Grisby v. Progressive Preferred Insurance Co., 343 Or. 175

Summary

The Oregon Supreme Court held that an insured who prevailed in an action against an insurer for personal injury protection benefits was entitled to attorney fees under ORS 742.061(1). The statutory exception for PIP actions did not apply because the insurer had denied coverage of the particular chiropractic services and the dispute involved more than only the amount of benefits due. The court reversed the Court of Appeals and the circuit court and remanded for further proceedings.

Holdings

1. An insurer does not accept coverage for purposes of ORS 742.061(2)(a) merely by acknowledging that an accident falls within the policy; acceptance or denial must be evaluated with respect to the particular claim for services. Because Progressive denied the chiropractor's claim, it had not accepted coverage of that claim.
2. A dispute over whether a particular medical treatment is related to the insured's accident and therefore covered is not merely a dispute over the amount of benefits due under ORS 742.061(2)(a). The phrase 'amount of benefits' refers to the dollar level or quantum of a claim, while a denial of a particular claim is a distinct issue.
3. Because Progressive had not accepted coverage of the disputed claim and the action involved more than the amount of benefits, the ORS 742.061(2)(a) exception did not apply. Grisby was entitled to recover a reasonable attorney fee under ORS 742.061(1), assuming the statute's other requirements were satisfied.

Questions Presented

1. Whether Progressive had accepted coverage of the disputed chiropractic-treatment claim within the meaning of ORS 742.061(2)(a).
2. Whether the dispute over whether the chiropractic treatment was related to the accident constituted an action in which the only issue was the amount of benefits due the insured under ORS 742.061(2)(a).
3. Whether Grisby was entitled to a reasonable attorney fee under ORS 742.061(1).

Disposition

reversed_and_remanded