified questions from the federal court 'not in the abstract but based on the certified

record provided by the federal court.'" Brady, 188 Wn.2d at 579 n.l (quoting Carlsen, 171

Wn.2d at 493). Here, the record shows that State Farm uses the MMI provision as a primary

criterion for limiting PIP benefits. So used, the MMI provision violates WAC 284-30-395(1).

On that basis, the answer to the second certified question is no.

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No. 94771-6

WE CONCUR:

18