It is axiomatic that the claimant is required to be a party to the insurance contract in order to claim an insurance contract. When an insurance company reduced the payment to the care provider based on an agreed schedule rather than the amount invoiced by the provider, the provider – not a party to the agreement – has no reason to claim that it was damaged by the insurer.
Stephanie Allen, Mark Allen, as individuals and Absolute Life Wellness Center, Inc., a Texas Professional Services Corporation, independently and for all others alike v. United Services Automobile Association, USAA Incident Insurance Insurance Company, USAA General Indemnity Company, Garrison Property And Incidently Insurance Company, And USAA County Mutual Insurance No. 01-20-00305-Cv, Court of Appeals for the First District of Texas (December 22, 2020) "Allens", and Absolute (collectively, "appellant"), questioned the decision of the Court of Justice that they lacked the power to bring an action, both and on behalf of classes of other policyholders and caregivers, against the United Service's Automobile Association, (USAA) for breach of contract and violations of the Texas Insurance Code and the Deceptive Trade Practices Act ("DTPA").
In its second amended petition, the complainant claims that in March 2018, Allens was insured under a standard USAA "Texas Auto Policy" with personal injury protection ("PIP") coverage. According to the complainants, the insurance provides "coverage for all" reasonable "and" necessary "expenses" of up to $ 5,000 for each insured "which is the result of a covered car collision – without regard to the fault of the collision." Under the policy, "USAA promises to – or have someone on their behalf – review and investigate, by review or otherwise," claims for benefits under this coverage to determine if fees and costs were reasonable and if the treatment was medically necessary and appropriate . "" USAA "also promises to pay for the medically" necessary "and" reasonable "fees."
Allens was injured in a car accident. They authorized their caregivers to claim according to their PIP policies with USAA. The refundable amount for Allens claims for payment of all reasonable and necessary treatment were reduced based on coded fee reductions. Complainant states that USAA automatically reduces PIP claims and then provides a fee reduction declaring that "
The USAA denied the allegations, arguing that Allens has no position to sue USAA entities that have not issued any insurance policy to them and has absolutely no position to bring suit under the DTPA because it is not a "consumer." And Absolutely can not claim based on any policyholder's alleged allocation of rights, as the insurance's claims under DTPA and Texas Insurance Code Chapter 541,060 for unfair settlement methods can not be transferred.
The Court's conclusions
The test for standing requires that there be a real controversy between the parties which will in fact be determined by the legal declaration sought. Without infringement of a legal right belonging to the plaintiff, no action can cause its benefit. A plaintiff has a position on:
- it has arisen, or immediately risks suffering any direct damage as a result of the wrongful act that it complains about.
- there is a direct link between the alleged damage and the damages
- it has an individual share in the controversy;
- the contested measure has caused some damage, either economic, recreational, environmental or otherwise; or
- it is an appropriate party to assert the public interest in the matter as well as its own interest.
A plaintiff has the burden of asserting facts that conclusively demonstrate the court's jurisdiction to hear a case. The ongoing investigation requires careful judicial review of the allegations in order to determine whether the applicant in question is entitled to review the specific allegations. A standing challenge cannot be used to require the party to prove his entire case but should be limited to facts that can be characterized as primarily jurisdiction.
Under Texas law, it must have been an endangered or actual injury to have a party standing. . The insured does not claim in this case that she has any non-reimbursed medical expenses. She does not claim that the suppliers refused medical treatment as a result of the insurer reducing its bills, or threatening to sue her for deficiency or harassing her in any other way. From all appearances, her medical providers have accepted the amount the insurer paid them without complaint and thus fulfilled the insurer's obligation under the insurance.
Allens does not claim that they paid, or were asked by their caregivers to pay, any portion of the bills that the USAA had refused to fully reimburse. Nor have they claimed to have incurred any costs as a result of the USAA's discounting and claim methods. Absolute has not asked its patients to pay any portion of their bills that the USAA has not refunded or claims that they have refused to accept the discounted benefits as payment. without the consent of the USAA. Assignment clauses are enforceable unless they are made ineffective by law. Texas courts have consistently enforced clauses that are not assigned in different situations. The law on prompt payment of damages requires proof that an insurance company is liable under the insurance. A right to statutory damages under the Texas Insurance Code requires as a predicate violation of a contractual right belonging to the insured. Since the trial court did not err in concluding that the appellants lacked jurisdiction to bring their action against the USAA, the trial court had no jurisdiction to do anything other than dismiss the appellants' cases. promised. It is just as important that an insurance company refuses to pay claims that it is not liable for. An insured, who has been paid as promised by the insurer, has not suffered any loss and therefore has no available reason to sue his insurer. Similarly, the caregiver assigned to an insured person under a "no assignment" clause in an insurance policy has no privilege and no reason to sue an insurer for his patient for more than it has accepted. As the great basketball reporter, the late Chick Hearn, would always say: "no injury, no foul" and therefore no case.
© 2020 – Barry Zalma
Barry Zalma, Esq., CFE, now limits his practice of serving as an insurance consultant specializing in insurance coverage, insurance claims handling, fraud and insurance fraud almost equally for insurance companies and insurance companies. He also acts as an arbitrator or mediator for insurance-related disputes. He practiced law in California for more than 44 years as an insurance coverage and claims lawyer and more than 52 years in the insurance business. He is available at http://www.zalma.com and firstname.lastname@example.org.
Mr. Zalma is the first recipient of the first annual Claims Magazine / ACE Legend Award.
For the past 53 years, Barry Zalma has devoted his life to insurance, insurance claims and the need to defeat insurance fraud. He has created the following library of books and other materials to enable insurance companies and their claims staff to become insurance claims personnel.
https://zalma.com/zalmas-insurance-fraud-letter-2/ Last read two issues of ZIFL here.
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Go to Barry Zalma on YouTube – https://www.youtube.com/channel / UCysiZklEtxZsSF9DfC0Expg] / [1965900Gotoinsuranceclaimslibrary-https://zalmacom/blog/insurance-claims-library/
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