NOTICE Decision filed 08/17/04. The text of this decision may be changed or corrected prior to the filing of a Petition for Rehearing or the disposition of the same. |
NO. 5-03-0579
APPELLATE COURT OF ILLINOIS
OLA AUSTIN, Plaintiff-Appellee, v. ILLINOIS FARMERS INSURANCE Defendant-Appellant. | ) ) ) ) ) ) ) ) ) ) | Appeal from the Circuit Court of Madison County. No. 02-L-1194 |
This appeal stems from the trial court's August 21, 2003, order denying thedefendant's motion to compel arbitration and to stay the plaintiff's claims. The arbitrationprovision at issue provides as follows:
"If an insured person and we do not agree[] (1) that the person is entitled torecover for medical services, (2) that the medical services are a result of a coveredaccident, or (3) as to the nature, frequency, or cost of the medical services, either thatperson or we may demand that the issue be determined by arbitration.
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The arbitrator shall determine (1) if the medical services are as a result of acovered accident, (2) if the medical services incurred are reasonable expenses andnecessary medical services, and (3) the amount of any payment under this part asdetermined by this policy."
The trial court, ruling from the bench, essentially concluded that the arbitration clause atissue was unenforceable because the claims raised by the plaintiff were different from thosereferenced in the arbitration clause. The court also found that arbitration would be cost-prohibitive. The defendant's appeal is before this court pursuant to Supreme Court Rule307(a)(1) (188 Ill. 2d R. 307(a)(1)), because the motion that was denied sought injunctiverelief.
On December 23, 1996, Ola Austin (the plaintiff) was in a motor vehicle accident inwhich she sustained bodily injuries. At the time of the accident, the plaintiff was insuredunder an automobile policy issued by defendant Illinois Farmers Insurance Company(Farmers). The standard policy contained a medical-payments-coverage section. She soughtand received chiropractic treatment, beginning on January 13, 1997. For some reason, herchiropractic physician did not include an initial examination and diagnosis in the plaintiff'srecords. The first mention of the plaintiff's condition did not occur until March 17, 1997,at which time he diagnosed her with a mild cervical sprain/strain. The plaintiff was seen byher chiropractor a total of 61 times over the course of 71 weeks. She turned the associatedmedical bills in to Farmers for payment pursuant to the medical-payments coverage.
The medical-payments-coverage section of the policy stated that Farmers would pay"reasonable" expenses for "necessary" medical services furnished within two years from thedate of an accident "arising from" the use of the insured automobile that resulted in "bodilyinjury." "Necessary medical services" are defined as "medical services which are usual andcustomary for treatment of the injury, including the number or duration of treatments, in thecounty in which those services are provided," and which are "necessary for the treatment ofthe injury." The policy defines "reasonable expenses" as those that are "usual and customaryfor necessary medical services in the county in which those services are provided."
Additionally, the policy provides that Farmers has the authority to submit claims formedical expenses to outside evaluation services:
"At our expense, we may employ or enter into contract with an independentmedical consultant(s) to assist us in determining whether all or any portion of anyclaim is for reasonable expenses or necessary medical services. We may submit tosuch consultant any medical records, reports, bills, statements, results of tests andexaminations, and any other documentation or material we deem appropriate."
Pursuant to that provision, Farmers submitted the plaintiff's medical file to TerranceFlanagan, D.C. Dr. Flanagan found problems with the documentation of the plaintiff'sdiagnosis and care. Specifically, Dr. Flanagan noted that given the diagnosis, the plaintiff'scourse of care should only have endured for about one month and would not have requiredtreatment as frequent as that the plaintiff received. Dr. Flanagan also found fault withongoing documentation in the plaintiff's progress record. He concluded that the plaintiff'sinjury should have been resolved on or about March 10, 1997, and that ongoing care wasmore like maintenance in nature. Maintenance type of care would not "be consideredessential to treatment of the injuries" the plaintiff had received. Dr. Flanagan recommendedthat Farmers deny the charges for the plaintiff's care after March 10, 1997.
Dr. Flanagan did not examine the plaintiff and based his opinions solely upon therecords review he was hired to perform.
As a result of Dr. Flanagan's recommendations, Farmers declined to reimburse theplaintiff for any expenses for treatment after March 10, 1997.
Nearly three years later, the plaintiff filed suit against Farmers on behalf of herselfand a putative class of insureds. Counts I and II were for breach of contract and alleged thatFarmers failed to pay all the plaintiff's "reasonable and necessary" medical expenses. Theplaintiff alleges that Farmers hired a biased medical reviewer and that, as a direct result ofthis biased review, not all the plaintiff's medical bills had been properly reimbursed. CountIII of her complaint alleged a violation of the Consumer Fraud and Deceptive BusinessPractices Act (815 ILCS 505/1 et seq. (West 2000)). She claimed compensatory damagesof $2,852, representing the amount of medical expenses that Farmers refused to pay.
In response to the complaint, Farmers gave the plaintiff written notice of its intent toinvoke the binding arbitration clause contained within its insurance policy. Farmers filed amotion to compel arbitration. In addition to the arbitration clause, Farmers' policy alsoindicated that no legal action could be taken against it "unless there is full compliance withall the terms of this policy."
Thereafter, the plaintiff amended her complaint, alleging that the arbitration provisionwas unenforceable because it was a part of an alleged fraudulent scheme and because it couldbe used to prevent the plaintiff from effectively vindicating her statutory and common lawclaims since the costs of arbitration would likely exceed the disputed amount.
On August 21, 2003, the circuit court held its hearing on Farmers' motion to compelarbitration. At the conclusion of the hearing, the trial judge denied the motion. The court'swritten order does not indicate its reasoning. At the conclusion of the hearing, the trial courtstated as follows:
"[I]t seems to me that the complaint clearly sets out this as being the wrong, that aparty is injured, has medical bills. He first submits those to the company forpayment. In that initial process the company uses these biased reports as part of thefraudulent scheme to say that [']we are not going to pay all of your bills, we are goingto pay some amount less, which is some amount less than what you've asked for.['] Then as part of the scheme they've put in the arbitration clause, and the company nowsays[,] ['][F]or you to determine this as to who is right and who is wrong, you mustgo to arbitration, but the way we have set this up, the arbitration will cost you morethan what the initial dispute is.['] I think that's four square with the other cases.
The motion to compel arbitration is denied."(1)
Farmers appeals from this decision.
On appeal from a denial of a motion to compel arbitration without an evidentiaryhearing, the standard of review is de novo. Travis v. American Manufacturers MutualInsurance Co., 335 Ill. App. 3d 1171, 1174, 782 N.E.2d 322, 325 (2002).
LAW AND ANALYSIS
Arbitration in General
In 1925, Congress enacted the Federal Arbitration Act (FAA) (9 U.S.C.