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HomeMy WebLinkAbout96-05105 ~ , J i ~ 1 4W ~ I H , J 1 t? I I ~ i ~ r ~ '1 ~ . ..Q . ... -Q ~ '\ ! j 6' f J I t I I I I i I ... I .~ ~ t I ~ \;; , ....) 0' .. H _ __ _ _ ___..___..___,__.___.__..__~"_....c..__~~_ . ALIA HABIB and her husband : IN THE COURT OF COMMON PLEAS KHALIL HABIB, Plaintiffs I CUMBERLAND COUNTY, PENNSYLVANIA . . . . NO. 96- ~'/c "CIVIL TERM ve. I . . TRAVELERS INSURANCE I CIVIL ACTION - LAW COMPANY, . . Defendant . JURY TRIAL DEMANDED . AND NOW COMES this COKPtIIIT /2 '" day of September, 1996, ALIA I HABIB and her husband KHALIL HABIB, Plaintiffs above-named by and through their attorney JOHN M. GLACE, Esquire and presents this Civil Complaint aqainst TRAVELERS INSURANCE COMPANY and, in support hereof, presents the following: 1. Plaintiffs ALIA and KHALIL HABIB are adult individuals and husband and wife, who reside and resided for all ti:lles relevant to this Complaint at 1428 Bradley Drive, Apartment J312, Carlisle, CUlIIberland County, Pennsylvania. 2. Defendant TRAVELERS INSURANCE COMPANY b an insurance company licensed to transact business in the C~nwealth of Pennsylvania with offices situate; inter alia at 1105 Berkshire Boulevard, Nyo.bainq, PA 3. On or about February 3, 1996, Plaintiffs _ra involved in a actor vehicle accident wherein ALIA HAllI. as _11 .s ItUALIL HAllIB I and their minor children sustained personal injuries. 4. Prior thereto Defendant TRAVELERS INSURANCE COMPANY issued automobile insurance to the Plaintiffs ALIA and KHALIL HABIB. Defendant, through its authorized agent, employee andlor servant, Andrea D. Griffith confirmed coverage to Plaintiffs' counsel by her letter of February 9, 1996. Said letter is attached hereto and made part hereof as Exhibit A. 5. Pursuant to the terms and conditions of the aforesaid policy, both Plaintiffs are the named insureds. Additionally, said automobile insurance policy provided coverage as described in Exhibit A in first party medical loss benefits in accordance with the Pennsylvania Motor Vehicle Responsibility Law, 7S Pa. C.S.A. 1701, et seq, as llII8nded. A copy of this policy ia in the possession of Defendant. 6. As a result of the aforede.cribed IIOtor vehicle accident, ALIA HABIB suffered severe and debilitating injuries, s~ of which may be permanent, including, but not lialted, to cervical disc herniation at C4-C5 and CS-C6. 7. As a further result of the aforede.cribed IIOtor vehicle accident, Plaintiff ALIA HABIB was obligated to receive and undergo medical attention and care and to expend various suas of IIOney or to incur various expen.es for which -.dical benefits are payable. Further, Plaintiff ALIA HABIB will be obligated to continue to incur .uch obligation. for indefinite period of ti_ in future for trea~nt of her accident-related injurie.. 2 COURT I BREACH OP' COHTRACT B. Paragraphs one (1) through seven (7) ara incorporated herein as if set forth in full. 9. Acting pursuant to the terms and conditions of their automobile insurance contract, Plaintiff ALIA HABIB, after initial emergency medical treatment, presented on February 6, 1996 at Mas land Associates, Inc. of 220 Willow Street, Suite 109, Carlisle, Cumberland County, Pennsylvania for treatment of her accident related injuries. 10. At various times thereafter Plaintiff ALIA HABIB incurred medical billing obligations for reasonable and necessary treatment of various health care providers as follows: Masland Assoc., Inc. Alexander Spring. Physical Therapy Carlisle Imagining Assocs. prescriptions (paid by Plaintiffs) 11. At various time., Plaintiffs ALIA and KHALIL HABIB have submitted or the provider has directly subaitted -.dical billings generated by the trea~nt of ALIA HABIB for her eccident related injurie. to Defendant insurer. 12. On or about May 8, 1996, Defendant insurer, by and througb it. authorhed agent, ellployee and/or servant Andrea Griffith, info~ Dr. Debra Taylor, an ...ociate of Haaland A.aceiate., Inc., that an April 23, 1996 bill wa. questioned a. to it. relation to ALIA HABIB'. accident related injurie.. Said letter 1. attached hereto a. Exhibit 8 and ..de ~rt hereof. 3 13. On Hay 15, 1996, Dr. Douglas Bower also of Has land Associates, Inc. wrote to Andrea Griffith requesting reconsideration of Defendant's denial and reiterating Plaintiff ALIA HABIB's recurrent accident-related symptomology of headache and neck discomfort. Said letter is attached hereto as Exhibit C and made part hereof. 14. On July 3, 1996, Defendant's authorized agent, employee or servant notified Dr. Bower that his billings would be submitted to Peer Review pursuant to the "amended Pennsylvania Financial Responsibility Law" at section 1797B. Said notification is attached hereto as Exhibit 0 and made part hereof. 15. The aforedescribed July 3, 1996 notification was addressed to Douglas J. Bower, M.D. at Alexander Spring Rehab, 27 Boulevard Avenue, Carlisle, PA. Upon knowledge and belief, Dr. Bower is not associated with that rehabilitation service nor does he receive mail at that address. 16. Defendant insurer knew or should have known the address of Doctors Taylor and Bower and Hasland Associates, Inc. by prior correspondence and by their purported review of billings generated on or after April 23, 1996 prior to Peer Review subaittal. 17. Defendant insurer contracted with Consolidated Rehabilitation Co.pany, 2616 North Broad Street, P.O. Box 1719, Lansdale, PA 19446-0127 to initiate a Peer Review. 18. By notice of the dored.scribed Peer Review Organization, all Dr. &aw.r's progre.s and clinical note. and diagnoetic .tudy report. frOll April 23, 1996 _re requested. This notice is dated 4 both July 11, 1996 and July 16, 1996 and is attached hereto as Exhibit E and made part hereof. 19. Peer Review referral is permitted by regulation only when a prudent person believes a PRO is necessary to determine the reasonableness and necessity of care 31 Pa. Code S63.S2(a) and Defendant insurer at or after April 23, 1996 had no such basis to request PRO for the treatment of Plaintiff's headaches and neck pain and his continuing diagnostic process. 20. Plaintiff ALIA HABIB continued to be treated by various health care providers and by medication after April 23, 1996 and, as a continuing step in her diagnostic process was administered a MRI along with radiologic tests on August 8, 1996. Those tests disclosed cervical disc herniations at C4-C5 and CS-C6. Said results are attached hereto as Exhibit F and made part hereof. 21. By letter of August 14, 1996, Defendant's authorized agent employee and/or servant sent Dr. Bower a copy of Peer Review Report of R. Nathan Link, H.D. purportedly dated July 31, 1996. This letter was again sent to an address than Defendant insurer knew or should have know was not that of Dr. Bower or Mas land ABBociate., Ine.. Said letter is attached as Exhibit G and the PRO report a. Exhibit H and they are made part of. 22. The PRO report of Dr. Link which is attached hereto as Exhibit H is baaed on Dr. Bower.s diagnostic !.pression of orthopedic injury. That impreBBion was fo~d February 6, 1996 and included only the radiologic tests performed at the ...rveney care provider February ., 1996. Dr. Bower, ALIA HABIB's priaary care 5 provider, and Dr. Link are internists and neither is an orthopedist. 23. Dr. Link's PRO report, based solely on the records provided including a February 6, 1996 diagnostic impression, determined that all passive treatment modalities after April 4, 1996 were unnecessary and Defendant insurer through Andrea Griffith its authorized agent, employee andlor servant, by its August 14, 1996 letter (Exhibit G) demanded Dr. Bower return reimbursement of all payments since April 29, 1996. 24. Premised on Dr. Link's PRO report which relies on a diagnostic impression of an orthopediclneurologic injury by an internist two (2) days after the traumatic event, Defender insurer has refused payment of medical treatment for ALIA HABIB including future treatment. 25. Defendant insurer has confused ALIA HABIB's medical care provider. by addressing the August 14, 1996 reimbursement demand to Dr. Bower to Alexander Springs Rehab and demanding reimbursement of funds never paid to either Dr. Bower or Hasland Assocs., Inc. 26. Defendant insurer's PRO review request is overtly premature, premised on a primary care providers first diagnostic impres.ion, and clearly .pecious in light of the MRI re.ults. It i. averred that all aedical billings of Plaintiff ALIA HABIB before and after the Peer Review are fair and reasonable and that her continuinq treatment by the aforede.cribed provider. was and i. aedically nee....ry and related to the accident. 6 27. Defendant insurer has refused to pay the balance due of ALIA HABIB's medical billings and, further, demanded reimbursement by her health care provider(s). As a direct result the above Plaintiffs have had to retain an attorney to collect the medical dues and, therefore, pursuant to Section 1716 of the Pennsylvania Hotor Vehicle Financial Responsibility Law said Plaintiffs are entitled to attorney fees and twelve (12\) interest. 28. Plaintiffs are further entitled to attorney's fees because Defendant insurer has acted with no reasonable foundation and in violation of Section 1798 of the Pennsylvania Hotor Vehicle Financial Responsibility Law. 29. Defendant insurer's course of action was unilateral, arbitrarily premature, without notice or consultation with Plaintiff's counsel, without justification, and wanton and its refusal of the Plaintiffs' first party claims with its demand for reimbursement has made Plaintiffs personally responsible for medical bills arisinq out of the maintenance and use of their insured motor vehicle and is in breach of the terms of the insurance contract, the Pennsylvania Motor Vehicle Financial Responsibility Law and the cas. law of the Co.-onwealth of Pennsylvania. WHEREFORE, Plaintiff ALIA and KHALIL HABIB demand paywent in full of all ALIA RABIB's medical bills related to her trea~nt of her accident related injurie., additional cOllp8nsatory andlor consequential daaages allowed by law, her reasonable attorney'. fees, costs of this suit, and interest on all overdue benefits. 1 COURT II BAD FAITH 30. Paragraphs one (1) through twenty-nine (29) are incorporated herein as if set forth in full. 31. Effective July 1, 1990, Pennsylvania law at 42 Pa. C.S.A. 58371 provides a private cause of action for bad faith against insurance companies as follows: "In an action arising under an insurance policy, if the court finds that the insurer has acted in bad faith toward the insured, the court may take all of the following actions' (1) Award interest on the amount of the claim from the date the claim was made by the insured in an aIIOunt equal to the prime rate of interest plus 3'. (2) Award punitive damages against the insurer. (3) Assess court costs and attorney fees against the insurer." 32. All treatment was provided to Plaintiff ALIA HABIB after the effective date of the above statute and the alleged bad faith occurred after the effective date of the statute. 33. It is believed and, therefore, averred that the Defendant, insurer, ha. eaployed the aforedescribed Peer Review Organization in bad faith in that said peer review organization does . 8ubstantial .-aunt of peer review work for Defendant and, therefore, has a financial intereat in providing to Defendant a biased peer review report. 8 34. Additionally, it is alleged that Defendant insurer had knowledge that Plaintiffs were naturalized American citizens with limited financial wherewithal and its Peer Review request was over- reaching, prejudicial, and pre-conceived to take advantage of Plaintiffs' limited understanding of their statutory rights and lack of resource. 35. Additionally, it is alleged that the July 31, 1996 PRO report of Dr. Link is overtly flawed and premised on an initial diagnostic impression of a non-specialist and Defendant insurer, by and through its agents, employees andlor servants, knew said report was not current, inaccurate, andlor nonreliable at the date of its issuance and that the August 14, 1996 reimbursement demand letter to Dr. Bower was not based on Plaintiff ALIA HABIB's current condition. 36. Its is averred that Defendant insurer's request for Peer Review was arbitrary, without articulatable prellise, and requested in reliance that the PRO aforementioned would provide justification to refuse to provide Plaintiffs' contractual benefits. 37. Defendant insurer knew or recklessly disregarded its lack of reasonable basis in denying Plaintiffs first party benefits and subllitting the -.dical billings of Plaintiff ALIA HABIB to Peer Review. 38. The 8ubaittal to Plaintiff ALIA HABIB's -.dical billings as described herein to Peer Review were for purpose. not statutorily envisioned and Defendant insurer used the Peer Review process illproperly and in deviation of SI197(b). 9 08/22/1996 08:58 7172499332 MASLANDASSO PAGE 01 - . Medical Case Ma"".emenl . Peer Review OraamUltlon . Hospital RelmbuBcmcnt Services Michael A. Momme. M. Ed . Independent Mecllc:al Eaam Director . \\x:a1lonaJ RehabllltatlOll 11Jt.~:X~~ o..llI!: 'Z....=..LL.::. (;, A:Y'" Claimant n~.t.......~LH'l~ J!"1-tJM ~. 011.: ~-"'-'1~ .....J..U . ,;' d '} Claim ,: G V IV .... ~~ " ~ . ~ '701" aeRIe: /9.1J.9 9/ ~/7) .;1'7,;'Q ~ q A. per s.ctIon 1m SubsedIon 69..52 paracraph (8). _ 4. ~ting .ufficien( ~~tIOn to "'pport the bill. A. per .ubMctlon 69.52. parapaph (e) -'I no .hall NIp'" In wrill". tt-. lb. pro..;du all ......... and donllnanl. .........,. ... .......rtak. 1110 mi.w." 1lw foIIowInl dwdIist dacrlbes In detaiJ OW aKt ftCllIIdI req_L AI per .ubs<<tion 69.52. paragraph (d). . ..... PRO aI', -.._ I.. reNw JO cia,. .te.1Iw ""I_I tar ~llon i. posllftarbL' J ~ TX-Dallle ~ ~..., . 9 (, ~ ,t.. "7 V" ~ . HOSPITAL I'In'SIClAN OR HEALmCAKE PltOFESS10NAL Coalplete Hospital 0\U1 .lC Oonot'$ f'rog.eu/Clinial Nota CIxharp Summary J< I>>&nostic Study RepoI1s E.l'~_~"Y Room R.epon PT R<<o.d. (All docwnl!ntatiCll\) Opftatintl Roam Rec:onb a.uo Il<<onis (All dOC\llNl\..lionl ~~ ~~ 0thIr. ~ ~RG> Consolidated Rehabilitation Company ~tMiDnsptdDlisu ~c! ~> Y'c<""'1 You have 30 da~ from 1Iw lime oIlNt ""t"tsl to ptoricI. the WlIffideatl do<vlMn~tlon requested Your ~.tion will aYOid any w.+ ,ry <lNy in peyn.e.OL In lICCOrdancw with SedIon 1797, Subt<<1ion 69..52 plIrapaph (d. ow dUculliol> policy \I .. follows: . Arty dlacuoaion )'011 wuh II> hav. 0JNiden0d in 1Iw initW no detemunation must be subnvlted tn wril1n& p<- to noport .o.,+IetIon. . U...... ia Myth.. within the Ift'tlrd that 1Iw .....,.... physician ftftlds d.nt..... pricw 10 ...4.tllI ." opinion. au: will a.w\tan ,..... ~. . U )'011 waN tit fti'MUy d1Kuat dw m. w.." 1Iw ... it _. .....,. compIele a.nd mwon tills partkJrl ollhis 1Htet. DiKwui_ ............., Yn N. . lIpedfic u.... .u lUll.. yo. .11I a..ibble Ie nut.. lellJ>l- .aU, I. 0... r_ 2. 0... n... J. 0... Time 1M rnI...... pIt,.........aI plan. cal' ...., 01."_ opeotic __ w""",... ..ut ... ..all.W. ..... ~- ClaIm ~ ~ ~~ '".'-,,' ~ . . ~.b'" , ," 'lIt. .,'- -- , . ~ -,- . t, lnt......... Compar., ...... _"po,," 1". ~IO" _1M _ '0 _'II. 1 . p,,- .......,~ ,21"'" It,. ......, 11Ul", )J~ o.'t* o _..... ,,_ --- -....-, _ '''.'11' 'U~M'.t!' _ J.L. ""- , C lIU__I... _0' " I 11-..... IU." 7i~~y"._. Dln.1T I L~ '\ H' 'n :..-';~ j' \"\\ . 88/22/1996 e8:S8 7172499332 HASLANDASSO . A\ Carlisle Hospital ~, and Health Services 2046 PaftetStreet. P.O,1Ioa 310. Carllale, PennsylYaniClI7013-o310. (717) 2<19.1212 DEPARTMENT OF RADIOLOGY CARLISLB IMAGIftG ASSOCIATlS, P.C. HABIB. ALIA 1428 BRADLEY CARLISl.E, PA 5lY DRIVE APT. .1312 17013 08/08/1996 X-RAY .121:261 HED. RBC. .7S1297 DR. BOWBR CIRVICAL SPI" - PIVK VISWS Blight diffuse demineralization is noted. Degenerative change. involve the mid and lower cervical vertebral bodies. "arrowing with associated degenerative change. involve C5-C6 interspace. On each oblique projection, po.terior osteophytes project into the intervertebral foramina bilaterally at the fifth cervical l.vel. Several .mall calcifications ar. noted in the right .ide neck which may be vaacular. Small bil.teral cervical ribs ar. noted. IHPRBsstOIf: De.ineralization and degener.tive change. of the cervical .pine. Degen.rative di.c di..... of C5-C6 int.rspac.. S~ll bilateral cervical ribs. MItt or ".. czavICAL aPIn Multipl. .ag1ttal and axial i.aq.. v.r. made of the cerVIcal .pine in routine pulse .equence.. Th. .tudy is evaluated in conjunction with x-ra, .xamination of the cervical .pine done on the ...e date. The ..rrow signal inten.ity 1. normal. "arrowing with a..oclated degenerative change a involve C5-C6 inter.pace. At the C'-C5 inter.pace, centrallY and so.ewhat right 1at.rally lying protruded diac herniation 1. noted without causing any significant spinal steno.i.. At the C5 C6 inter.pace, diffuae cantrally and bath laterally lYln9 protrudad disc harniation 1. noted. No .ignificant apinal stano... 1. seen. The rematning intarspaca. are nor.a1 and the po.terior ele..nta show no abnormality. The appeeranca of ~he poeterior foa.a nor.al. and cervlcal .'i~;~~d [. . . r lUll t ,-. ~.... '" ..., .__ C,"" lIE" 4t>norlllaltty, .~'':~''1'' The parasptnal soft tissue. teve.l no C'1lL -l."OlI'!' I WUftl. 'C' . . .,..,,_.. "'Sf t......~...;."'~.~ Q "..A'''' t.. ~ 'V4 " I r n 11\ "'l lttlt r tHl" . ~ Consolidated Rehabilitation Company RdwblliwlitJlI SI','ciali.1/.I CONFIDENTIAL REPORT A comprehcnsivc Peer Rcvicw Organizalll1fl cenificd by lhc Commonwcalth of Penns~" Jr.IJ Name: File: Date: Alia Habib 2i8 PP GUN 4639 July 31, 1996 -... ,._.~ "ED t1..C '-..:.; " l- ~UG - 5 ". CilC Submitted for my review are medical records. of Alia Habib as they I'elate to injuries sustained in a motor vehicle accident on February 4. 19%. I received these records for review on June 26, 1996. Ms. Habib was the front seat passenger in a vehicle that was struck fron behind by another vehicle on February 4. 1996. She was taken to the emergency room at Chester County Hospital where she was treated and released but I did not receive a copy of the physician's note from that visit. On February 6. 1996. Ms. Habib presented to the office of Douglas Bower. MD, with complaints of pain in her head. neck. shoulders, and chest. Her exam was notable for tenderness over her neck. upper shoulder girdle. and anterior chest. Dr. Bower's impression was minor contusion to the head. whiplash injury to the neck, and scathelt area discomfon across the chest and upper abdomen. His plan was for analgesia and physical therapy. . Beginning February 14, 1996. Ms. Habib underwent physical therapy treatments by passive modalities such as hot packs. electrical stimulation. and massage. Treatments were provided up to three times per week at least through May 20. 1996. On February 12, 1996 a CT scan of the head was performed to evaluate persistent headaches. It was reponedl)' negative. On April 23, 1996. Ms. Habib continued to complain of head and neck pain. On May 29, 1996. her only complaint was left sidCl.! neck pain 'becoming worse since Friday.. I was also provided copies of prescriptions for cyclobenzaprine. ibuprofen, and Roxicet on February 6, 1996 and February 12. 1996 only. According to the records submitted for my review, the initial evaluation and treatment of Ms. Habib by Dr. Bower were appropriate for the sotl-tlssue injuries she sustained; however, passive modalities were cmployCl.! for an unusually long period of time following the onset of injury. In general, inuooblliution and passive modalities of treatment are most appropriate in the early period fOllOWing soli-tissue injury (n. Mild isometric uercises 1t1.1)' be staned cautiously shonl)' after injury. followed by Iflltlt .' .,', ;.\c, 1,1" '\ \ ~\-' .. .' Dlnlrr I /) i:--: _t I ,.,~. ..- . t'"..._.... '....1. C-I c-.....---. ....Ii I __ou,_,. -; ..,.=-.-:: . .--- . - . -. - " L:.J:-. ::'::~::'t:::i:: #. I -" .-...., .-'-- "1 I ':l~"'''''''vl'I--;- 1_..'..... _4,..... I ~lia ~abib and Khalil Habib .,. .., . -. Travelers Insurance ~ompany -.; _.c. 96-5105 Civil Term .~ "- :-;cw, SEPT. 16. 1996 'e T c-_-:"":' ~ 0-: c.~!3Z:':"_,1_"~ CO~-X":"?, :~ :~ .-- - ..--- ..- . . '" .- ci Berks ','.,':::, =--'1 c.:-.- = -= C:.-- ::l __e. -.. . --: ---- - .. -. - . . ~.::.:..-: . . :--! -..... - .. - ::.: -- ....~_. . ::; :-..::c. ei :.:.: ':t_:_~= .--. .1 >>>~.~...<.~ s:::~-~ :~ ~==~..::: '::="1. ?:. . .\. ~.. -... .. - . .~c.2.-n.. or :::-=-. ~= !Q c:.....e-_ 1lIa:.! eI c:.aG..-r. 1:.. CC~..: :.-.;~ :.::: ~~ ~;;-; ~._- _.:...... t........:;. . .. =,:~_:.:...,u ::- ~f""- ~ ,;~! .1...::_,.l..,-:-:- ----' . .. -' IN TIlE COURT OF COMMON P1.EAS OF CUMBER1.AND COUNTY. PENNSY1.V ANIA ALIA HABIB and her husband KHALIL BABIB. CIVI1. DIVISION Plaintiffs. No. 96.5105 \'. TRA VEI.ERS INSURANCE COMI)ANY. Defendant. PRAECIPE FOR APPEARANCE TO: 1.a\\Tenee E. Welk~'I". ProthoDOlar)" You are hertby directed to enter the appearance of BROWN &. I.EVICOFF on behalf of Trnelers Insurance Company in the aoo\c-captioned case. JURY TRIAl. DEMANDED BY: --Bryan J.' . Esquirt BRO I.EVICOFF Fi .0. #245 600 (julf Tower Pittsbult\h. PA 1~219 Attorneys for IlI:fendant ., .. ~ STEFANON & GlACE A1TORNF.YS AT LAW 407 NO",":..50Jl(f STREI,T POST OI'I'ICF. BOX 12027 HARRISBURG, PENNSYLVANIA 17108-2027 .....~ ..... ALIA HABIB and her husband : IN THE COURT OF COMMON PLEAS KHALIL HABIB, Plaintiffs I CUMBERLAND COUNTY, PBNNSYLVANIA . . . . vs. : NO. 96-5105 CIVIL TERM . . TRAVELERS INSUR.2.':::::E : CIVIL ACTION - LAW COMPANY, . . Defendant : JURY TRIAL DEMANDED PRAECIPE OF SITTLIMIHT AIID DISCOHTIIlUAlfCE ro 'rBI PROTBOIIOTARl' I Please discontinue the above-captioned case as settled. RIS'I!CTFULLY )r'.... lace, Esqu re , GLACE h Front Street x 12027 Ha isburg, PA 17108-2027 (717) 232-0S11 1.0. 123933 .... l-'~ r-. 1.-. t!. . , , . COI ,~ . (): .- !~:: ' at -- ... . :.,~ ~ ;',. ~ ,.; .- , '1 "." ..... . ,') .... -- l.._~ i '.' ;.... :5 - ". __.-..._...............______.'___'M".-~<""',.., .-..-.--,. ~~- ."... _. -- -n