When a plaintiff policyholder filed a GLc 176D complaint regarding the defendant insurance company’s alleged failure to promptly pay a claim for medical services rendered to the plaintiff following a trip to a hospital emergency room, the defendant’s motion to dismiss should have been denied because whether the insurer was careless or unreasonable in his investigation is a question for the fact finder.
Canceled and held.
“Scott D. Pita (“Pita”) appeals the trial court’s dismissal of his complaint against Harvard Pilgrim Health Care (“Harvard Pilgrim”). Pitta’s claims against Harvard Pilgrim for unfair claim settlement practices, as defined in GLc 93A and GLc 176D, §3(9), and for negligent infliction of emotional distress arise out of Harvard Pilgrim’s alleged failure to promptly pay a claim for the provided Pitta’s medical services following a trip to the hospital’s emergency room in October 2019. It is undisputed that at all relevant times Pitta was insured under a Harvard Pilgrim health insurance policy.
“In response to Pitta’s complaint, Harvard Pilgrim filed a motion to dismiss the complaint on the ground that Pitta has failed to state a claim upon which relief may be granted, as required by Mass. R. Civ. S. 12 (b) (6). A district court judge granted the motion without specification and this appeal followed. …
“In his complaint, Pita points to an approximately six-month gap between the time he was treated and the final payment of the claim by Harvard Pilgrim.” During that time, according to Peeta, he repeatedly pleaded with Harvard Pilgrim to further investigate his coverage, but to no avail. Pita also claims that he undertook to obtain proof that he was no longer covered by the previous policy and provided it to Harvard Pilgrim, which also failed to induce payment of the claim. …
“At the motion to dismiss stage, we find the complaint sufficient. There’s no getting away from the fact that Pitta received outpatient emergency room treatment while covered by a Harvard Pilgrim policy. It is also clear that despite taking the steps any insured would take, such as providing the hospital with his insurance information and responding to Harvard Pilgrim’s erroneous statement, he was covered by another policy, months passed before the claim was paid and only after Pitta sent Harvard Pilgrim a request letter GLc 93A. Although an insurance company is not held to an “omniscience or perfection” standard, we find that whether Harvard Pilgrim was careless or unreasonable in its investigation is a question for the fact finder. … The fact that Harvard Pilgrim ultimately paid the claim in full and Pitta received a refund does not change the analysis. …
“In support of his negligent infliction of emotional distress claim, Pitta alleges that Harvard Pilgrim’s actions caused serious financial strain on Pitta and his family, resulting in a measurable and apparent increase in the severity of his generalized anxiety disorder.” …
“Against this background, we conclude that Pitta has alleged enough in its complaint to withstand Harvard Pilgrim’s motion.” In its complaint, Pitta claims that Harvard Pilgrim’s negligence led to a “documented increase in anxiety medication.” A change in medication suggests more than “mere upset, horror, humiliation, grief and anger.” … Expert medical testimony may be required to make the necessary showing that Pitta suffered physical symptoms as a result of Harvard Pilgrim’s negligence, but it need not. …
“The grant of the motion to dismiss is reversed. The case is remanded to Brockton County Circuit Court for trial.
asks v. Harvard Pilgrim Health Care (Lawyers Weekly No. 13-016-23) (5 pages) (Finnigan, J.) (Southern District) Appealed judgment of Dilorati, J., in Brockton Circuit Court. Scott D. Pita, for himself; Donna M. Marcin and Brian E. Sopp, both of Hamel, Marcin, Dunn, Reardon & Shea, for Respondent (Div. App. No. 21-ADCV-57SO) (May 2, 2023).
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