REPORT TITLE:



DESCRIPTION:


 
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HOUSE OF REPRESENTATIVES                H.B. NO.           
TWENTIETH LEGISLATURE, 2000                                
STATE OF HAWAII                                            
                                                             
________________________________________________________________
________________________________________________________________


                   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.
 
 5      [For purposes of this section, the term "personal injury
 
 6 protection insurer" includes personal injury protection self-
 
 7 insurers.  Every personal injury protection insurer shall provide
 
 8 personal injury protection benefits for accidental harm as
 
 9 follows:
 
10      (1)  Except as otherwise provided in section 431:10C-305(d),
 
11           in the case of injury arising out of a motor vehicle
 
12           accident, the insurer shall pay, without regard to
 
13           fault, to the provider of services on behalf of the
 
14           following persons who sustain accidental harm as a
 
15           result of the operation, maintenance, or use of the
 
16           vehicle, an amount equal to the personal injury
 
17           protection benefits as defined in section 431:10C-
 
18           103.5(a) payable for expenses to that person as a
 
19           result of the injury:
 

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

 
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 1                in whole or in part, the insurer shall within
 
 2                thirty days, notify the claimant in writing of the
 
 3                denial and the reasons for the denial.  The denial
 
 4                notice shall be prepared and mailed by the insurer
 
 5                in triplicate copies and be in a format approved
 
 6                by the commissioner.  In the case of benefits for
 
 7                services specified in section 431:10C-103.5(a) the
 
 8                insurer shall also mail a copy of the denial to
 
 9                the provider; and
 
10           (C)  If the insurer cannot pay or deny the claim for
 
11                benefits because additional information or loss
 
12                documentation is needed, the insurer shall, within
 
13                the thirty days, forward to the claimant an
 
14                itemized list of all the required documents. In
 
15                the case of benefits for services specified in
 
16                section 431:10C-103.5(a) the insurer shall also
 
17                forward the list to the service provider;
 
18      (4)  Amounts of benefits which are unpaid thirty days after
 
19           the insurer has received reasonable proof of the fact
 
20           and the amount of benefits accrued, and demand for
 
21           payment thereof, after the expiration of the thirty
 
22           days, shall bear interest at the rate of one and one-
 
23           half per cent per month;
 

 
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 1      (5)  No part of personal injury protection benefits paid
 
 2           shall be applied in any manner as attorney's fees in
 
 3           the case of injury or death for which the benefits are
 
 4           paid.  The insurer shall pay, subject to section
 
 5           431:10C-211, in addition to the personal injury
 
 6           protection benefits due, all attorney's fees and costs
 
 7           of settlement or suit necessary to effect the payment
 
 8           of any or all personal injury protection benefits found
 
 9           due under the contract.  Any contract in violation of
 
10           this provision shall be illegal and unenforceable.  It
 
11           shall constitute an unlawful and unethical act for any
 
12           attorney to solicit, enter into, or knowingly accept
 
13           benefits under any contract; and
 
14      (6)  Any insurer who violates this section shall be subject
 
15           to section 431:10C-117(b) and (c).]
 
16      (a)  Except as otherwise provided in section 431:10C-305(d),
 
17 the personal injury protection insurer shall pay, without regard
 
18 to fault, to the provider of services on behalf of the following
 
19 persons who sustain accidental harm as a result of the operation,
 
20 maintenance, or use of the vehicle, an amount equal to the
 
21 personal injury protection benefits as defined in section
 
22 431:10C-103.5(a) payable for expenses to that person as a result
 
23 of injury arising out of a motor vehicle accident:
 

 
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 1      (1)  Any person, including the owner, operator, occupant, or
 
 2           user of the insured motor vehicle;
 
 3      (2)  Any pedestrian (including a bicyclist); or
 
 4      (3)  Any user or operator of a moped as defined in section
 
 5           249-1;
 
 6 provided that this paragraph shall not apply in the case of
 
 7 injury to or death of any operator or passenger of a motorcycle
 
 8 or motor scooter as defined in section 286-2 arising out of a
 
 9 motor vehicle accident, unless expressly provided for in the
 
10 motor vehicle policy.  For purposes of this section, the term
 
11 "personal injury protection insurer" includes personal injury
 
12 protection self-insurers.
 
13      (b)  Payment of personal injury protection benefits shall be
 
14 made as the benefits accrue, except that in the case of death,
 
15 payment of benefits under section 431:10C-302(a)(5) may be made
 
16 immediately in a lump sum payment, at the option of the
 
17 beneficiary.
 
18      (c)  Within thirty days, an insurer shall either:
 
19      (1)  Provide payment of personal injury protection benefits
 
20           after the insurer has received reasonable proof of the
 
21           fact and amount of benefits accrued, and demand for
 
22           payment thereof.  All providers shall produce
 
23           descriptions of the service provided in conformity with
 

 
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 1           the workers' compensation supplemental medical fee
 
 2           schedule;
 
 3      (2)  Elect to deny a claim for benefits in whole or in part
 
 4           by notifying the claimant in writing of the denial and
 
 5           the reasons for the denial, unless there is a dispute
 
 6           between the provider and the insurer over the amount of
 
 7           a charge or the correct fee and procedure code to be
 
 8           used under the workers' compensation supplemental
 
 9           medical fee schedule.  The denial notice shall be
 
10           prepared and mailed by the insurer in triplicate copies
 
11           and be in a format approved by the commissioner.  In
 
12           the case of benefits for services specified in section
 
13           431:10C-103.5(a), the insurer shall also mail a copy of
 
14           the denial to the provider; or
 
15      (3)  Request additional information or loss documentation
 
16           because the insurer is unable, without the additional
 
17           information, to pay or deny the claim for benefits.
 
18           The insurer shall forward to the claimant an itemized
 
19           list of all the required documents.  In the case of
 
20           benefits for services specified in section 431:10C-
 
21           103.5(a), the insurer shall also forward the list to
 
22           the provider.
 
23      (d)  Disputes between the provider and the insurer over the
 

 
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 1 amount of a charge or the correct fee or procedure code to be
 
 2 used under the workers' compensation supplemental medical fee
 
 3 schedule shall be governed by section 431:10C-308.5.
 
 4      (e)  Amounts of benefits which are unpaid thirty days after
 
 5 the insurer has received reasonable proof of the fact and the
 
 6 amount of benefits accrued, and demand for payment thereof, after
 
 7 the expiration of the thirty days, shall bear interest at the
 
 8 rate of one and one-half per cent per month.
 
 9      (f)  No part of personal injury protection benefits paid
 
10 shall be applied in any manner as attorney's fees in the case of
 
11 injury or death for which the benefits are paid.  The insurer
 
12 shall pay, subject to section 431:10C-211, in addition to the
 
13 personal injury protection benefits due, all attorney's fees and
 
14 costs of settlement or suit necessary to effect the payment of
 
15 any or all personal injury protection benefits found due under
 
16 the contract.  Any contract in violation of this provision shall
 
17 be illegal and unenforceable.  It shall constitute an unlawful
 
18 and unethical act for any attorney to solicit, enter into, or
 
19 knowingly accept benefits under any contract.
 
20      (g)  Any insurer who violates this section shall be subject
 
21 to section 431:10C-117(b) and (c)."
 
22      SECTION 2.  Section 431:10C-308.5, Hawaii Revised Statutes,
 
23 is amended to read as follows:
 

 
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 1      "431:10C-308.5  Limitation on charges.  (a)  As used in
 
 2 this article, the term "workers' compensation [schedules"]
 
 3 supplemental medical fee schedule" means the [schedules] schedule
 
 4 adopted and as may be amended by the director of labor and
 
 5 industrial relations for workers' compensation cases under
 
 6 chapter 386, establishing fees and frequency of treatment
 
 7 guidelines[, and contained in sections 12-13-30, 12-13-35, 12-13-
 
 8 38, 12-13-39, 12-13-45, 12-13-85 through 92, and 12-13-94, Hawaii
 
 9 administrative rules].  References in the workers' compensation
 
10 [schedules] supplemental medical fee schedule to "the employer",
 
11 "the director", and "the industrial injury", shall be
 
12 respectively construed as references to "the insurer", "the
 
13 commissioner", and "the injury covered by personal injury
 
14 protection benefits" for purposes of this article.
 
15      (b)  The charges and frequency of treatment for services
 
16 specified in section 431:10C-103.5(a), except for emergency
 
17 services provided within seventy-two hours following a motor
 
18 vehicle accident resulting in injury, shall not exceed the
 
19 charges and frequency of treatment permissible under the workers'
 
20 compensation [schedules.] supplemental medical fee schedule.
 
21 Charges for independent medical examinations, including record
 
22 reviews, physical examinations, history taking, and reports, to
 
23 be conducted by a licensed Hawaii provider unless the insured
 

 
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 1 consents to an out-of-state provider, shall not exceed the
 
 2 charges [permissible under the workers' compensation schedules
 
 3 for consultation for a complex medical problem.] for a maximum of
 
 4 one hour and thirty minutes based on the appropriate codes in the
 
 5 workers' compensation supplemental medical fee schedule for
 
 6 complex consultation pursuant to section 386-79.  The workers'
 
 7 compensation [schedules] supplemental medical fee schedule shall
 
 8 not apply to independent medical examinations conducted by out-
 
 9 of-state providers[; provided that] if the charges for the
 
10 examination are reasonable.  All records relating to an
 
11 independent medical examination shall be made available to the
 
12 claimant upon request.  The commissioner may adopt administrative
 
13 rules relating to fees or frequency of treatment for injuries
 
14 covered by personal injury protection benefits.  If adopted,
 
15 these administrative rules shall prevail to the extent that they
 
16 are inconsistent with the workers' compensation [schedules.]
 
17 supplemental medical fee schedule.
 
18      (c)  Charges for services for which no fee is set by the
 
19 workers' compensation [schedules] supplemental medical fee
 
20 schedule or other administrative rules adopted by the
 
21 commissioner shall be limited to eighty per cent of the
 
22 provider's usual and customary charges for these services.
 
23      (d)  Services for which no frequency of treatment guidelines
 

 
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 1 are set forth in the workers' compensation [schedules]
 
 2 supplemental medical fee schedule or other administrative rules
 
 3 adopted by the commissioner shall be deemed appropriate and
 
 4 reasonable expenses necessarily incurred if so determined by a
 
 5 provider.
 
 6      (e)  In the event of a dispute between the provider and the
 
 7 insurer over the amount of a charge or the correct fee or
 
 8 procedure code to be used under the workers' compensation
 
 9 supplemental medical fee schedule, the insurer shall:
 
10      (1)  Pay all undisputed charges within thirty days after the
 
11           insurer has received reasonable proof of the fact and
 
12           amount of benefits accrued and demand for payment
 
13           thereof; and
 
14      (2)  Negotiate in good faith with the provider on the
 
15           disputed charges for a period up to sixty days after
 
16           the insurer has received reasonable proof of the fact
 
17           and amount of benefits accrued and demand for payment
 
18           thereof.
 
19 If the provider and the insurer are unable to resolve the
 
20 dispute, either party may submit a request to the commissioner
 
21 for a hearing.  The request shall be filed within one hundred
 
22 twenty days after the insurer has received reasonable proof the
 
23 fact and amount of benefits accrued and demand for payment
 

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

 
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