Does the insurance company have to pay for a surgery that was not billed within 60 months due to a clerical error?

Summary: Respondent moved for summary judgment, asserting that Petitioner’s medical benefits terminated under the 60-month rule at § 39-71-704(1)(f), MCA (2005).
It is undisputed that Petitioner saw his treating physician within the 60-month period, but his physician’s office made a mistake and did not bill Respondent for the appointment within the 60-month period. Because Petitioner’s physician did not send Respondent the bill, Respondent asserts that the appointment does not constitute use of medical benefits.
Petitioner moved for summary judgment, arguing that he used his medical benefits within the 60-month period by obtaining treatment from his physician, and that he cannot suffer a consequence because of his physician’s office’s mistake in failing to bill Respondent for the appointment.

Held: Respondent’s Motion for Summary Judgment is denied, and Petitioner’s Motion for Summary Judgment is granted. Petitioner used his medical benefits within the 60- month period when he saw his treating physician for treatment. As a matter of law, the physician’s office had the duty to bill Respondent, and Petitioner cannot suffer a consequence because of his physician’s office’s mistake in failing to bill Respondent.

ORDER
¶ 36 Westre’s Motion for Summary Judgment is granted and Liberty’s Motion for Summary Judgment is denied.
¶ 37 Because he prevailed, Westre is entitled to his costs under § 39-71-611, MCA.
¶ 38 Pursuant to ARM 24.5.348(2), this Order is certified as final and, for purposes of appeal, shall be considered as a notice of entry of judgment.

DATED this 14th day of August, 2018.

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http://wcc.dli.mt.gov/w/Westre_2018MTWCC14.pdf