The Hawaii Supreme Court ruled on July 29, 2026, that a doctor’s treatment for a car accident victim does not qualify for insurance payment under state law. This decision affects healthcare providers and insurance companies in Hawaii, clarifying the requirements for personal injury protection (PIP) benefits.
The case involved Dr. Christopher Lawinski, who treated Sean Tilton after he was injured in a car crash. Lawinski used low-level laser therapy (LLLT) and billed Tilton’s no-fault insurer, United Services Automobile Association (USAA), for the treatment. USAA contested the claims, leading to a legal dispute over whether the treatment was covered under Hawaii’s PIP laws.
Hawaii law mandates that no-fault insurers pay PIP benefits for injuries sustained in car accidents, as outlined in Hawaii Revised Statutes (HRS) § 431:10C-304. However, there are specific conditions that must be met for a treatment to qualify for coverage. The treatment must be appropriate, reasonable, and necessarily incurred due to the accident, and it must also be “substantially comparable” to the requirements for prepaid health care plans, according to HRS § 431:10C-103.5(a).
In this case, Lawinski argued that he satisfied the first condition, but the court found he did not meet the second condition. The court noted that Lawinski failed to provide evidence that LLLT is substantially comparable to what prepaid health plans cover. This lack of evidence ultimately led to the rejection of his claim.
The legal dispute began when Tilton was injured in a motor vehicle collision on June 26, 2017. Following the accident, Lawinski treated him with LLLT six times and billed each session at $75. However, USAA only reimbursed him $7.17 per session, recoding the claims to a different treatment that it argued was more accurate. Lawinski contended that infrared therapy, which USAA used for reimbursement, was scientifically different from LLLT.
After USAA denied the claims, Lawinski sought a review through the Office of Administrative Hearings. USAA moved to dismiss the case, arguing that Lawinski had not demonstrated that LLLT was a treatment eligible for PIP benefits. The hearings officer agreed and dismissed the case, a decision that was later adopted by the Insurance Commissioner.
Lawinski appealed the dismissal, and the circuit court reversed the decision, stating that the dismissal without a merits hearing was unauthorized. The case was remanded for a new hearing, where Lawinski presented evidence, including testimony from an expert about the efficacy of LLLT. However, the expert admitted he did not know if any prepaid health care plan in Hawaii covered LLLT.
Ultimately, the hearings officer ruled in favor of USAA, stating that Lawinski had not provided evidence that LLLT was reimbursed by prepaid health care plans. This decision was upheld by the circuit court and later by the Intermediate Court of Appeals (ICA), which affirmed the ruling but on different reasoning.
The ICA initially found the statute ambiguous regarding the phrase “substantially comparable” but later acknowledged that the definition in the following statute clarified the matter. The Hawaii Supreme Court, however, disagreed with the ICA’s reasoning and emphasized that the statute was unambiguous. The court stated, “A phrase the legislature has defined is not ambiguous. The definition is the meaning.”
In its ruling, the Hawaii Supreme Court stated, “Lawinski had to prove comparability. He didn’t.” The court affirmed the ICA’s decision, which upheld the circuit court and the Commissioner, emphasizing that both conditions outlined in the statute must be met for a treatment to qualify for PIP benefits.
This ruling has significant implications for healthcare providers and insurers in Hawaii. It clarifies that treatments must not only be necessary and appropriate but also align with the standards set by prepaid health care plans to qualify for insurance reimbursement. This decision may influence how healthcare providers approach billing for treatments and how insurers evaluate claims in the future.
Moving forward, healthcare providers may need to be more diligent in ensuring that their treatments meet the requirements for PIP benefits as defined by Hawaii law. Insurers will likely continue to scrutinize claims to ensure compliance with these standards. The case also highlights the importance of understanding the legal definitions and requirements surrounding insurance claims in the state.
Lawinski may consider appealing this decision, but the court's ruling is a strong affirmation of the statutory requirements for PIP benefits. As of now, there are no related cases pending that could impact this ruling.