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Home My WebLink About00-01204 , .. ..-... JAMES E. BONN, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 00-1203 CIVIL STATE FARM INSURANCE CO.,: Defendant CIVIL ACTION - LAW JURY TRIAL DEMANDED TO: STATE FARM INSURANCE CO, 115 Limekiln Rd.. New Cumberland, PA 17070 DATE OF NOTICE: April 6, 2000 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DA YS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOU~T ~ A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOUL ", TAKE THIS NOTICE TO A LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNO AFFORD ONE, GO ,TO, OR TELEPHONE, THE FOLLOWING OFFICE TO FIND OUT WHERE YOU C~:: GET LEGAL HELP: \,\.: CUMBERLAND COUNTY BAR ASSOCIATION 2 Liberty Avenue Carlisle, PA 17013 Telephone 717-249-3166 or 800-990-9108 c::,- c:::<:) "'-':J By: Matthew S. Crosby, Esq, Supreme Court ID #69367 319 Market Street. P,O, Box 1177 Harrisburg, Pennsylvania 17108 DATE: 'i' (" 17f((' Attorneys for Plaintiff :1 ..,...... ,. ~~r '! ~ ,'" " .J p--..... CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing document was served on the Defendant, STATE FARM INSURANCE CO_, by sending a copy of the same to said Defendant at 115 Limekiln Rd., New Cumberland, PA 17070, by United States Mail, regular service, in Harrisburg, Pennsylvania on April h, 2000, 1 ~ U{'O Matthew S, Crosby, Esq. Attorney 1.0. #69367 P,O. Box 1177 Harrisburg, PA 17108 (717) 238.2000 Attorneys for Plaintiff DATE: - -~~" "1 " ~"~ " SHERIFF'S RETURN. OUT OF COUNTY ~, - CASE NO: 2000-01203 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND BONN JAMES E VS STATE FARM INSURANCE CO R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: STATE FARM INSURANCE CO but was unable to locate Them in his bailiwick. He therefore deputized the sheriff of YORK County, Pennsylvania, to serve the within COMPLAINT & NOTICE On March 27th , 2000 , this office was in receipt of the attached return from YORK Sheriff's Costs: Docketing Out of County Surcharge DEP. YORK CO 18.00 9.00 10.00 33.00 .00 70.00 03/27/2000 HANDLER, HENNING S~~': /-:::>"/' ~"~~/ R 'Thomas Kline Sheriff of Cumberland County & ROSENBERG Sworn and subscribed to before me day of ~ this (, ~ c2tn:ro A.D. ~, {2 ~ ~ Prothonotary CIJU!\! I Y U!-' 'YUHk _. OFFICE OF THE SHERIFF SERVICE CALL (717) 771-9601 28 EAST MARKET ST" YORK, PA 17401 -_.._-~-'-- SHERIFF SERVICE INSTRUCTIONS PLEASe TYPEONLY~I~ESl T012 PROCESS RECEIPT, and AFFIDAVIT OF RETURN DO NOT DE:TACH A.NYCOPIES, 1. ~LAJNTIFF/S/ 2. COURT NUMBER L!T-~l~Uj ClVLL James E. Bonn 4. TYPE OF WRIT OR COMPLAINT 3, DEFENDANT/Sf Notice & Complaint State Farm Insurance Co SERVE . AT { 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED, OR SOLD. State Farm Insurance Co 6. ADDRESS (STREET OR RFD WITH BOX NUMBER, APT NO., CITY, BORO, TWP" STATE AND ZIP CODE 115 Gimellln Rd, New Cumberland, PA 17070 OUT OF COUNTY CUMBERLAND ADVANCE FEE PAID BY CUMBERLAND COUNTY NOTE ONLY APPUCABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN. Any deputy sheriff levying upon or attaching any property under within writ may leave same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plilintiff herein lor any loss, destruction, or removal 01 any property before sheriff's sale thereo'- 9, TYPE NAME AND AP.QRESS of ATffiANEV/OAIGINATOR and SIGNATURE Macnew ~. crosny, ~sq. 319 Market St., PO Box 1177, Harrisburg, PA 17108 (717) 238-2000 12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed it notice is to be mailed), Cumberland County 10. TELEPHONE NUMBER 11. DATE FILED 3/2/00 1:3. 1 acknowledge receipt of the writ or complaint as indicated above. SPACE BELOW FOR ,USE OF THE $IilEI'I:IFF ONLY . DO NOT WRITE BELOW THIS LINE SIGNATURE OF AU'fHORIZED CLERK 14, Date Received 15. Expiration/Hearing Date J. Ludwig 3/10/00 4/1/00 POSTED ( SHERIFF'S OFF ( ) OTHER (~ SEE REMARKS RESIOENeE ( 1/). HOW SERVED: PERSONAL ( ) 22, REMARKS: ~ '- 44, Signature of De . Sheriff 45, Signature of Yo County Sheriff William M. Hose ~ 23, Advance Costs S- 75.00 " '" 34. Foreign County Costs 35. Advance Costs 36. Secvice Costs ~~~ 3/22/00 49. Date 51. Date Received 2. PINK. Anorney 3. CANARY - Sheriff's Office 4, BLUE - Sheriff's Office '~f- CUUN r Y Ur' YUHK - OFFICE OF THE SHERIFF SERVICE CALL (717) 771-9601 28 EAST MARKET ST., YORK, PA 17401 SHERIFF SERVICE INSTRUCTIONS PROCESS RECEIPT, and AFFIDAVIT OF RETURN PLEASE TYPE ONLY LINES 1 TO 12 DO NOT DETACH ANY COPIES. 1. PLAINTIFF/S! 2, COURT NUMBER LU-L/-U.J c.lVLL James E. Bonn 4, TYPE OF WRIT OR COMPLAINT 3. DEFENDANTISI Notice & Complaint State Farm Insurance Co SERVE . AT { 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED,.ATIACHED, OR SOLD. State Farm Insurance Co 6 ADDRESS (STREET OR RFD WITH BOX NUMBER, APT NO" CITY. BORO, TWP., STATE AND ZIP CODE 115 Gime!lln Rd, New Cumberland, PA 17070 NOW 7. INDICATE SERVICE: 0 PERSONAL 0 PERSON IN CHARGE Xl DEPUTIZE CUlIObt:Rlr.JA:aIod - 0 1ST CLASS MAil 19 _ I, SHERIFF OF Xcnoo:COliNTY~~eput' 'f 0 r K COUNTY to execute t' ~ r to law. This deputation being made at the request and risk of the plaintiff. . H , 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT Will ASSIST IN EXPEDITING SERVICE: C urn be r 1 a rid OUT OF COUNTY CUMBERLAND ADVANCE FEE PAID BY CUMBERLAND COONTY NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.S, WAIVER OF WATCHMAN. Any deputy sheriff levying upon or attaching any property under within wril may leave same without a watchman, in custody of whomever is found ih possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any plaintiff here,io for any loss, destruction, ()r removal of any property before sheriff's sale thereof. 9, TYPE. NAME AND ADDRESS of AT(.QRNEYfORfGINATOR a'd'SIGNATURE Matnew ~. crosoy, ~sq. 319 Market St., PO Box 1177, HarriSburg, PA 17108 10, TELEPHONE NUMBER 11. DATE FILED , 12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BELOW: (This area must be completed if notice is to be mailed). Cumberland Coimty (717) 238-2000 3/2/00 13, [acknowledge receipt of Ihe writ or complaint as indicated above. SPACE BELOW FOR USE OF THE SHERIFF ONLY~ 00 NOT WRITE BELOW THIS LINE S-jG'NAiUR~- OF AlJTflORI 0 CLERK 14, Date Received J. Ludwig 3/10/00 16. HOW SERVED; PERSONAL ( ) RESIDENCE ( POSTED I POE(~ SHERIFPS OFF ( ) SEE REMARKS 22. REMARKS.: :A. ',- SO ANS 41.AF 44. Signature 01 D heriff 45. Signature of 'Vi County Sheriff William M. Hose /----z~~ 3/22/00 42.da 43, 46. Signature 01 ForeIgn MY COM SION EXPIRES Coun Sheriff 50.1 ACKNOWLEDGE RECEiPT OF THE SHERIFF'S RETURN SIGNATURE - OF AUTHORIZED ISSUING AUTHORITY AND TITLE 1. WHITE. Issuing Authority 2. PINK, Attomey 3. CANARY" Sheriff's Office 4. BLUE. Sheriff's Office 49. Date 51. Date Received ~ f ,.0,) \ JAMES E. BONN, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA Plaintiff, vs. CIVIL ACTION-LAW STATE FARM INSURANCE CO., No. 00-1203 Civil Term Defendant. JURY TRIAL DEMANDED TO: Prothonotary Cumberland County Court of Common Pleas: Pursuant to 28 U.S.C. ~ 1446 (e), Defendant State Farm Mutual Automobile Insurance Company, incorrectly designated as State Farm Insurance Co., hereby files the attached certified copy of the Notice of Removal filed with the Clerk of Court for the Middle District of Pennsylvania on the 12th day of April, 2000. FORRY, ULLMAN, ULLMAN & FORRY, P.C. ~~1J$uu L E . ULL~, ESQUIRE By: '!;~lilIf"!b_-r""""" I .'. ; , IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA JAMES E. BONN, Ci vil Action /,/" Plaintiff, 1 : e.vo- 00-0671 vs. STATE FARM INSURANCE CO. Defendant. ! I tl. jJU NOTICE OF REMOVAL '~'1~... 1\. .. '. . '1.' nK Per __.~ I. . ,~ L:r-t .Jul)' L-Ie,i-.--- Insurance Company, Defendant State Farm Mutual Automobile incorrectly designated as State Farm Insurance Company, ("State Farm") by and through its attorneys, Forry, Ullman, Ullman & Forry, P.C., hereby files the following Notice of Removal, and in support thereof states as follows: 1. A Complaint in the above-captioned civil action was filed in the Court of Common Pleas of Cumberland County on or about March 2, 2000, and docketed as Cumberland County Court of Common Pleas No. 1203 Civil Term 2000. A true and correct copy of the Complaint is attached as Exhibit A. 2. The Complaint alleges that Plaintiff James E. Bonn is a citizen of the Commonwealth of Pennsylvania, residing at 96.7 West Trindle Road, Lot 24, Mechanicsburg, Cumberland County, 17055-4056 and that plaintiff was a State Farm insured pursuant to a policy of automobile insurance when hhe was injured in a motor vehicle accident on June 12, 1998. --~ .~..;- ~. 3. The Complaint further alleges that State Farm has acted improperly in denying c~verage for some of Plaintiff's medical bills following the submission of those bills to a peer review organization. 4. The Complaint includes a breach of contract claim under Pennsylvania's Motor Vehicle Financial Responsibility Law, 75 Pa. C.S.A. ~~ 1716 and 1798, a claim under Pennsylvania's bad faith statute, 42 Pa. C.S.A. ~ 8371 (Count II) and a claim for deceit (Count III). 5. Defendant state Farm is an Illinois corporation in the I business of insurance, with its principal place of business located at One State Farm Plaza, Bloomington, Illinois, 61710. 6. Removal is timely under 28 U.S.C. ~ 1446 (b) because less than thirty (30) days have elapsed since State Farm was served with the Complaint on March 15, 2000. 7. State Farm will give written notice of the filing of this Notice, as required by 28 U.S.C. ~ 1446 (d). 8. A copy of this Notice will be filed with the Cumberland County Prothonotary, as required by 28 U.S.C. 1446 (d). 9. State Farm is filing this Notice of Removal in that diversity of citizenship exists between Plaintiff and State Farm and the amount of controversy exceeds the jurisdictional amount of $75,000.00, not including interest and costs, because the 2 "'---r- Complaint includes a claim for punitive damages and treble damages under Pennsylvania law. WHEREFORE Defendant State Farm Mutual Automobile Insurance Company requests that this action proceed in this Court as a Civil Action properly removed. FORRY, ! , ULLMAN & FORRY, P.C. Dated, ~ By: /~tt----- L E. ULLMAN, ESQUIRE MARK ALAN RAITH, ESQUIRE Green Hills Corporate Center 100 Kachel Boulevard, Suite 200W Reading, PA 19607 (610) 777-5700 3 , i ~~.~ IN THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF PENNSYLVANIA JAMES E. BONN, Ci vil Action Plaintiff, No. 00- vs. STATE FARM INSURANCE CO. Defendant. VERIFICATION The undersigned hereby verifies that I am attorney of record for Defendant State Farm Mutual Automobile Insurance Company and that the statements contained in state Farm's Notice of Removal are true and correct to the best of my knowledge and information. This statement is made subject to the penalties of 18 U.S.C. ~ 1621, relating to perjury. Dated: 4fo By, , ULLMAN & FORRY, P.C. E. ULLMAN, ESQUIRE -'-~ 03/20/00 oM.ON.11.: 35 to'AJ.. .JOt:! I b() (S.~v" .c.vJ...",,) 03/17/00 12;26 FAX 717 764 5007 STA1E FARK ," --~---- --. - - -< ------ - .-.- li!I002 ....j]Ol ^ . JAMES E. BONN, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUN'rY, PENNSYLVANIA v: NO. 2000 CIVIL ./ ~ 00 - 120.) GCJt.l.. ~ CML ACTION. LAW JURY TRIAL DEMANtlED STATE FARM INSURANCE CO.,: Defendant NOTICE u___"'" You have been sued in qourt. If you wish to defend ltgainst the claims set forth in the following pages; you must takl) action within twenty (20) days after tI" is complaint and noUc:e are served. by entering a writbm appearance personally or by attomElY and filing in writing with the Court your defenses or objections to the claims set forth against 'fOU, You are warned that if you fail to do so the case milY proceed without you and a judgmen'; may be entered against you by the court without furthu notice for any money claimed in the complaint or for any other claim or relief requested by tM Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPEOR TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CA'NNOT AFFORD ONE, GO TO OR TELEpHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, L,- L;_ ':IJmberland County Bar Association 2 Uberty Avenue . ~;, Carlisle, PA 17013 .::, Telephone (717) 249-6166 " :: I. .,..-1 ~'I ., :'~ fd";r' ,_ I' ~:;~: c...r-: I. ! ,_ ~. ~ t" . ,-> '.": '::':J ~_'~ ~,.;~: r-i ~~~ MattliewS. rtiiby, Esq:- I.D.#69367 31!l Market Street P.O. Box 1177 Hanisburg, PA 17108 (717) 236-2001) '.;..} .::. ~:J DATE: "I2.9/2aOCl Attorneys for Plaintiff .' .. '/0~' ~ - . .__.~ ~:'~ '~1. :~.. _ 1', In ~=2,SrJ~~"RECORD and thi.~~ .~!!J' ,m,ll~ my hand '- T~r;::.:::.i " a;~le, Pa. ' ,:" ~~~~"'" ....".. rcrnatary ",w: r <".~ _ ~__ 'Cl"....... (() (Q), 9QJ t=:-:.,.~~" 03/20/00 MON 11;35 FAX 309 766 8202 EeLS IilJ007 OF17/0Q 12;26 FAX 717 764 5007 .--'_. .--- -~.- STATE FARK -+t - -------..... li!I003 JAMES E. BONN, Plaintiff IN T E COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2000 CIVlI_ ' ' STATE FARM INSURANCE (:0.,: Defendant : CMl ACTION:~ LAW . ' JURY TRIAL DEMANDE:D COMPLAINT ~'.;--...,.. AND NOW, comes the Plaintiff, JAMES E. BONN, by and through his attorneys, HANDLER, HENNING & RO:3ENBERG,'by Matthew S. Crosby, l:sq., al1d brings this Complaint against the Defendant, State Farm Insurance Co:-anc. in support thereof, avers as follows: 1. Plaintiff, Jameu IE, Bonn, is an adult individual currently residing at 967 , ,",< '. West Trindle Rd., Lot 24, M/1Chanicsburg, Cumberland County, PA 17055-4056, 2, Defendant, Stllbs Farm Insurance Co., is,an,insurimce company licensed to tr;1nsact business in the C:clmmonwealth of Pennsylvar:Jia, with offices situated, inter ",.d'"' " alia, at 115 Limekiln Rd., NHW Cumberland, Cumberla~~..C_oun~/, Pennsylvania 1707'"' ' 3, Defendant, State Farm Insurance Co,. regularly clmducts business in Commonwealth of Pennsylvania and, specifically, in Cumberland County, Pennsylvania, 4, On or about June 12, 1998, Plaintiff, James E. BClnn, was traveling on Simpson St. in Mechanicsburg, Cumberland County, Pennsylv'3nia, when a vehii::;le operated by Lauren F. Bogar, also traveling on SimpsQnSt., violently struck the r.;>--" .;1 another vehicle, causing a chain reaction collision involving th~ Bonn'':i;;.:;!e. Page -1- '''''''''''''_J_ ~" OJ/20/00 MON 11;J5 FAX J09 766 8202 EeLS 141008 03/17/00 12:27 FAX 717 764 5007 , , STATE F.uuI 1i!I004 5, Prior to the aforementioned collision, on or about F.abruary 19, 1998, ~he Plaintiff, James E. Bonn, had purchased a policy of motor vehiclE! insurance with the Defendant insurance company, through its authorized agent, BolJ May, at 382 Market St., Camp Hill, Cumberland County, PA 17011. Said policy was in full force and effect on June 12, 1998. 6. Pursuant to thE,lerms and conditions of.~i:liq.Eglicy with Defendant, the Plaintiff, James E. Bonn, wai a named insured. Plaintiff had pa d an additional policy premium to obtain $100,000.00 in first-party medical loss benefits, in accordance with the Pennsylvania Motor Vel",ic:le Financial Responsibility law, 7. AI; a result of the collision, Plaintiff, James E. Bonl', sustained serious bodily injuries, including, but not limited to, injuries to, ~is. ~iClal and lumbar spine and intervertebral discs. ,,' ':~ 8. As a further result of the aforementioned collision, Plaintiff has been . ".~... . compelled to receive and unclergo extensive medical attention and care and to el<pend large sums of money and/oJ" incur various expenses for which medical expenses are payable. He will be obligatl~d to continue to expend ancllqrincllr the same for an indefinite period of time in ha future.' 9. After the cOIli/.ion, Plaintiff, James E, Bonn, sougtlt reasonable and necessary medical treatmel,t and received reasonable ar:d necessary prescription Page .2- '.,-~ " 03/20/00 MON 11;36 FAX 30~ 766 6202 EeLS ~009 ,-- .-.-------- ---- Ii!J005 03/17/QO 12;%7 FAX 717 784 5007 , STATE FAlUI medication from various meclical providers for said injuries, These medical providers include, but are not limited to: a. Dr. Steven B. Wolf, Orthopedic Institute of Pennsylvania, 890 Poplar Ghurch Rd., Ste. 106, Medical Arts Building, Camp Hill, Cumberland County, PA 17011; b. Rudi CI ider, Holy Spirit Hospital and Health System, Medical Arts Buildin!), 503 North 21"' St, Camp Hill, Cumberland County, PA 17011; -." -_. ._,'~-' c. Dr. The,mas Malin, 99 November Drive, Camp Hin, Cumberland County, PA 17011; 10, It is averred lhat all medical bills have been, and continue to be, fair, reasonable, and medically :lscessary, and that all treatm~l'lt hEIS been, and continues to be, related to the aforementioned incident. 11. Defendant, Siate Farm Insurance Co., pursuant tJ 75 Pa, C,S.A, ~1797(b){1) of the Pennsylvania Motor Vehicle Financial Responsibility law, as ,,".-, ' amended, has contracted Clr; three separate occasi9ns wIth thE: same peer review organization (PRO) for the alleged purpose of confirming that Plaintiff's treatment c:onformed to professional standards of performance anq,wasnedically necessary, The name and address of :;aid PRO is: Disability Management: Associates, 1489 Baltimore Pike, Building 200, 3n1 floor, Springfield, Delaware County, PA. hereinafter nOMA," , - ~ Page -3- '~'"-~ , OJ/20/00 MON 11:J6 FAX J09 766 8202 EeLS ~010 03/17/00 12:28 FAX 717 764 5007 (' ._.'--~-'-' _0- ------=- -----~- STATE FAb 1aI008 1\..411' 12. Defendant, St~lte Farm Insurance Co., has also contracted with Dr. Bruce Goodman, 1515 North Front. St, Harrispurg, Dauphin County, PA 17102, in order to conduct an insurance medical examination, for the alleged purpose of confirming that said treatment conformed tc. the professional standards of perfe.rmance and medical necessity. 13. Defendant, Stale Farm Insurance Co., allegedly as a result of the aforementioned peer reviews and insurance medical examil1ation, has denied payment to various medical providers, including, but not limited to: a, Dr. Ste~l9n 8, Wolf; b. Rudi Crider; c, Dr. Thomas Malin; - -:~, ._.,~.. d. Weis F'harmacy; ,0 e. Central Pa. MRI; and !, f. Annap'Jlis Radiology. 14. From the commencement of treatment, and, at various times thereafter, Plaintiff, James E, Bonn, and his medical care provider~},lelve requested that Defendant pay the aforementioned mmfical and prescription bills." ,. 15. Plaintiff's cre,jit history has been, and Will in.~e f.Jture, be adversely affected, as long as Defendant continues to deny responsibility for payment of reasonable and necessary medical bills. Page + -"JI'lf-- ~~-~r~"'''''' I 03/20/00 MON 11;36 FAX 309 766 8202 EeLS ~011 03/17/00 12:28 FAX 717 764 5007 ,. STATE FARM li!I007 ';;~Ill~. 16, Plaintiff's third-party personal injury claim has been, and will in the future be, adversely affected, as long as Defendant continues to deny responsibility for payment of reasonable and necessary medical bills. PI'. Stan lev Askin. Review No.1 Julv 29, 1999 17. On June 1, 19S19, Defendant, Stale Fann!!ls!;~nce Co., wrote to James Bonn and Dr, Steven Wolf, Ildvlsing both parties that It had requested DMA conduct a peer'review. 18. Defendant, State Farm Insurance Co., forwarded 110 correspondence at that time, notifying Dr. Thomas Malin, Annapolic Radiology, and/or Weis Pharmacy, of its request for a peer review. ' .~ -l::~~ t 19. On June 4,1599, DMA received Defendant's request for a peer review. ,,' ... ,_J..... 20. On June 29, 1999, DMA received Dr. Wolfs medical file, with regard to the Plaintiff, James E, Bonn 21. On June 29, ~ 999, DMA commenced its peer review of the medical treatment proVided by Dr. Wolf, :';SU;". 22, On July 29, 1999, Dr. Stanley Askin, the r~~iewing orthopedic physician, wrote a peer review report letter to DMA. !'- .<~ ':- . .. ~;-: , Page -5- :-i'_'~""""- __~ - 03/20/00 MON 11;37 FAX 309 766 8202 EeLS ~012 . .L.... 03/17/00 12:28 FAX 717 764 5007 _...--- STA.'l!...-~ ___n _ Ii!l008 ..",.....l~ 23. In his fiVe-page report, dated July 29, 1999, Dr. Asldn opined, inter alia: a) "Please consider triat there are schools of thounht in the practice of medicine, in that the opinion Which must be proffered regarding la particular case certainly depends upon the l;chool of ~hought held by the reviewer." b) "The source of back pain is controven;ial. There are those who ""---""~ may holj that the disc is a primary or proximate source of back pain. Different thoughts abound as to the pJtential neuroanatomy which might explain back pain." c) "Please observe that I would not, in any manner, dispute the possibility of significant discomfort experienced by Mr. Bonn." d) "In summary, it is my opinion that the care provided by Or. Wolf from April 22, 1999 and ongoing would not )e considered . ,; '.. ' reasomlble or necessary for injuri~s;:ilustairled on June 12, 1998," , 24, A copy of the llforementioned peer review report lutter is attached hereto made a part hereof, and ma-ked, "Exhibit A" 25. Nowhere in hi:; five-page report does Dr. As~n rerider an opinion with regard to the reasonablenel;s and/or necessity of care provided by any medical provider, other than Dr. Wolf. 26. On August 2, '1999, State Farm received Dr. ~kir,'s peer review report and a one-page leller from IJMA, outlining his conclusions. Attached hereto, made::l part hereof, and marked, "Exhibit B," is DMA's letter to the Defendant, Page -6- -'~..,..,..,~~~ ~ ~ 03/20/00 MON 11;37 fAX 309 766 8202 J;CLS ta]013 03/17/00 12:29 FAX 717 764 6007 STATE FARlI . -- --- ---- IdJ009 , , "."II~~lP 27. On August 4, 1!399, Defendant, State Farm Insurance Co., sent letters to Annapolis Radiology, Central PA MRI, and Dr, Wolf, advising these providers that they would not pe paid, purslJant to Dr. Askin's peer review repcrt letter. 26, On February 9, 2000, Defendant, State Farm Insurance Co" sent a letter to Dr. Wolf, again denying his medical bills and further advising him to contact Plaintiff directly or Plaintiff's health insurance carrier for payment, in violation of 75 Pa, C,S.A. ~69.52(h). 29, Pursuant to 31 Pa, Code, ~69,53 (e), the PRO must apply national or, where appropriate, regional norms In conducting determinationli. Where nalional and regional normS do not exist, a PRO must establish written criteria to be used in conducting its reviews, basE'ci on typical patterns of practic~ in Ihe PRO's geographic area of operation. 30.. Despite Dr. Al,kin's admission that no nati9J),al or regional norms exist, DMA failed to establish or apply any written criteria to use in its review, in violation of 31 Pa, Code, SS9.53 (e), Defendant's acquiescence of ;;uch a(:tion is also violative 0'1 31 Pa, Code, s69.53 (e). r, 31, Pursuant to 7!i Pa, C.S.A. ~1797(b) and 31 Pa, C:lds, 969,52 (g), there must be a determination of "not medically necessary," for there to be an adequate b~s;", for a PRO to deny payment of a medical provider's bfJl. 32. Despite the f~ct that Dr. Askin's review was clearly limited to the treatment rendered by Dr. Wolf, DMA denied payment of bills, from ~oth .l\nnapolis Radiology and Central PA MRI, in violation of 75 Pa, C,S,A. 91797(b) and 31 Pa, Code, S69.52 (g), Page -7- .,'M<t......... ! 03/20/00 MON 11;37 FAX 309 766 8202 EeLS 141014 Oj/17/00 12:29 FAX 717 764 5007 . STATE FARK Ii!I010 ..,i\NI~ ~ 33. Plaintiff beliel/es and, therefore, avers that there was no reasonable basis to deny payments to Dr, Wolf. because the peer review n3port relied on blanket characterizations of aCC8pl.,~d treatment without any physical e;(amination of Plaintiff, James E. Bonn, The PRO did not consider Plaintiffs prior health, specific injury, mechanism of injury, or his current medical condition, before relaching its conclusion. 34. Plaintiff belie.res and, therefore, avers_~haut!~re 'Nas no reasonable basis to deny paYments based on the July 29, 1999 report, bec:ause Dr. Askin did not perform a detailed analysis Of the case and overlooked specifh: findings. 35. Plaintiff furthllr avers that Dr. Askin exhibited bia!;, circular reasoning, and arbitrariness in his analysill. Defendant's acquiescence of such action is violative Of 31 Pa. Code 969.52, et sea. Daniel Looreto's Review,. : Auaust 17,1999" 36. On June 1, 1999, Defendant, State Farm Insurar ce Co., wrote to James 1-."'" , E. Bonn and Rudi Crider/Holy Spirit Hospital, advisi'19 both parties that it had requested DMA conduct a peer review, 38. On July 8, 1 ~199. DMA received Rudi Criqer's medical file with regard to the treatment he providod Plaintiff, James E. Bonn. Page -8- .~ I ~ . 03/20/00 MON 11;38 FAX 309 766 8202 EeLS ~O1.5 03/17/00 12;30 FAX 717 764 5007 . .----- , . STATE FARII /lion 39. On July 8, 199E'. DMA commenced its peer review on the treatment provided to Plaintiff, James E. Bonn, by Rudy Crider. 40. On August 17, 1999, Daniel Lopreto, the reviewing psychologist, wrote a pear review report letter to DMA, 41. In his August 17, 1999 report, Lopreto opined, inter alia: a) "I believe that the claimant's current level 01 depression, which appears to render him dysfunctional, is partially attributable to his chronic and severe level of pain." b) "I believe; based upon the information provided. that the claimant's pain is influenced by his depressive state Ji 'ld his medical condition." .. . ~T _ -,.j\', c) "In the c:ase of Mr. Bonn, as is typical of most chronic; pain patients, a vicious cycle of pain-depressiol'l(~n!;lElrH'ain is operating. It is necessmy to interrupt this cycle, if the patie'nt is to achieve some degree o~ resolution, Psychother!'lPy:~~~ornes a reasonable and necessHry treatment for this type CJf prpblem.... Psychotherapy must be' active, directive, time-Iimited,~ith specific goals and objectives. The focus must be on function;;.Ilty, rather than subjectivl~ pain. The therapy as provided by Rudi Crider and Holy , , Spirit Hospital meets these criteria," d) "In summary, based upon my review of the documentation submitted, as well as my conversation with Mr. Crider, I view the Page -9- '~-I ~, 03/20/00 MON 11;38 FAX 309 766 8202 EeLS ~016 03/17/00 12;30 FAX 717 764 5007 STATE FARH ,__ .<.--- -_.---- ~ _..._-~------ li!I012 "11' . 5ervice~ provided by Holy Spirit Hospital frc.m 1/11/99 through 6/16/99, as being reasonable and necessary for injuries sustained in the motor vehicle accident of 6112/98," The aforementioned peer review rePort is attached hereto, made a part hereof, and marked, "Exhibit C." 42. On August 25,1999, eight days after Lopreto's report was completed and ..----,.. 48 days after it had all of thl~ information it had previously requllsted to conduct the peer review, DMA compleled its peer review. 43. On February H, 2000, Defendant, State Farm Insurance Co., sent a letter to Holy Spirit Hospital. again denying payment of their bills and further advising Holy Spirit to contact Plaintiff dimctly or Plaintiffs health in~.~r~"l;e carrier for payment, in violation of 75 Pa. C.S.A. !!i l~r97 and 31 Pa. Code !!i69..52 (h). 44. On August 31, 1995. despite the clear lan~u13ge (If Loprelo's peer review report letter, Defendant, SUIte Farm Insurance Co., sent a letter to the Plaintiff, advising him that it would not be issuing any payment for services rende,red by Rudi Crider and/or Holy Spirit Hospital :m or after June 17, 1999, Attachec, hereto. made a part "I '. -.. , hereof, and marked, "Exhil::it D," is said letter. 45, Pursuant to 75'Pa. C.S.A., !!i1797 (b) and 31 Pa. Code !!i69,52(g), there must be a determination of "not medically necessary;" for there to be an adequate basis for a PRO to deny payment of a medical provider's bill. 46, Despite the fHct that Daniel Lopreto's review failed to conclude that any psychological treatment PI:aintiff had received was medically u'1necessary, Defendant, Page -10- ~r"""'" ~~ , "I UJ/ZU/UU MON 11;38 FAX 309 766 8202 EeLS 1ill017 - --",. -.-. 12:~0 fAX 717 764 5007 STATE FARk .-' .----------------- li!I013 03/17/00 State Farm Insurance Co., ~dvised the Plaintiff, James E. Bonn, that it would not pay any future bills from Rudi Crider. 47. P,ursuant to 31 Pa. Code ~69.52(d). a PRO'sinitiEl1 determination must be completed within 30 day:; after receipt of its requested information. 48, DMA did not complete its peer review in this mattftr within 30 days after it had received all of the information previously requested, in violation of 31 Pa. Code ....,-~... g69.52(d). Defendant, Stah Farm Insurance Co.'s acquiescence in such act is also violative of 31 Pa, Code ~6!152(d). 49. Plaintiff belie\res and, therefore, avers that there was no reasonable basis to deny prospective paymellts to Rudy Criderl Holy Spirit Hospital, based on the Daniel Lopreto peer review report letter. .;; ':'.. .::( ~Ir, Stanlev Askin's Second Review September 15.1999 -!.:;" : ~ ~ i:~ 50. On August 4,1999, Defendant, State Farm!nsumnce Co., wrote to Plaintiff, Dr. Thomas Malin, and Weis Pharmacy, advising,all parties lhat it had requested DMA conduct yet another peer review with resRect to a Prozac prescription, . '!"-'" written by Dr. Malin. 51. On August 4, 1999, DMA received Defenda~t:s rnquest for yet another peer review, 52. On August 4,1999, DMA had, in its possession, 511 of the information it deemed necessary 10 conduct the peer review. Page -11- -;-~'" -I ,.~ ,"""'- ' ~", ,. " - 03/20/00 MON 11;39 FAX 309 766 8202 EeLS 1ai018 03/17/00 12;31 FAX 717 764 5007 ___1_._- STATE FARII 1ilJ014 , " "^~II~la 53, Dn August 26, '1999, DMA commenced its peer re'liew on Dr, Malin's prescription of Prozac. 54. o.n August 31,1999, the Defendant, State Farm Insurance Co., wrote to Dr. Malin, denying payment of his medical bill and referencing Dr. Askin's July 29, , , 1999 report, wherein Dr, Askin makes no mention of Dr. Malin's treatment. 55. o.n September 15,1999, Dr. Stanley Askin wrote his second peer review n__~_ report letter in this case to CIllIA. In his report, Dr, Askin opined, inter alia: a) ''The pmliided records (previously enumerated in my report of July 29, 1999) do not yield sufficient medical or psychologic information that would pennit a thoughtful consideration of the need for an antidepressant medication." i!s ~~i8 ;1 b) ''The bottol'l1line is that, if Mr. Bonn is deprel;sed, the use of an antidepressant, such as Prozac.}sm~dically reasonable and ....-._., I., necess,~ry...." Attached hereto, made a psrthereof, and marked, "Exhibit E," is Dr. Askin's second .. .j.'. peer review report. : '_ i \ ',,":;. 56, Cn Septembe~ 15, 1999, some 42 days laft~jt ha:! received all of the information necessary to ccnduGt its review, DMA completed itll third peer review in this case. 57. Pursuant to 31 Pa. Code 969,52(d), a PRC'sinililll determination must be completed within 30 days after receipt of its requested information. :; , Page -12- ~ ,~ 03/20/00 MON 11:J~ tAb.. .)v~ tUb O""V"" :u....I....) -.::.I"...... 031)7100 12:31 FAX 717 764 5007 "~ STA1E..~_ li!I015 58. DMA's failure t.) complete its peer review within 30 days after receipl of the information requested is in violation of 31 Pa. Code 969.!i2(d). Defendant, State Farm Insurance Co.'s acquil!scence in such action is also viola':ive of 31 Pa, Code S69,52(d). 59, Plaintiff believ'!s and, therefore, avers that there was no reasonable basis to deny payments to Dr. Ma:in and/or Weis Pharmacy, because, the peer review report ..-..--." relied upon blanket characbuizations of accepted treatment, without any physical examination of James E. B,,"n. The peer review report letter did not consider Plaintiff's prior health, specific injury, mechanism of injury, or his current medicaL condition, before reaching its conclusion. 60. Plaintiff believes and, therefore, avers that there 'Nas no reasonable basis ,-".,.. - , to deny payments, based 011 the September 15, 1999 report, bf~cause Dr, Askin did not ".,,-.- ,;1 perform a detailed analysis of the case and overlooke,d ,liP~cifil: findings. 61. Plaintiff further avers that Dr. Askin exhibited biali, circular reasoning. and arbitrariness in his analysis. Defendant's acquiescenc';l of such action is violative of 31 Pa. Code s69.52, fZl~, 62. Pursuant to Pa~ Code 959.52(c), a PRO must affclrd the medical provider , , ' an opportunity to discuss thel case with the reviewing phYsician amI to submit any information to the reviewer prior to a final determination. 53, DMA's failure to provide Dr. Malin and/or Weis Pharmacy with the opportunity to discuss this case with the reviewing physician is violative of 31 Pa. Code Page -13. ," '--r-' .' , 03/20/00 MUN !L:4V ~AA JO~ '00 o~v~ ~~~- 03/17,00 12:32 FAX 717 784 5007 STATE FARM ----. -~-;-+".__.". .--..-----.- -...-..- ----- ~Q16 , ,1'iMII~I<< 69.52(c). Defendant's acquiascence in such action is also violative of the above-- referenced code section, 64. In addition, DMA's failure to provide Dr. Malin with an opportunity to submit additional information to the reviewing physician is also IIiolative of 31 Pa, Code @69,52(C), Again, Defendant's acquiescence in such action is ~llso in violation of the above-referenced code section. ...,--.... 65, Pursuant to 31 Pa, Code S69.52{e), a PRO's writtan analysis shall include specific reasons for its decillion. 66. DMA's and Dr Askin's written analysis failed to include specific reasons for Its decision, in violation of 31 Pa. Code sS9.52(e), Defendent's acquiescence in such action is also in violation of 31 Pa. Code S69.52(f;l),.: i 67, With respect to all three peer reviews conducted ;n this matter, it is averred that the initial referrals were violative of 31 Pa, Cod~ ~69.52(a), whereby a provider's bilf shall be refemro to a PRO, only when cir::un;astances or conditions relating to medical and reh~lbilitative sel'\lices provided, cause a prudent person, familiar with PRO procedums, standards, and practices to beliove it necessary that a PRO determine the reasonableness and necessity of care. "."'" ; Dr. Bl'\JCe Goodman Insurance Medical Examination October 29. 1999 68. Following the aforementioned peer reviews, Defendant, State Farm Insurance Co., continued to deny medical bills submitted l:lY thi! aforementioned Page -14- 1'~_ - ~ 0'120100 MON 11;40 FAX 30ij 766 ..0< r,(,.,L.::i ~,,-~ 03i17100 12;32 FAX 117 764 5007 STATE FAR. li!I017 : medical providers and Plaintiff, James E. Bonn, continued to rec:eive medical bills and/or collection notices. 69. By virtue of De,fendant, State Farm Insurance Co.'s, continued qenial of , the aforementioned medical bills, Plaintiff, James E. Bonn, was compelled to submit to an insurance medical examination, conducted by Dr, Bruce GOI)dman on October 29, 1999. ..~_......"" 70. On October 2H, 1999, Dr. Goodman wrote an insurance medical exam- inatioo report letter to DMA 71. In his October 29, 1999, report, Dr. Goodman opined, inter alia: a. "This man sustained cervical and lumbar strains in 8 direct and causal fashion to the motor vehiclJl':I~ f,c,:cident of June 12, 1998," b. "I believe his large disc protrusion at L4-L!i on the left, as well as a large posteriorly displaced left-sideddilic ilt C5-C6 were either .', . ..~_, "I. aggravated by. or, more remotely, a direct cause of the motor .... 'I vehicul~ accident." c, ''The surgery utilized for the treatment of tis lumbar disc in September 1998, as well as all treatll1~t to that date, would have a direct '3r,d causal relationship to the motor vehicular accident on June 12. 1998," Nowhere in his repc:,rt doe!> Dr. Goodman address the r~asonableness and/or medIcal necessity c.f prospective medical treatment, after October 1999, . -i " Page -is.., j~-r-. " ~ ~. UJ/ZU/UU MON 11:40 FAX 309 766 8202 EeLS ~022 03'/17/00 12;32 FAX 717 764 5007 .- "~----- ._--... ST~,!!, F,\RJ1 raJOlll '"j.j IIi , 72, On November ~9, 1999, Defendant, State Farm In:lurance Co., sent a letter to Plaintiff's counsel, ir.cluding a copy of Dr. Goodman's irsurance medical examination report and stating that, "His findings agree with the PRO findings." 73, On December 3,1999, Defendant, State Farm InslJrance Co., sent another letter to Plaintiff's c(lunsel, stating, inter alia, "The IME report was very thorough and supported the findings of the two PRO reports, T1erefore, we stand by our previous denials of Mr. Ilonn's continuing treatments:.....- 74. Despite the fallt that Dr. Goodman's report did nol address the reason- ablen9SS or necessity of on!~ing medical care, Defendant, State Farm Insurance Co" continued to deny payment of medical bills, in viOlation of 75 Pi!. C,S.A. ~~1716 and 1798. .' , :-.rr: 75. Plaintiff believes and, therefore, avers thatt~ere was no reasonable basis to deny payments to any modical providers, based on Dr. Gooclman's insurance '. ., I medical examination report The insurance medical examinaticln did not consider . ~_. Plaintiff's prior health, specific injury, mechanism of injlJry. ,or his current medical '. " condition, before reaching its conclusions. "'-" .., 76, Plaintiff further avers that Dr. Goodman e~ibited bias, circular reasoning, and arbitrariness in portion'i of his analysis. Defendant's ,acquiescence of such action is violative of 75 Pa, C.S.A flS1716 and 1798. 77. To date, Defendant has refused to pay the balanGe due the I . aforementioned providers, under the terms and conditions of tile applicable policy of insurance and the Pennsylvania Motor Vehicle Fi~andal Responsibility law. Page-16- "---r-'" OJ!lO/OO MU~ 11;41 rAX J09 766 Sl02 BCLS 1aJ023 03/17/00 12:33 FAX 717,764 SOOT ~A1E FARII --- _...---- -~--_..- .-.- ~.-_. , 1i!l019 !j,i 1....III~ As a result of the aforesaid, Plaintiff, James E. Bonn, has been r:!quired to hire the services of an attorney to collect the medical bills herein due. Defendant's course of conduct in this case has been unreasonable and without reasonable foundation. Therefore, pursuant to 75 Pe. .c. SA ~~1716 and 1798, respectively, Plaintiff is entitled to attorneys' fees, as well as 12% interest on the unpaid bills. COUNT I BREACH OF CONTRAQ,_ 78. Plaintiff incorporates Paragraphs 1 through 77 herein as if fully set forth at length, 79, By withholding payments with no authority to do 5'J, unnecessarily and improperly referring bills to II PRO, not adhering to the several ':emporal, procedural, I .."- ~ 'I ;.,). and substantive requlrementg, as set forth in law, and aCql.ifescing in the PRO's failure -! . . ( ~- -, .0'- to do so, Defendant has undertaken a course of action thalhas been designed to ", unilaterally, and without justification, refuse claims for med'ieal benefits, causing Piaintiff to become persona'l}' responsible for medicaf bill~' arh5ing out of the maintenance or use of a motor vehicle, in contradiction to the b3rms of their contract , the Pennsylvania Motor Vehil~le Financial Responsibility law, the medical cost- containment regulations, ar,d' established case law oI this Commonwealth. 80. Plaintiff believes and, therefore, avers that the al:ove-described actions of Defendant are unreasonable and without reasonable foundaticn. 81. The above-de'scribed actions constitute a breach of contract by Defendant, State Farm Ins\lrance Co" with Plaintiff, James E. 130nn, Page -17- ~ < OJI20100 MON 11:41 YAK J09 766 8202 "3/17/00 12:33 FAX 717 764 5007 EeLS @024 STATR FAIUI li!I020 1'1 82. Pursuant to 75 Pa. C.S.A. 991716 and 179B, in th,;! event that the insurer has acted in an unreasonable' manner in refusing to pay the benefits when due, the' insurer shall pay the benefits owed and interest of twelve percent (12%), costs, and all attorneys' fees. WHEREFORE, Plaintiff demands judgment in his favor, in an amount in excess of twenty-five thousand doll;afS ($25,000.00), including the benl~ts averred, interest of twelve percent (12%), and "II attorneys' fees. COUNT il BAD FAITH 83. Paragraphs 1 through 82, above, are incorporatej herein as though fully set forth at length. 'ism i 84, On or about February 7, 1990, the Governor of U- e Commonwealth of ::r:'_'] t;'1(;; Pennsylvania signed into le,w 42 P .S. 98371.. effective July 1, 1990, titled, "Actions on '1': . 'if':' :,r Insurance PoliCies," which ,Jl'ovides 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 amount 1_., .~,.,' equal to the prime rate of interest plus 3%; (2) Award punitive damages against the insurer; '.', ,J '. ,t ',r Page .18- .- 3i' " " ;!;'>O*""""""~~I_ '. D3/20/00 MON 11;42 FAX 309 766 8202 EeLS 141025 O~/17/00 12;34 FAX 717 764 S007 . '-- S'fATll F ARK liIl021 i1i1I1111I~1l (3) Assess court costs and attorney fees against the insurer, 85. All treatment was provided to Plaintiff after the effel~tive date of the above Statute and the alleged bad fl~ith occurred after the effective datE' of the Statute, 86. It is believed and, therefore, averred that the Defendant insurance carrier has employed the reviewing (lrganization, DMA, in bad faith. Sa,d organization does substantial review work for the Defendant and, as a result,..has a strong financial interest in providing a biased review report to the Defendant. 87. Moreover, said review organization has, or may have, continuously been providing negative review reports to this Defendant and other automobile insurance carriers for the purpose of m;3intaining a steady source of businElSs, thereby showing a ; ~ ' 88, DMA is a sham PRO, invariably providing Def~rldanl with findings that medical treatment is not rea!;onably necessary, 89, DMA is a "captive" reviewer that is known by the De/endan; to i:;sue favorable reports to Defendslnt, so as to induce Defendanfs corltinued use of its organization. .,< Page -19- I ; .'~-r- ~ ~ -~ ..,- OJ/20/00 MON 11;42 FAX J09 766 8202 EeLS Ii.!J026 03/17/~_2:_~!,,~7~--2!I!, 5007 ___ _.sTAT!! FARII III 022 90. Defendant, throuJt1 its representatives, agents and/or employees, has breached its its duty to act in good faith and conducted said peer review for an impermissible purpose by thE! following actions: (a) Representing that the Plaintiff, James E, Bonn, would be covered by the full amount of the medical benefits purchased undl~r the above-referenced policy, when, i.n fact, said promise was _~o~,)lIusIJry; (b) Purporting to offer a specified amount of medical (;overage, when, in fact, defendant had no intention of providing coverage ':0 said extent; (c) Charging a premium, based on a specified amount of medical benefits, when, in fact, Defendant purposely avoided fulfilling its contract to provide said amount of' benefits; (d) Denying Plaintiff, James E. Bonn, mediCf!lI b~nefit:l anellor payment of medical benefits without a reasonable basis; (e) Refusing to piiy'the Plaintiff's claim withoutponducting a reasonable investigation based upon all available information; (f) In failing to use DMA to evaluate the rea,sonableness and necessity of ;', . -: Defendants with biased reports; Page -20- --"...~ 03/20/00 MON 11;42 FAX 309 766 8202 Oa/17/00 12;35 FAX 717 764 ~007 EeLS ~027 S'rATE: FARI{ li!I023 (h) Not attempting, in good faith, to effectuate prompt, 'fair, and equitable coverage of claims, once the Defendant's responsibility under its policy of insurClnce had belcome reasonably clear; (i) Failing to evaluate and determine Plaintiff's entitlernent for treatment rendered, based I:Jpon the terms of the policy providing coverage to Plaintiff, James E. Bonn, thereby compelling Plaintiff to institute litigation; 0> By intentionally ignoring the authorized peer review process of the Act 6 amendments to the Motor Vehicle Financial Responsibility law; (k) By intentionally ignoring the clear language of the aforementioned peer review reports and advising Plaintiff thai future mejical bills would not be honored; (I) By referring all bills, incurred by State Farm ~olicy'olders who have purchased extnnsive first-party medical benefits like Plaintiff's policy of $100,000 in ml~dical benefits in the case at bar, to PROs; (m) By allowing a peirson unfamiliar with peer ,review ~rocedures, standards and practices fa determine that peer reviews were necessary, in violation of 31 Pa. CodEl ~69.52(a); and (n) By advising PI.ai:nff's medical providers to bill andl~r contact Plaintiff individually for bills it was denying on the basis of a peer review, in violation of 75 Pa. C.S.A. ~1797 and 31 Pa, Code !i69.52(n). Page -21- """""""~ ~ -,,- '- - ~, 03/20/00 MON 11;43 FAX 309 766 8202 EeLS 14J028 03/17/00 12;35 FAX 717 76~ 5007 STA1E F ARII IilI024 'jll'. . WHEREFORE, Plaintiff demands judgment in his favor in m amount in excess of twenty-five thousand dollars (:525,000.00), including interest, pun,tive damages, costs, and attomey fees. COUNT III DECEIT 91. Paragraphs 1 through 90, above, are incorporated herein as though fully set forth at length, ~'~-""""P" 92. The conduct of 1 hii' Defendant, State Farm Insurance Co., constitutes misrepresentation, fraud, and deceit, in that, inter aDa, Defendant: knowingly, willfully, and/or recklessly refused and failed to comply with the tenns ancl conditions of the subject insurance policy, including, but not limited to, the poncie~;, implied covenant of good faith and fair dealing, tr e Statutes of the Commonwealth of Pennsylvania, and the regulations of the Insurance Department of the Commonwealth cf Pennsylvania, and in ! .~' otherwise violating its fiduciary,contractual, and statutory duties in dealing with the Plaintiff. 93. The Plaintiff justifiably relied upon Defendant'srep~esentations in the policy and sales presentations by the Defendant's agents and/or pUblic advertising that all claims would be fairly anc promptly paid, which representations were false when made, which Defendant knew and intended thai those. represenlations would be relied upon, which Plaintiff did rely upon, to his detriment, and, therefore, the Defendant's conduct constitutes the common law tort of deceit, for which Plaintiff seeks compensa- tory and consequential damrlges, Page -22- ~'^'" . !"- - 03/20/~0 MON 11;43 FAX 309 766 6202 0'/17/00 12:35 FAX 717 764 5007 EeLS 14J029 STATE I'ARK li!I025 , WHEREFORE. Plaintiff, James E. Bonn, demands compensatory, consequential, and punitive damages from the Defendant. State Farm Insurance- Co., in an amount in exCE!SS of twenty-five thousand dollars ($25,OOO.OO), including interest, punitive damages, costs, and attomey.fees. Respectfully submitted, Date: "l.} Z '1/"W'o'?> . HANDLER,HENiIIING "n- By Matthew S, Cro:iby, Esq. Supreme Court J.D. # 69367 319 Market Stre,et P.O. Box 1177 Harrisburgi:PA 171 DB (717) 23B-2000 AttomeY~for Plaintiff Page -23- "'" 03/20/0~ MON 11;.8 FAX 309 766 8202 EeLS 1aJ004 03/17/00 1%:36 FAX 71~_764 5007 STATI! FARII IilIOZ6 r . ;I--~~,\I r '.., . YORK AU6 02 f999 STAlNLEYlL ASKIN. M.D. u.... A ~~SlIrpI)' TooIoIp....2U/~f5.,., :Ju2u.c:1Ul2A RANCOCASHPSPD'Al. ' ~IllDLIlINGEAST'lll/j 1113 ~J)Il1vE \VlI.LINCJBORO. NEW.nmsEY ll8046 1080 ClIJ:l YOlIl: 1lDAD 1201 (EUJNS]IAllKSQUA1IE It'm 6111i7 CIlJllCHROAD) ELIONS PAllX"l'A 190:17 Ms. ludithF. EVlIIIS, !IN., CD.M.S" C.C.M. Disability MiIIlagemedt A ......,.;.t.. 1489 Ba1t:imoa:l Pike Building 200, 'Ibird Floor Spr'~..t<J, PA 19064 ,,,",- -~--..~~ --"'''/1""",,, .JUI ....u ,~.: ~ 9 15'9~ U>'.r-.4 fP.. 'l;,~j,\1t.~tJ.. ~_f" ) July 29, 1m- AUG 0 6 1999 REceiVE.., BE: James BODD Claim f#: 38J023-737 DMAIh Cl'A6197 Dear Ms, Evans: A review ofsubmi.ucd mediCll!. Illl:O'. was ~ ofmc. Addq;Qftally. I Willi asbd to amtact the attorney, Mr. Crosby, lUIlisuchdid OOQJronJ'uly 19,1999. Mr. Cmsbywas mainlyinteratedin insuringtbatlhad been provided wi1:Tl all ofthencords. p.....,r.b. asl do IICthave a list ofwbat would constitute the cutirety ofncxds, lmerd.y obsem:cl that I was provided with abouttbree orfuur , cenn,..,.h"1l waRh ofn:cords whicb,l\llUIIded about rlsbt to Mr. CrosbyiusofilI' as the bulk of the recoo1ssbDllhhepm ~ ' ' Therequcst to c:ontactDr. Wolf;}"fr. BOIIIl's curraltphysiclan, seems to bay: been engendered. by Mr. Crosby as well :Even so, I did CDlltactDr. WoIfon J'u1y20. 1999. and hC sbllred with me his thoughts regarding Mr. Bonn. To parapbrar.e,; Mr. Bonn bas been recommended to submit fur "themud ablation of the ItillC" wbid\Dr. Wolf considel'S the 9OIlIC8 afMr. Boon's symptoms. Dr. Wolf apprised me that he is aware afMr. Bonn's large gUlhi. and he does not Iook::tavorablyupon tllC prospect of perlbnniDg SUJ:gmy upon Mr. Bonn. I did UDdeI.'SlaIId, 1iom Dr. WoJ; that lIIlI'PIY would be conducted, however. ifMr. Bonn cantVwed to \Xl""I.;., despite tI'Mfm- short of lIIIQ!lllY_ Provided for my review lIJC the following records: l. 2. The letter from Mr. Cros\;ydatedJ'Ulle3.199!J. _ The Scnice Request Fom.1 Brtd letter ofrefi:nal t:equeSliDg this re\'UIW, -'^~~ 0__ 031Z0/0~ MON 11:48 FAX 309 766 8202 EeLS 1li005 _, .,J!.3LU(Qo. 12: 37 FAl 717 764 5007 STATE FAR![ llJo29 r::. ,'l\lIIIUIll~_ Page 2 July 29,1999 BE: lama Bonn YORI( AU6 02 1999 3. The~oofu('bendiI3dpD:dlWUt23,l998. Alof'tbatdatr:, theselt'describedinjuly\WS .~ necIc, lower back m1 ;m...""eu infeet8. 4. MllI scan of the hunblf spi.1e dated J)e(o.emn..r 28, 1998 which was S11bsequeot to surgmy upon the US diac. 5. Ml.U pn ofJ'UIIe 30, 1998 ottbe cerW:a1 spine meaIins disc abnortlllllities cbaracteri:r.ed u "bulging! and at CS-6 modelate, IaIp sizaI, ~= ..,clem pWpos.lS. . . . 6. MlU scaD. ofhunbuspiuc ruly 2,. 1998 de8aibiDs disc ~. IItI3-411J1d IA--S. 7. MlU lIClIIl of April 26, 1999 Of the aniaIllpi,Dll dmal:tcrizins the liixlings, in so many wonls. u a~ type ofp:oc:eu at 0004, ~5 aad CS.(j. 8. ~gramof'S~9,1998, 9. EMGofNavember 20, 199$ by Dr. T...V"'M till" both upper cmenJities findi'1g "moderate to severo ~ ncuropamy, mixed motor 1IlIISCXY:with both clcrn,e1iDa1ing IIJId axonal ...rnnp^"......... Dr. Lupilllll:ci's report rD:nu:es past lllUFYupon tile nr:rves ofMr. Bonn's l_A -.too'. . .....upper.......eu.ity, ~,,:yeatSago. . . f~-.J, ...... ',., Also provided were bilIina ~ fottbe fbregoing imaging studiell, ~gram and EMG. 10, PainlllllJll8ement:recordaaFDr.Momin~I.u':"81u1y22, 1998 m1deacribing ~W 0 6 1999 injections that had bemp.~ with biI\iDg inwicea. 11. ~tbempyrec:oIdacnw-nPllCl1eto;""l,,""biIlinsinvoices iotsame. RECElva:. 12. The omce notes ofDr. M3I1n ~nnI'18 July 28, 1998 \1Iith','ta~"ed billing advice. ... 13. Recordsfi:omp;,."a~I"BJ)&pita1.datedMard117,1999" 14. Records ofDr. Wo1t'besiarlingMarcb.ll,l999, 15,' Records ofDr.Mi,.""l~ aneuroJosisL h ' 16. Hospital records fi:omHcly Spirit Bospital. These ;n.;:lnde the emeI~room record of June 12, 1998 d-mhina theDl8rhlD1mn ol'i.qjwybeingthatMr. Boiln VI'lIS a selUbeha1 drlwrwho was bit from. the I'ClIl" aDd p!1Shed into 1hc car in &oat ofhim with cclll1p1ainta ofhis back and neckhmtiug. , . '" , WJt!Jin the same sheafis dulnx:onl ol'hillWJlic:al ~byDr. Malin DOtio8 a pasthistmy of depre3aionand hypertJmon, IDd that be is ~ll;4 to be mmo:~ intact iDso&r as his bistOly IIIId physical CilllIII~on wwId reveal. "PnrlO8l:dwith these records is the opemtive . J:ePOrt of'September 30, 1998 which wiI1 be tl'1""'......, bmow. . 17. Chest x.-ray perlbnned on September 30, 1998 aod lIIl iutraopentitn: x-ray of'the Wmbar spine were provided without si,gnificant iDlbnDatioD 1'Lmt>lm..n thcn:in. 18. Labomtcnyreportsibtthe,pedoperativetesting. , A..ln,;,.'Il synopsis is tbatMr. B.mn is a rmt""1.1l" c:iJaprt~ lit tbumcrgency room and by Dr, Wolf as being obese. He was inlTlllved in a motorvebidc ar;clOeut on JlWl 12, 1998 when he WllS approximately 48 y= of ase- Be had the oDSCt of oedc lIDII baclc pain lI!'llnI"illTN! therewith. The MR.I stUdies revealed what MRJ: lilUdies usuaI1y reveal fOr people in the m'.ddIe years of1ife which is muItiple levels ofdisc lIbnonnatty. Such abno,...",tiriM arc wriously categorized by radiologists as bulges, protrusions, OI' hcrniatkn1-without any appatCIlt distinctimi inSOfk: as the choice of'tenDinology ;'~~.~ ~~. - ". nllllf' , ' - OJ/20/~O MON 11;49 FAX J09 766 8202 .. _,..Q:3L!J1QO 12:38 PAl 717 764 S007 EeLS 141006 STATE FA1lx 1aJ030 '.. ,iI'l1Ildllr-- ~ ( , YORK AUG 02 19S9 Page 3 July 29, 1999 BE: James DODD (the fiu:t ~ MlUIClIIl mveaIed dbJ; ilemiation has aO air1filAll\Ce iIIasmuch as any ,............ of lIS)'Il1pt~ iadiYiduals can be&llllO haw "disc herwoI"tl"ll- byMlU SCIII1l:1iteria. Jf~ with no symptoms can hIM: disc baDialinml, the "di.agn.osis" of disc bemiation is lD/...m"s'_ ) The EMGtbat was reportecl as rewaIiug pc..~..l neuropatbic tM"r might have same reIaIionsbip to the prior bistmy ofnerve ~ ill. ]d;uppc:rextnmil:y reli::raIcccJ by'Dr. UJpiDaa:i.. Buw1Mr. the ~ were ob8erWd to be biIitJnl BilattraJitywu DOt ri:jlu..c:d by disc; on the fitst cenical MRI scaD, aad iDI1o&c, as bilatcmlityOll tbe lIlDIIIlI cenical MlU scaa, it was by ClStIlOpbytll fijl'lJlllfiO'1 cIIar1rt~ as "mild",' , The operaliw tepOI& dated ~ 30, 1998 c:miect a ~.diw U1d. p:lStDpendiw .4l"S""'I:i~ of be:miated DII"''IIll pulpolUl Ii IA-5ob. the Jeft. ReYeaIed in the operative report is that M. auciate incision was madcinto it IIld cIisc II'lItaial WlII removed". Please obsarvIl thn iran ~.,;'V' hlultok.-. made into the disc to remove the dillll material, the disc; had DOt been hemiauxl. 1 " While I 40 appreciate that there wu aniDitial report to Dr. Malin ofimprovUn=l1 aAcr tbA~ 1999 that improvement seems not to haul'been Jo.og-Jived I_.llng to Mr. DODds ultimate repP'.....twtinn to Dr. Wolt: RECEI"E~ Dr. Walts ....t,...;.t. begirl";,,g on Mard111, 1999 desaibe "ew1uation by 1:11'. Janton who teIt that he does haVli ChaI:cot-Marie- Tooth". Please observe that such woul4 be lID CXJ?,""OtlOl1. tor the features notedinDr, ~"'EMG, n" WoIf'd1anlaerizedtbefindings onMr, J3onn'sx-rays andMlU scan. wulhe "^"<llt\lnd Mr. Bomis symptoms due to "probably paintblilltenllll disc disruption in a lumbar sPine with some spiDa1. steLiOBia. .... 'Ibc diaical findiqp described lJyD!'. Wolfineblde a norJnal neuroIogi.c e\"'h,,,tl,,,, ofthefawer IlXtremities at illso&r as BDY.,SUSSIllltion oflj(;i"tlca.. , _. ,.:',..:. ' 'l"..j:."~~'-'- OnAprl122, 1999,Dr. Wolfrepa:tedtbatM1.Bma1 "wasRllt~racrlCllllof'theeervicallllld~ "JC"" lumbar spine '-'qISl" we could net ~ tbe myeJogml1 due ofhls ~" pmeociDg his obesity. Dr. Wolfreferenced the discographlc iDfinmationsbowing wamarlcedIyprol7oca1ive test uIA-5. This reproduced his back: pain completely". The report of tile May 24, 1999 stuliy was provided. I was charged, in the Ietter of re&traI, with providing an imPartia1 and unbUlSed opinion and a thorough analysis. ,Please ,"^"ol"ertba! there are ~la Dfthougbt in the, practk:e of m..m,,;n.e. and that the opinion wbil:h JDisht be JIlOftilred l'l!lgIrdiDg a parIio.1IlU' c:a; g:rtajpIy' depellds upon the school of thought bcld by the revisw.!r. The fbIIowiDs opinions are ..&....d by me to a reaonn.hl.. degree of medical certainty based on my ap~on of tile patPno""''''''Y of~ pun If__,_,.~"""'" ,~ . ," .~". .., 03/20/00 MON 11;49 FAX 309 766 8202 03/17/00 12:38 FAX 717 764 5007 EeLS tal 007 STATE: FARII ijJ031 r ~I' ,.... 'T vaftl( AllG 02 _ Page 4 1uly 29, 1999 REI J"llIDtlS DODD AssIIJC2~I'!ftt: "~ 1. The soun:e ofbadc paiD is l:oiltnmlnial. 'lba'c are thole who may bold that the disc is a primaIy DC I'fO"''''llW lIOUrl:e ofback pain. Diffe.~ t""'~ abourIli 81 to the potelltia1 IIllUI'D8IIBtmD which mfsbt ~~'" back JIIIin. Ccmcepts such ~ "im1lnl31 disc dlsnzption., disc buIgiIIg DC disc pmtrwiDn (1('_ herm" are aD frequently invoke! It is due to the f'ocus on 1ht. disc as a primay Cll"pmriln"'" IQUJCe ofback pain tbatwrious surgicalproc:edures are reo:o,,,.,,.-IallIIId pedbrmecL 'Ilu:sc canw:\ude pcrr.Ilf2~ type or procecJura, such as themId Jb'''licJro. or pea- .....-..1' dilCCClOlDy, or open surgical proccdurca lIUCb. as tsnm"""ltomy ad ~se~041y. I do believethu most IIlIF)' on the intemmbn1 disc tor back moit! has been thoroughly disc:redited. Such does 1IOf. QIean that the SWFY does DOt routinely 0CQIr, merely that wben one carefully analy.ees the /1ISUltS ofsuch surgeIy, p.tf....., ordiIIllrily are DOt" POt improved, . but are fhlqucntlyw0rsc0e4 .' Please observe that back~ 8IIii IlIlCkpaiu are common tr.Mib llIttODg mmun ~ lIIJd 1 do beIieYe that the disc is indiJ:ectIy fIlIlP"",lblc AUG 0 61999 B~';,.aI1y, the intelvcrtebnl ~ whm we are YOUII& is 80'/0 WIItcr, IIIIli whca the cIisc is .fullY i"R..iM. it ho1ds the space ~...... tbe vertebta1 bodieswbichis iml'ortllllt tbr mRliCEi"J:.... 1Unctioningoftheiilccltjoiots. As we age, the~loscsits water'Cl:IllteDt, the disc d~lIWs" the space is lost. IUJd the &cet j6lnts can JlO Iooger work: wilhout "fiidic1l1" causing arthritic c1Janses. ' The sequence then is that lUdisc lint loses its WlIfcr conteIIt and dI~ the joints hHnm,. arthdtic, but such does DOt nr--'1Tily mean that pain will be,presect. However, DIJe can slip on ice. pick IIOft'IetMtg up in an awkward fiL'lhinrI, aIeep ~bly, DC get rear-endc:d in a motor wbicle ......;doonl:. ... move an a1Rady lIl1hriIic joiDtin'. 'painibl mshioo, which is, in my considered opinion, the IICClI81 prnvl....~ or primllly ~ ,of.back discomfhrt. This lIOR of ""'P,..ftJltiQQ fill',back or IIIlCkpain is re..Lod ''''''Ii;!:i~n~l" and fur my DWnpotf_ 1 ,,",,"'~ this as ifthlftwaea "nJSQ' hiDp" within the" 'with the provClC:lllive eveut c:ausiag DIOlioll of the "nJ.,hiup"...., .7....,&0.'.. It llhOuId bcundcntaocl ~Iy.that w~ resolution does occur, llIId it otdinariIywiD OCQU' it'1eft to its own dcvicca. it is net to a pristine staI11S but to a stUtls of someoae who is middle-aged and with dcgeoerative changes. Mr. Bonn's obesity is a drJUble edged sword. In one respect. it does contribute to pUn Cltpedenced at arthritic j(~ ~-,;"1ly coDSidl:ring that tbe low bllck is a weigbtbeariDg part of the body; however, being swathed in lI11 exubenmt layer of.padding" also suggests the lar..t;luvvl that the slalIctoo. is actually protected iom. trauma in 11I\C the same way that pacldng beads protect a tIagiIe stnIdure beiDg shipped in a bOx. Please obsexve that I wooId not, in any m:annm-, dispute the possibility of significanl: discomfort experienced by Mr, Bom, merely that tbe IIllalysis of his back and necIc: pain seems to me to have been t;utgential to the actual source and predicts that the more treatment that be getS the WlXllC he will be. 2. 3_ ~ m. -, "Ti _." . ~ 03/20/00 MON 11:50 FAX 309 766 8202 EeLS \>3/17100 12:39 I'A!.!,~7__,7_6~7.____ -.-m'~1'E...J'"\RlI 'I!I008 1ilJ032 'i"ilI~lII( , "t'ORIt AUS 0'," Page S July 29, 1999 BE: James BOIlIl 4. -,- s. So IoDg asMr. Bozm plII$.e$ to ...-~ ofm invasive IIlltun; it would be my eo-ltIend opiIjon~such .....~,_ is DOt I-'I""'D1\Lo JIOI" "'eceI"'IY.1IId it is IiIa:Iy to be ~ JwmfiJl to him:. 'Ibm: is !lOt 1Dytr--1hIt,a doc:tor could do to or fix' Mr. BDQIl that would impJ;ove IJIiOll tbe aatut.Il hiItmy oflowbd:pIiD 'wbida is ilr spcmtaneous ,....oL~nn Tbevario!Js.llIlbllureperformcd upailMr. BOlllure fQQ,eM on the intavertebral cIisc as&Dm:e CIfbis dilK1l~,.liul, IIDd asbeell.....if'!\ll~dabavc. lUChia DOt ordina1ily I1w: case, ~ IlOt till: case in SOIIII:DIlC W1iOii:ii:a Dllt ~ sciatic tIonoinn lIigna. n:ftex a1mDmla1ilics or the lib. It does.seem to me that CClllllDllll1l1C1l&e. as well is good ...~ Ilhice. that Mr. Bom1 sbouId lose weight. A man. is 10 heaYy tbat be e--4. the ....P"dtJ' of'the imIIaing lItudytablc is too heavy llIIli ~ is perp""'-:.,gbia low bade symptoms. It is mybottmn line CoAlside:tatioI tbatMr. Boon'I tpatonPftt. CldIq~iMll1y, in the setting d~ ia COIIUal'y to bi.~ \best iDIenIsIs lIIIIl sbouId be c1iSC""-;"'-J fixthwith. Hewil1 not profferAmn~, DO Illlil1erwhat SllIF)',lIIIIlllO maucl'llowalpllbly pe..li:..med. The diagnostic: tests ate Iibwi:Ill ineIcvant in this -"8 He bas !lad sulRM-t IaliDg to make mre that IIOtbiI!i danJFQUS w.u pn:selIf. 8Dd now 11I1 tbat is beiDa JllU8I:I& are n::aSODS to po;dh.... surgery, )'~ as meclicatiolls, tbeuse afmild. aailgesicI.lUCh lIS TylCDCl DC Pamx:et-N, would be appropriate pendiF his c:oopera!ion with an appropdatc,weight loss pmm. , In~, it is my opinion that 1hc c::are provided by Dr, Wolffrom Aprilzz,' 1999 & DilSoins would not be COJlsidered T""SOIl"ble or rece<''''"Y fur iqjwies "1~~ on Jutft'P.l, 0 6 19,Q9 1~~ REC ~.. -- I hope this iDIDrmation plOVl:S helpfiIl to you. Again, lJI1Ch Was oJfi:red to a reaonn.hle degree , DfmediCal certainty, 8Dd [bopemy,."titvi".tinn prows belpfulin:fourcoaaiderationofthis ..'." intbnJIaSion. """. . .~,""''-' ' 6. 7. Sincerely, ~ G2 (M..~ ,???, .10, S~eyi AiAMD. /~(1~ SRA!3G HS_36A724 'C\'>'l'f""""""'F""""'l 03/20/00 HON 11;50 FAX 309 766 8202 03/17/00 12;40 PAX 717 76~9~_ Be.luS 141009 STATE FARII li!I033 , , , .....~"':~.,..~-_... . :<;.-:_-:,-- . "... i YORK AUG 02 1999 .' H8AL7H8OIITH. l/SABILfTY M/INN3EMENT ~ C u,,"TIIIlI LOG l'U;aDl'l una; cr....1Jr '1 DK1\II ~B 0-. ~I l'ROV1:DBlL: AlDIS Jlenor 38-.7023-'737 ClIatlll7 DO .'.1:_.... B. lrOLI', JjJ) AUG 0 6 1999 RECEIVE... DA~B de:.nvBD: Juns 04, 1999 DA~ .cJ:1\io1fLBDu~ LBftBll SJlft: 6/419'1 DA'J!B BCnn:DBR IiBh;. 8E!1'.rl ;run. 04. :U99 DA'J!B P1l.OVZDBR 1lEB'lOBS1U 6129199 RBCODDS 8El1'r: ns DA':rB COlmDCED: June 29, 1999 \.~~~~~.. DA'J!B co:GLBHD: J'Uly 29, 1999 llBV:IBWBJl: B'.rMILBY ASlaJI. :..'W 1489 Baltimore Pilce, Building 200. Third FlCOr . Spring.'1eld, PA 19064 800 388-,7877 . 610604-0450 . Fax 610604-0461 ' '''''!''''''-'~ -r~ '" - - , . EeLS 03/20/00 MON 11:50 FAX 309 766 8202 03/17/00 12:.0 FAX 717 784 5007 State Farm August 4, ~999 STATE FAIUl .rr- . ~ Insurance James E. Bonn 967 W Trindle Rei Lot 2~. . Mechanicsburq, PA j, 705~;-4056 RE: ClaiJll Number: Date of Loss: Our Insured: Patient: Dear Mr. Bonn: 38-.J023-737 JWle ~2, 1998 JiUlles E. Bonn Janes E. Borni il1.IOll li!I035 (, Co +m pan i e:) DATI ,..... A INIUUNCt . Medical C1oi.... Unit Po 80x '4007 ' York, P.. '7404.0867 '''86-23001187:1 "'l.l.'..........r~-!".... ..~._._- AUG 06 1999 RECEIVED Pursuant to Section 1797 (b) of Act 6, your 11Iedi(~al file was submitted to Disability Management Assoc, a Peer Review Organi:l;ation (PRO) app:t"oved by the Insurance Depl1rtment of Pennsylvania, for revi'i!w of the medical records. This review concerns treatlllent reniered by Dr. Wolf. Encloslad is a copy of the PRO's determinatio~. Based on this report, -ole will not be issuing any payment for services rendered on 4/22/99 & after. Section ~797 (b) of Act 6 states: "If it is determined by a PRO or court that a provider has provided unnecessary uedical treatment or rehabilitative services or merchandise, or tha~ future provision of such treatment, services or merchandise' will be unneoessary, or both, the provider may not collect payment for the medically unnecessary treatment, services, cr merchandise"... HOME OFFICES: BLOOMINGTON, IlUNors 81710.000 I "~ ~ '" . -,~ YON 11;51 FAX 309 766 8202 03(20(00 n U~/17/00 12:41 FAX 717 764 5007 ~'- \, EeLS STATE FhRIi( Ii!l 038 .r .'~"'.'J. ~.~....... fi!j012 James E. Bonn Page 2 August 4, 1999 AUG 0 6 1999 RECEI\tJ:1J An: insurer, provider, Ill:" insured may request, in writing, recon-' sideration of -the initial PRO determination within' 3,0 days frOlll" the date the initial d"ltermination is effected. ''l'his request for ieconsideration shOUld be sublai.tted directly 1:0 1;he attention of t~e Disability M~al1ellll~t Assoc. state Farm wil:L 'advance the ,c:ost for this recons:i.<1.JJt'ation. If the reconsidel:ation is against you, you will be responsible for its cost. Should you have any qu.astions' concerning the above, please contact me. "___.. Sincerely, Audrey B. Crilley Claim Specialist (717) 767-01.21 state Farm Mutual Auto;nc.bile Insurance Company ,', Enclosure co: Mat:thew s. Crosby -~~I~'"- I!lilillilnll^' " ~3/20/00 MON 11;51 FAX 309 766 &202 ~J/17/00 12:42 FAX 717 76t~007 , , ~' EeLS ~OH STATE FAIll4 ..-- ( .1 Ii!1038 r JANIEL B. LOPRETO, PJHU). c ,INlCALPSYCHOLOGY Dipltl_ A....ni_ BrIrItJ *fQ.wJU.1.............. """ Uti..,;.. Rntkw~ - p,l ,BOX 260l . DAtA CYNWYJ), l'ENNSYLVANJ,I.1SOO4. PHONE, FAX (610) 668-85$3 PA1JC. PS~2.l HI UCIt Sl.QX307 BClAC4f3477 August:. 17, 1999 Eloise Manning, RN, BSN. CO!: HealthSauth 1489 Baltimore Pike Building 200, Third Flo'~r Springfield, PennsylvaniB 19064 - -, ---.........,.~ ~ECE~t) ~UG 'lJ.\m aYoM/l. ClaImant; ,. DMA: DOl: James Bonn CPA 6298 6/12/98 Provider Reviewed: Holy Spirit Hospital 2/22/99 ,and ongoing .. Records Reviewed This peer review is based. upon careful examination of all available records as they pertain to the claimant,' s medical and psychological status, including: 11 Application for benefits, dated 6/22/98, and disability statement, dated 7/14/98; 2) Emergency room records, dated 6/12/98, 8/23/98, and 9/9/98, subsequent treal:nient notes dat.ed 7/1/98 to 7/6/98, and 9/30/98 to 10/3/98, and bills for services rendered by Holy Spirit Hospital; 31 MRt report. dated 6130/98, from .Open MRl:, and MRI reports, dated 7/2198, 12/28/98, and 4/26/99, from Magnetic Imaging Center; 4) Initial evaluation report, dated 7/22/9~:, progress notes, dated 7/22/98 to 8/25/98, and bills for serviCeS rendered 7/9198 to 8/25/98, by HealthScluth Rehabilitaticn of Mechanicsburg; 51 Treatment notes, dated 7/28/98 to date i.l1egible, 1999, and bills for services rendered 7/~/98 to 4/7/99, by Orthopaedic Surgeons of Central Penn,~ylvania, Ltd.; YORK AUG 8 119~l - ~ 03/20/00 MON 11:52 FAX 309 766 6202 EeLS 141015 03/17/00 12;42 FAX 717 764 5007 ( , STA1E F.\lUI li!I039 ",J''''''''III " Bonn 1 2 6) Evaluati.on rep,)rt, dated 9/1.4/98, and bill for services rendered on tlUlt. dat.e by Todd Samuels, H.D., of Neurology Cenl:t;lr; E!(G/NCV test:in!1 report, dated 11/20/98, clnd bills for services rend<!red on tha,t date by MichaEll Lupinacci, M.D. : 7) 8) Notes from Pirulacle Hospital, dated 3/17/99; 9) Treatment/as6ellsment notes, dated;.3.tJ.'L/9S to 6/3/99, and bills for serlrices rendered 3/11/99 to 4/22/99., by steven B. Wall:,: M.D., of Orthopedic Xnstitute of Pennsylvania; . .-.'. . . .. ... . .... 10) Lumbar spine allsessment, dated 3/22/99, and Dills for services rendured on that; date by The McKen:de Inst:itute: 11) Treatment note~:, dated 1/11/99 to 6/16/99, and bills for services rendE!red 1/11/99 to 3/15/99, by Rudi Crider from Holy Spiri~ Hospital: ... :r bad an opportmdty itjo discuss the case wi'th awli Crider ,by' telephone, as per bis r~e8t. on 8/17199. We Spent approximately 4S minut:e~1 reviewing the case. Discussion According to the n,eords reviewed, the claimant. James Bonn, WaS the restrained drivE,r of an automobile t~t was rear-ended by another vehicle on 6/12/9.8. A pOlice report of the accident was not contained iri the file for review. The cla~mant presented at' Holy spirit Hospital foJlowing the incident, with complaint5 of neck. upper and lower back pain. There was no loss of consciousness. Documentation revealed an .obese. individual, with a history of depreesion, hypertension, bone S:;lUrs, and left shoulder surgery due t.o a rotator cuff tear. ~~e :raimant was also taking a number of medications for his'pre,existing condition, including Prczac. He was examined and 'iischarged the same day with a diagnosis, of back strain. MIU of the cervical spine, conducted 6/30/98 ,it Open MRJ:, revealed mildly bUlgi.ng discs at. C4-5 and C6-7, wi':h a moderately-sized RNP at CS-6, MRI of the lumbar Imine. conducted 7/2/98 at Magnetic Imaging Center, revealed a mo~e~ately large disc protrusion at L4-S, and a small central disc protrusion at L3-4. YORK AU6 3 1 1999 - - 14JOJ.6 iJ3/20/CO MON 1.1;52 fAX 309 766 8202 "'/17 L0..!L-11j43 FAX 711 76~007 _.- ,. , EeLS STf.TE 'fARJI. 1i!J040 "',~lliI.11Il ' Bonn I 3 On 7/1/98, the da~ following his MRI, the claimant returned to Holy Spirit Hospital with coropla1nts of severe pain in his 'neck and lower back. HE was admitted to the hospital under the care of Dr. Malin, thrcugh 7/3/98, where he rece1ved oral steroid therapy. On 7/22/98, the claimant presented at HealthSouth Rehabi,litation of Mechanicsburg, with complaints of .severe pain in his lower back, left leg, as well as chronic neck pain.- He was evaluated on this date by Malik Moulin, M.D., 'who recommended and subsequently provided two epidural stArn~~'injections on 7/22 and 817 /98. The claimant also participated in physical therapy at this 'facility.' He ~as last seen ~ Dr~ Momin ~n 8/25/98. , ,Qn.7/28/98, the-clai1nant,presented for follo'".";;up'witlf'Di-::'''-' Malin after his recent emergency room visit. Notes of this date indiCate that .steroids do make h~ have a bizarre personality apparently. His personality is very difficult for 2-3 days.. The claimant subsequent.1y continued under Dr. Malin's care through at least 4/7/99. according to the most re:ent progress note reviewed. This note reveals cont.inued compl,!Iints of .pain to his back wit.hout leg p~in,. On 8/23/98, the clajimant again presented' at. ":he emergency room of Holy Spirit H05~lt.al with complaints o~ ~'sterior headaches fOllowing an epidural steroid injection approximately two weeks earlier. Admission notes of this daie .indicate an "adult male of average build., and a psychiatric :~istory .within nOrIll\\l. limits. He was diagnosed as experiencing ,~ cervical traction headache. was given an injection of Deme:col and released. On '9/9/98, the claiinant again presented at Ht)ly Spi:i-it ..' Hospital following a fall in which he reportedly :.truck his head and lost consciousness for 3 to 5 minutes. This brief syncope was secondary to severe pain in his lower back;' '~e claimant was examined in the emergency room, given Fiorice!:, ~ld released the same day with a diagnosis of closed head injury'alld chronic neck and back pain, Neurological evall,l.,:l.tion. conducted 9/14./98 ~f Todd SantUels. M. D., of Neurology Center. resulted in a diagnosil~ of migraine headaches, and a recommendation for continuation l)f Fioricet PRN. On 9/30/98. the claimant was admitted to Ho~' Spirit Hospital for excision oE a disc on the left at L40--5 (decompression 1aminect':ll'llY). The procedure reporl:edly occurred without incident and tha clail\'Klnt was dischar.ged nn 10/3/98. YORK. AU6 S 1 1999 1 ig.1 VJ.f FAX 309 766 6202 EeLS _ ,!,'!D 7/lLo_ 12; 44 Fax 717 764 ,5007 S"fATl> FARII Ial041 ",,,... Bonn 1 4 EMG/NCV testing; conducted 11/20/98, by Mictlael Lupinacci, M , D ., revealed 1l1OQe,:z!at e to severe peripheral neuropa thY, -mixed motor-sensory with both demyelinating and axonal components. It. appears that t:ie claimant was admitted tel Pinnacle Hospital on 3/17/99. Notes from this provider were illegible. :r was unable to find doC\lIl\EU1tatiol1 of this episode of treatment in the notes submitted ~ other providers. On 3/11/99, the claimant. presented to St.evell Wolf, M.D., . for a second opinion ':::l: his l~a:r spine'-p'!""oI51etllS." 'l.'he claimant reported to D,C", Wolf that he has gained over 100 lbs. cecause 'of his back. pr':lblems. '!'his suggests that his .back. problems may have pre-~ted the incident of 6/14/98, as he had' , only "gai:ned approxill\i!t:f!lY 25 lbs. since' the actic:eriC" 'Iii any .. case. the claimant continued under Dr. Wolf's ca:r'e through 6/3/99, according to the 1IIOst recent treatment nc,te reviewed. On l/11/99, the claimant presented at the CCllUIIunity Mental Realth Center at Roly :3pirit Hospital. An initial eva,luat.ion report was not submitt,~d for review. Notes of this date, as we!.l as subsequent sessions tqrough 6/16/99 are somewhat difficult to read. :r had an opportllrtity to discuss with Rudi Crider, by telephone, on 8/16/99. oWe spent approximately 4S minut.es reviewing the case, as ~el1 ~s clari~ing tha Content of handwritten notes, . Mr. Crider, who iu 'an unlicensed provider~ reported that the claimant had been invo:,ved in therapy previou~lY at Holy Spirit Hospital. for problems with depression that seemed to have some paranoid features. At that time, the claimant was under the care of a psychiatrist, as well as Mr. Crider. At ,the present time, the claimant's diagnoai.s ~-as -depressive diSorder NOS' _ ''l.'his was a provisional diagnosia: rendered at the initial intake. 'Problems" identified elt intake, reportedly inclu:ied. "depression, wife dyin~r, no interest in activity, and auto accident", Mr, Crider provide,d) nine sessions of individ.lal and couples therapy from 1/11/99 tc, :6/16/99, according to the treatment notes reviewed, (A session Gated 5118 was absent from:he file but was discussed during the tE,lephone conference). Revi,=w of these notes reveals an appro~ch that utilized an active, direct.ive, and cognitively-hased apprcach to assist the claimant in bett.er managing his pain, regtJlating his emotional outbu:~sts. and aChieving some level of functionality. The claimant does helVe a history of depI;essi()n with substance abuse, and tbe concurrent stressor of his wife's VORK AUG S 1 1999 1 ~ ~ ,~ ,-- ~ ,-" 03/20/00 MON 11;53 FAX 309 766 8202 03/17/00 12:~4 FAX 717 761 ~007 14J018 EeLS STATE FARK 1i!l0U 'i'.IllI".' Bonn / 5 terminal illness. Mr. Crider stated that this wa,. difficult for the claimant because -his wife is his life line.- Summarv and Conclusions: Based on Il\Y review of the records submitted, and Il\Y conversation with Mr. Crider, it appears that the claimant is demonstrating SYIllPtol11S indicative of a Pain Disorder Associated With Both Psychological Factors and a General Med:lcal Condition. (DSM IV 307.89). I would incl:ude Back Pain as thl~ Axis III.. diagnosis, without being rore specific reg_4Lilg t:he claimant's medical condition. Although the claimant has a histo~ of depreflsion and was taking Prozac at the ti~e of the recent motor vehicle accident, he appears to have been functioning adequately. lIis wife's terminal illness represents an extreme stressor Which certainly would impact upon his' depression, but again the claiJnant, appears to have been able to cope with this stressor through various means. I believe that ::he claimant's current leVE!l of depression, which appea'r:a to render him dysfunc:tic-nal, is partially attributable ';0. his chronic and severe level of pain. Pain is by definitl<l>n subjective. Hence,---thE' claimant's own perception of pain is e:~fected by his own Subjective state. I believe, based upon the info~tion provided, that the claimant's pain is influenced by hilS depressive state ~ his medical condition, In the case af Mr. 50nn, as is typical of most chroI).ic pain patients, ii' vicious cycle of pain ',:, depression (anger) - pain is operating. ItisI1~c"'ssary to interrupt this cycle if tthe patient is to achieve some degree of resolution. ' Psychotherapy becaaes a reasonable and necessary treatment for this type of probl~J. More appropriate, in many cases, than continued medical inter"ention. The psychotherapy must be active, directive, time..limited, with specific goals and objectives. The foc:us must be on functionality rather than subjective pain. The thHrapy as provided by Rud.i, Crider and Holy spirit Hospital meets the!se criteria, , In SUlTl1Ilary, based \lpOn lIlY review of the doc;umentation submitted, as well as 11\\' conversation with Mr. Crider, I view the services provided b.Y Hol~ spirit Hospital, from'1/1l/99 through 6/16199, as being reasorla.ble and necessary for injuries sustained in the motor vehicle acc:ident of 6/lO!/98. This consu~tattt report remaas al1visory..:(zj :luiture OJ:lly. Final det:e.nr.iDatian regll~'d.ing rbe assigned 11.ab11.!tjr in this YORK ,. ADS 311999 n3/20/00 MON 11;53 FAX 309 766 8202 __9-3/17/00 12:45 FAX 717 76~ 5007 EeLS 1aI019 ~ ~:.. .. ..",~; ; ".. .', STA1E FA1lII .' Ii!I043 '. . Sonn I 6 case, given tJ1e :b2d1~ct, et1Cl~Clgy of tbeBJlDlPt~r, 1s solely tbs respcms1b1~1ty of tlie 1asu.roUlCeQ,q-riar. ~~ . - oni., D. LoPreto."'.t.. PA Lie t PS-005042-L; NJ liie' 5102307; ': Fel~ow, BioEefildback Cm-ci.1ileaciOlll Zastitut:e or Jlmeri,:;a Diplomate, American Sqard of ouality Assurance a,nd U~.ililZation Review PQys.:Lc.:i.ill2S ' ! ' Diplomate, ADterican Collt-!ge of Forez:1Bic: --'lIiaers, B.:)arcf of PSYc:'bologic:al Specialcies. Psyc:'bological D:J.sab:J.licies EvaJ,ua/;ion __'.. __ ... '....' ,. , , p ,",',' J:'__'; yORK AU6 S 1 1999 .~- " ~. :- '-_~_ ,-_ .~, _ , _ N_ YON 11:54 FAX 309 766 8202 rO/20/30 M 03/17/00 12;45 FAX 717 764 5001 EeLS ~020 STATE FARI! ~ ' . '1"oI;l~~ ..~044 '~"'.~,.""" ,,' o n...,....-.avu .n. J/SABIUTYMANAGEMBvT ,.~. .: ......._, :i :.~....:. ;"': :-~ ~::;: ~ .. - . -i...-..;~. ~:;'~~4l~~;f'~.: <!~~.;... ...- ~~T[!f"l!:::", -:..(:~. "~"'~"".:.';Io._..._.....~.;, . ';:.l~ r~~f~''':~,.~ . I'" "'llo.' .........:;, "'- J- . ~'.'h!ft. ", '::t~~ ,~,~t~.iP~':"".f~;:' '... -.... 'M._ ;r'l.. aar 5 .........I.Jlf.. Ji08 ':; ,...... . , ..'~. . :1" ...~;..:.. ~ -,. l'~ DiDrI ~-""""I . Dlla#1 , ~. or "Y~r l'JtO'nDBa:". .. ;au, 1IGIIIt-.-." s.~oaS-7S7 Cl'AIa.. no JIOI.'I: aDD- ~-_._.. .' DAD JlBCIlrrBr JIme 04, 1199 DAD ~G~ r...-_.._ 8B11'J!r fiJ"J" Imft nov~BIl LUra. 8Blr.fr .1'UIl. 04, 1'" DAD PaC'n>>. JUl:81'0B8Br 718'" '.. aBCOJU)& 8:Blll'J!: 'Y J)ATB CtmVIIIlfCBD: .1ll1y 08, 1'" J)ATB caa,~TBD: August 25, 1'" . .1biv.=o..JSKr '. ':DUrnm' i.01'JIftO, :a;liD ;':'\1 YORK. 'AU6 311999 " ;1 ~~ (:1 , ,! H 1489 Baltimore Pike, Building 200, Third Floor .. ,Sprtngf'lS/d, PA 1soiu BOO S88.78n .. 610604-0450 .. Fax 610 tJ04.0461 ' 'I :1 ,I '~r-"" o~(2.oYOO lION 11;54 FAX 309 766 8202 03/17/00 12;46 FAX 717 784 5007 . , -- " -----....--- STATE FAIUl EeLS IfflU"," .....,....., 'i!1046 State '(, Fa r ml n S Ij:r an c e ;;:~I.~' r-o, ( , 'Companle~; "A INSUaAMC\ August 3J., 1.999 Jam$S E. Bonn 967 W Trind~e Rd Lot 2.. ' Mechanlcsburg, PA 1705!i-4056 RE' claim Number: Date of Loss; our :Insllred: Patient: 38-J023-737 June 12, 199B Ja'1ltBs E. Bonn JaJIles Bonn Modi.., a.inul Unit PO Box 14C07 York. P.. 17404-0867 1-888.%311-8672 , "'~--'lIIIII'!:' Dea.r Mr. Bonn: Pu~suant to Section 1797 (b) of Act 6, your medica~ fi~e was submitted to Disa~illty Management. a Peer Review Organization (PRO) approved by the Insurance Department of Pennsylvania, for review of the medical records. This review concerns treatment rendered by Holy Spirit. . Enclosed is a copy of the PRO's determination. ! : ' Based on this report, ~e will not be issuing anli' paY'lllent for se:tvices rendered on li/17/99 & after. Section 1.797 (b) of A.:i; 6 states, "If it 1s determ:l1).ed by a PRO or court thai: a provider has provided unnecessary medical treatment or rehab:.litative services or merchandise, or th-1t ,future provision of sucll treatment, services or lI\erchandi,~e will be unnecessary, or both, the provider Illay not collect payment for the medically unnecessary treatment, services, Qr merc:bandis.."... HOME OFFIC~S: BLOOMlNGTON,IWNOIS 61710-0001 FI'\IIl!l"""""r ~,~ 0~/~0/0~ MON 11;54 FAX 309 766 5202 03/17/00 12:~7 FAX 717 784 5007 o < \ -~ (- Jall\es E, Bonn Page 2 p.ugust 31, 1.999 t.(.,L;, STATE PARI! c. -c::.l v_w ~047 , . p.n insurer, provider, mr insured. lIlay request, in writing, recon- sicleration of the initial P1Ul determinat10n within 30 days from the date the initial d~t:.ermination is effected. This request:. for reconsideration should be su1mlitted ,d,irect.lyto 'the attention of the Disability Manag-ement. St.ate Farm will. ad"al1ce the cost for this recbnsiderat:;ion. :If the reconsideration is ag-ainst you, you will be responsible for its cost. Should you have any questions conoerning.,.the,..a.bove, please contact me. Sincerely, Audrey B. crilley Claim Specialist (717) 767-8121 State Farm Mutual Automobile Insurance company Enclosure co: Matthew Crosby I < '! ,,~-r""- !," .,; 01/:~/"O MON 11;55 FAX 309 766 8202 Jo:CLb !lfJ UZ'l u::S/ 1 7 roO > 12:'8 FAX 7t7 764 5007 STATE FARIl ~049 ."'7f""1i.. " Dear Ms. Evans; I have been asked to prepare a s:.tpplcmental report regarding the use ofProzac, an antidepressant medication. being prescribed by orthopaedic surgeon. Thomas Malin. M.D. Please observe that Pro= is net a medication used to treat an orthopaedic malady, but certainly there are those affected by orthopaedic m. r..d;es who might require an antidepr,,,,,,,,nt The provided r=ords (previously enumerated in my report of July 29. 1999) do not yic:ld sufficient medical or psycholof.ic information that would permit a thOllgbtful consideration of the need for an antidepressmtt medication. That is to say, it is not specifkally descrlbc:d that the . patient is psychiatrically affect.:d by any orthopaedic malady. YORK SEP 2. () 19!5 4tJUZ~ ('1;2....LJO 11: 56 FAX liON 6 8202 309 76 EeLS '"'-- v__ .---..~- .. '1____ 'V ---=--=-=~C 'V ----- 9___...,'1 --.,-~!;~~~~~. -~:~~<~~t~l~~}~'Ji-r~!i:;;i;~: -"'~3..~ :i;.t.;;;';I~t~,'~'-''<';,t.!-._"~. 'V __..,..~"_. .' ,'., YORK srp 20 1999 (,j/20/~0 lIOK 11;57 FAX 309 7668202 (~,h7/~O 12;S2 FAX 717784 5007 EeLS I4J 026 STATE FAR!! 1itI050 -.,.; .' ~. , -.... .~ . .", , .. ;. ~.:;;:i..~;i:~~~~':~~". DAD COJD!LmJlDI ': .', '-::-'lr~' ---- - - --"-- - ~--~,."... :. RBVJ:nDl ::'~:;,: September 15,1999 STlUlLBY AS-][DI, JID . ' ,....' YORK' SEp 20 f999 Philadelphia Disability Management Assocs. 1489 Baltimore Pika" Building 200, Third Floor . Springfi,~/d, PA 19064 800 388-7E.177 . 610604-0450 . Fax 610 604-11461 " ...... ...'. JAMES E. BONN, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PA Plaintiff, vs, CIVIL ACTION-LAW STATE FARM INSURANCE CO., No. 00-1203 Civil Term Defendant. JURY TRIAL DEMANDED CERTIFICATE OF SERVICE The undersigned hereby certifies that on the 8th day of June, 2000, a true and correct copy of the certified copy of State Farm's Notice of Removal was sent to the following by First Class United States Mail, postage pre-paid, addressed as follows: Matthew S. Crosby, Esquire Handler, Henning & Rosenberg 319 Market Street P.O. Box 1177 Harrisburg, PA 17108 This statement is made subject to the penalties of 18 Pa. C.S.A. ~ 4904, relating to unsworn falsifications to authorities. FORRY By: ULLMAN & FORRY, PC. ~T-' - ri.. , JAMES E. BONN, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2000 CIVIL. CL- DO - /~CJ Gu( f~ CIVIL ACTION - LAW JURY TRIAL DEMANDED STATE FARM INSURANCE CO.,: Defendant NOTICE You have been sued in court If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you, You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Plaintiff You may lose money or property or other rights important to you, YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, Cumberland County Bar Association 2 Liberty Avenue Carlisle, PA 17013 Telephone (717) 249-6166 Matthew S, rosby, Esq, 1.0,#69367 319 Market Street P,O, Box 1177 Harrisburg, PA 17108 (717) 238-2000 DATE ?128 /ZiJOO . Attorneys for Plaintiff ~'.'"""'l" " , - JAMES E. BONN, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. NO.I'iJ-/';:03 2000 CIVIL STATE FARM INSURANCE CO.,: Defendant CIVIL ACTION - LAW JURY TRIAL DEMANDED COMPLAINT AND NOW, comes the Plaintiff, JAMES E. BONN, by and fhrough his attorneys, HANDLER, HENNING & ROSENBERG, by Matthew S, Crosby, Esq., and brings this Complaint against the Defendant, State Farm Insurance Co. and, in support thereof, avers as follows: 1, Plaintiff, James E. Bonn, is an adull individual currently residing at 967 West Trindle Rd., Lot 24, Mechanicsburg, Cumberland County, PA 17055-4056, 2. Defendant, State Farm Insurance Co" is an insurance company licensed to transact business in the Commonwealth of Pennsylvania, with offices situated, inter alia, at 115 Limekiln Rd" New Cumberland, Cumberland County, Pennsylvania 17070, 3. Defendant, State Farm Insurance Co" regularly conducts business in the Commonwealth of Pennsylvania and, specifically, in Cumberland County, Pennsylvania. 4, On or about June 12, 1998, Plaintiff, James E, Bonn, was traveling on Simpson Sf. in Mechanicsburg, Cumberland County, Pennsylvania, when a vehicle operated by Lauren F, Bogar, also traveling on Simpson Sf., violently struck the rear of another vehicle, causing a chain reaction collision involving the Bonn vehicle. Page-1- ~~ 1 5, Prior to the aforementioned collision, on or about February, 19, 1998, the Plaintiff, James E, Bonn, had purchased a policy of motor vehicle insurance with the Defendant insurance company, through its authorized agent, Bob May, at 382 Market St., Camp Hill, Cumberland County, PA 17011, Said policy was in full force and effect on June 12, 1998, 6, Pursuant to the terms and conditions of said policy with Defendant, the Plaintiff, James E, Bonn, was a named insured, Plaintiff had paid an additional policy premium to obtain $100,000,00 in first-party medical loss benefits, in accordance with the Pennsylvania Motor Vehicle Financial Responsibility law, 7, As a result of the collision, Plaintiff, James E, Bonn, sustained serious bodily injuries, including, but not limited to, injuries to his cervical and lumbar spine and intervertebral discs, 8, As a further result of the aforementioned collision, Plaintiff has been compelled to receive and undergo extensive medical attention and care and to expend large sums of money and/or incur various expenses for which medical expenses are payable, He will be obligated to continue to expend and/or incur the same for an indefinite period of time in the future, 9, After the collision, Plaintiff, James E, Bonn, sought reasonable and necessary medical treatment and received reasonable and necessary prescription Page -2- -,."... "1 -, - ~~ ' r i I """'""""f""" medication from various medical providers for said injuries, These medical providers include, but are not limited to: a, Dr. Steven B, Wolf, Orthopedic Institute of Pennsylvania, 890 Poplar Church Rd" Ste, 108, Medical Arts Building, Camp Hill, Cumberland County, P A 17011 ; b, Rudi Crider, Holy Spirit Hospital and Health System, Medical Arts Building, 503 North 21st St, Camp Hill, Cumberland County, PA 17011 ; c. Dr, Thomas Malin, 99 November Drive, Camp Hill, Cumberland County, PA 17011; 10, It is averred that all medical bills have been, and continue to be, fair, reasonable, and medically necessary, and that all treatment has been, and continues to be, related to the aforementioned incident 11, Defendant, Stale Farm Insurance Co" pursuant to 75 Pa, C,SA ~1797(b)(1) of the Pennsylvania Motor Vehicle Financial Responsibility law, as amended, has contracted on three separate occasions with the same peer review organization (PRO) for the alleged purpose of confirming that Plaintiff's treatment conformed to professional standards of performance and was medically necessary, The name and address of said PRO is: Disability Management Associates, 1489 Baltimore Pike, Building 200, 3rd floor, Springfield, Delaware County, PA, hereinafter "DMA" Page -3- -- - 12, Defendant, State Farm Insurance Co" has also contracted with Dr, Bruce Goodman, 1515 North Front St., Harrisburg, Dauphin County, PA 17102, in order to conduct an insurance medical examination, for the alleged purpose of confirming that said treatment conformed to the professional standards of performance and medical necessity, 13, Defendant, State Farm Insurance Co" allegedly as a result of the aforementioned peer reviews and insurance medical examination, has denied payment to various medical providers, including, but not limited to: a, Dr. Steven B, Wolf; b, Rudi Crider; c, Dr. Thomas Malin; d, Weis Pharmacy; e, Central Pa, MRI; and f. Annapolis Radiology, 14, From the commencement of treatment, and, at various times thereafter, Plaintiff, James E. Bonn, and his medical care providers have requested that Defendant pay Ihe aforementioned medical and prescription bills. 15, Plaintiff's credit history has been, and will in the future, be adversely affected, as long as Defendant continues to deny responsibility for payment of reasonable and necessary medical bills, Page -4- ,~-r- -~ ~~ 16, Plaintiff's third-party personal injury claim has been, and will in the future be, adversely affected, as long as Defendant continues to deny responsibility for payment of reasonable and necessary medical bills, Dr. Stanlev Askin. Review No, 1 Julv 29, 1999 17, On June 1, 1999, Defendant, State Farm Insurance Co" wrote to James Bonn and Dr. Steven Wolf, advising both parties that it had requested DMA conduct a peer review, 18, Defendant, State Farm Insurance Co" forwarded no correspondence at that time, notifying Dr. Thomas Malin, Annapolic Radiology, and/or Weis Pharmacy, of its request for a peer review, 19, On June 4, 1999, DMA received Defendant's request for a peer review, 20, On June 29, 1999, DMA received Dr. Wolf's medical file, with regard to the Plaintiff, James E. Bonn, 21, On June 29, 1999, DMA commenced its peer review of the medical treatment provided by Dr. Wolf. 22, On July 29, 1999, Dr. Stanley Askin, the reviewing orthopedic physician, wrote a peer review report letter to DMA Page -5- '~ 23, In his five-page report, dated July 29, 1999, Dr Askin opined, Lnter alia: a) "Please consider that there are schools of thought in the practice of medicine, in that the opinion which must be proffered regarding a particular case certainly depends upon the school of thought held by the reviewer" b) "The source of back pain is controversial. There are those who may hold that Ihe disc is a primary or proximate source of back pain, Different thoughts abound as to the potential neuroanatomy which might explain back pain," c) "Please observe that I would not, in any manner, dispute the possibility of significant discomfort experienced by Mr Bonn." d) "In summary, it is my opinion that the care provided by Dr Wolf from April 22, 1999 and ongoing would not be considered reasonable or necessary for injuries sustained on June 12, 1998" 24, A copy of the aforementioned peer review report letter is attached hereto made a part hereof, and marked, "Exhibit A." 25, Nowhere in his five-page report does Dr Askin render an opinion with regard to the reasonableness and/or necessity of care provided by any medical provider, other than Dr Wolf 26, On August 2, 1999, State Farm received Dr, Askin's peer review report and a one-page letter from DMA, outlining his conclusions, Attached hereto, made a part hereof, and marked, "Exhibit B," is DMA's letter to the Defendant. Page -6- -:"",~~ I ~ 'C"'''l"''~'1 - 27, On August 4, 1999, Defendant, State Farm Insurance Co" sent letters to Annapolis Radiology, Central PA MRI, and Dr. Wolf, advising these providers that they would not be paid, pursuant to Dr. Askin's peer review report letter. 28, On February 9,2000, Defendanl, State Farm Insurance Co" sent a letter to Dr. Wolf, again denying his medical bills and further advising him to contact Plaintiff directly or Plaintiff's health insurance carrier for payment, in violation of 75 Pa, C,SA 969,52(h), 29, Pursuant to 31 Pa, Code, 969,53 (e), the PRO must apply national or, where appropriate, regional norms in conducting determinations, Where national and regional norms do not exist, a PRO must establish written criteria to be used in conducting its reviews, based on typical patterns of practice in the PRO's geographic area of operation, 30, Despite Dr, Askin's admission that no national or regional norms exist, DMA failed to establish or apply any written criteria to use in its review, in violation of 31 Pa, Code, 969,53 (e), Defendant's acquiescence of such action is also violative of 31 Pa, Code, 96953 (e), 31, Pursuant to 75 Pa, C,SA 91797(b) and 31 Pa. Code, 969,52 (g), there must be a determination of "not medically necessary," for there to be an adequate basis for a PRO to deny payment of a medical provider's bill. 32, Despite the fact that Dr. Askin's review was clearly limited to the treatment rendered by Dr, Wolf, DMA denied payment of bills, from both Annapolis Radiology and Central PA MRI, in violation of 75 Pa, C,SA 91797(b) and 31 Pa, Code, 96952 (g), Page -7- - - 33, Plaintiff believes and, therefore, avers that there was no reasonable basis to deny payments to Dr. Wolf, because the peer review report relied on blanket characterizations of accepted treatment without any physical examination of Plaintiff, James E. Bonn. The PRO did not consider Plaintiff's prior health, specific injury, mechanism of injury, or his current medical condition, before reaching its conclusion. 34, Plaintiff believes and, therefore, avers that there was no reasonable basis to deny payments based on the July 29, 1999 report, because Dr. Askin did not perform a detailed analysis of the case and overlooked specific findings, 35, Plaintiff further avers that Dr. Askin exhibited bias, circular reasoning, and arbitrariness in his analysis, Defendant's acquiescence of such action is violative of 31 Pa, Code ~69,52, et sea Daniel Lopreto's Review Auqust 17. 1999 36, On June 1,1999, Defendant, State Farm Insurance Co" wrote to James E, Bonn and Rudi Crider/Holy Spirit Hospital, advising both parties that it had requested DMA conduct a peer review. 37, On June 4, 1999, DMA received State Farm's request for a peer review on treatment provided by Rudi Crider, a psychologist 38, On July 8, 1999, DMA received Rudi Crider's medical file with regard to the treatment he provided Plaintiff, James E, Bonn, Page -8- "-r-..- - 39, On July 8, 1999, DMA commenced its peer review on the treatment provided to Plaintiff, James E, Bonn, by Rudy Crider, 40, On August 17, 1999, Daniel Lopreto, the reviewing psychologist, wrote a peer review report letter to DMA, 41 In his August 17, 1999 report, Lopreto opined, inter alia: a) "I believe that the claimant's current level of depression, which appears to render him dysfunctional, is partially attributable to his chronic and severe level of pain," b) "I believe, based upon the information provided, that the claimant's pain is influenced by his depressive state and his medical condition," c) "In the case of Mr. Bonn, as is typical of most chronic pain patients, a vicious cycle of pain-depression (anger)-pain is operating, It is necessary to interrupt this cycle, if the patient is to achieve some degree of resolution, Psychotherapy becomes a reasonable and necessary treatment for Ihis type of problem,.., Psychotherapy must be active, directive, time-limited, with specific goals and objectives, The focus must be on functionality, rather than subjective pain, The therapy as provided by Rudi Crider and Holy Spirit Hospital meets these criteria," d) "In summary, based upon my review of the documentation submitted, as well as my conversation with Mr. Crider, I view the Page -9- '~~r- " - services provided by Holy Spirit Hospital from 1/11/99 through 6/16/99, as being reasonable and necessary for injuries sustained in the motor vehicle accident of 6/12/98" The aforementioned peer review report is attached hereto, made a part hereof, and marked, "Exhibit C," 42, On August 25, 1999, eight days after Lopreto's report was completed and 48 days after it had all of the information it had previously requested to conduct the peer review, DMA completed its peer review, 43, On February 9,2000, Defendant, State Farm Insurance Co" sent a letter to Holy Spirit Hospital, again denying payment of their bills and further advising Holy Spirit to contact Plaintiff directly or Plaintiff's health insurance carrier for payment, in violation of 75 Pa, C.SA 91797 and 31 Pa, Code 96952 (h), 44, On August 31, 1999, despite the clear language of Lopreto's peer review report letter, Defendant, State Farm Insurance Co" sent a letter to the Plaintiff, advising him that it would not be issuing any payment for services rendered by Rudi Crider and/or Holy Spirit Hospital on or after June 17, 1999, Attached hereto, made a part hereof, and marked, "Exhibit D," is said letter, 45 Pursuant to 75 Pa, C,SA, 91797 (b) and 31 Pa, Code 96952(g), there must be a determination of "not medically necessary," for there to be an adequate basis for a PRO to deny payment of a medical provider's bill. 46, Despite the fact that Daniel Lopreto's review failed to conclude that any psychological treatment Plaintiff had received was medically unnecessary, Defendant, Page -10- -~ f""""M r<~ " _J -,.- State Farm Insurance Co" advised the Plaintiff, James E. Bonn, that it would not pay any future bills from Rudi Crider, 47, Pursuant to 31 Pa, Code S69,52(d), a PRO's initial determination must be completed within 30 days after receipt of its requested information, 48, DMA did not complete its peer review in this matter within 30 days after it had received all of the information previously requested, in violation of 31 Pa, Code S69.52(d) Defendant, State Farm Insurance Co.'s acquiescence in such act is also violative of 31 Pa. Code S69,52(d), 49, Plaintiff believes and, therefore, avers that there was no reasonable basis to deny prospective payments to Rudy Criderl Holy Spirit Hospital, based on the Daniel Lopreto peer review report letter. Dr, Stanlev Askin's Second Review September 15, 1999 50, On August 4, 1999, Defendant, State Farm Insurance Co., wrote to Plaintiff, Dr. Thomas Malin, and Weis Pharmacy, advising all parties that it had requested DMA conducl yet another peer review with respect to a Prozac prescription, written by Dr. Malin, 51, On August 4, 1999, DMA received Defendant's request for yet another peer review, 52, On August 4, 1999, DMA had, in its possession, all of the information it deemed necessary to conduct the peer review. Page-11- -~~~ '~-r-""' T 53, On August 26, 1999, DMA commenced its peer review on Dr. Malin's prescription of Prozac, 54, On August 31, 1999, the Defendant, State Farm Insurance Co" wrote to Dr. Malin, denying payment of his medical bill and referencing Dr. Askin's July 29, 1999 reporl, wherein Dr, Askin makes no mention of Dr, Malin's treatment. 55, On September 15, 1999, Dr. Stanley Askin wrote his second peer review report letter in this case to DMA. In his report, Dr. Askin opined, inter alia: a) "The provided records (previously enumerated in my report of July 29, 1999) do not yield sufficient medical or psychologic information that would permit a thoughtful consideration of the need for an antidepressant medication," b) "The bottom line is that, if Mr, Bonn is depressed, the use of an antidepressant, such as Prozac, is medically reasonable and necessary.... " Attached hereto, made a part hereof, and marked, "Exhibit E," is Dr, Askin's second peer review report 56, On September 15, 1999, some 42 days after it had received all of the information necessary to conduct its review, DMA completed its third peer review in this case, 57, Pursuant to 31 Pa, Code S69.52(d), a PRO's initial determination must be completed within 30 days after receipt of its requested information, Page -12- " UII e--O.~' ~ 58, DMA's failure to complete its peer review within 30 days after receipt of the information requested is in violation of 31 Pa, Code ~69,52(d), Defendant, State Farm Insurance CO,'s acquiescence in such action is also violative of 31 Pa, Code ~69,52(d), 59, Plaintiff believes and, therefore, avers that there was no reasonable basis to deny payments to Dr. Malin and/or Weis Pharmacy, because the peer review report relied upon blanket characterizations of accepted treatment, without any physical examination of James E, Bonn, The peer review report letter did not consider Plaintiff's prior health, specific injury, mechanism of injury, or his current medical condition, before reaching its conclusion, 60, Plaintiff believes and, therefore, avers that there was no reasonable basis to deny payments, based on the September 15, 1999 report, because Dr, Askin did not perform a detailed analysis of the case and overlooked specific findings, 61, Plaintiff further avers that Dr, Askin exhibited bias, circular reasoning, and arbitrariness in his analysis, Defendant's acquiescence of such action is violative of 31 Pa, Code ~69,52, et seq, 62 Pursuant to Pa, Code S69,52(c), a PRO must afford the medical provider an opportunity to discuss the case with the reviewing physician and to submit any information to the reviewer prior to a final determination, 63, DMA's failure to provide Dr, Malin and/or Weis Pharmacy with the opportunity to discuss this case with the reviewing physician is violative of 31 Pa, Code Page -13- \-;;iJ'Ii'If1'/" I )\jU1l1 69.52(c), Defendant's acquiescence in such action is also violative of the above- referenced code section, 64, In addition, DMA's failure to provide Dr. Malin with an opportunity to submit additional information to the reviewing physician is also violative of 31 Pa, Code S69,52(c), Again, Defendant's acquiescence in such action is also in violation of the above-referenced code section, 65, Pursuant to 31 Pa, Code S69,52(e), a PRO's written analysis shall include specific reasons for its decision, 66, DMA's and Dr, Askin's written analysis failed to include specific reasons far its decision, in violation of 31 Pa, Code S69,52(e), Defendant's acquiescence in such action is also in violation of 31 Pa, Code S69,52(e), 67 With respect to all three peer reviews conducted in this matter, it is averred that the initial referrals were violative of 31 Pa, Code S69,52(a), whereby a provider's bill shall be referred to a PRO, only when circumstances or conditions relating to medical and rehabilitative services provided, cause a prudent person, familiar with PRO procedures, standards, and praclices to believe it necessary that a PRO determine the reasonableness and necessity of care. Dr. Bruce Goodman Insurance Medical Examination October 29. 1999 68, Following the aforementioned peer reviews, Defendant, State Farm Insurance Co., continued to deny medical bills submitted by the aforementioned Page -14- ~"~, I~"'~ -~ medical providers and Plaintiff, James E, Bonn, continued to receive medical bills and/or collection notices, 69, By virtue of Defendant, State Farm Insurance Co.'s, continued denial of the aforementioned medical bills, Plaintiff, James E. Bonn, was compelled to submit to an insurance medical examination, cqnducted by Dr, Bruce Goodman on October 29, 1999, 70, On October 29, 1999, Dr. Goodman wrote an insurance medical exam- ination report leUer to DMA. 71, In his October 29, 1999, report, Dr. Goodman opined, inter alia: a, "This man sustained cervical and lumbar strains in a direct and causal fashion to the motor vehicular accident of June 12, 1998," b, "I believe his large disc protrusion at L4-L5 on the left, as well as a large posteriorly displaced left-sided disc at C5-C6 were either aggravated by, or, more remotely, a direct cause of the motor vehicular accident." c, 'The surgery utilized for the treatment of his lumbar disc in September 1998, as well as all treatment to that date, would have a direct and causal relationship to the motor vehicular accident on June 12,1998," Nowhere in his report does Dr. Goodman address the reasonableness and/or medical necessity of prospective medical treatment, after October 1999, Page -15- "~- ".--, - 72, On November 19,1999, Defendant, State Farm Insurance Co" sent a letter 10 Plaintiff's counsel, including a copy of Dr. Goodman's insurance medical examination report and stating that, "His findings agree with the PRO findings," 73, On December 3, 1999, Defendant, State Farm Insurance Co" sent another letter to Plaintiff's counsel, stating, inter alia, "The IME report was very thorough and supporled the findings of the two PRO reports, Therefore, we stand by our previous denials of Mr. Bonn's continuing treatments." 74, Despite the fact that Dr. Goodman's report did nol address the reason- ableness or necessity of ongoing medical care, Defendant, State Farm Insurance Co" continued to deny payment of medical bills, in violation of 75 Pa. C, SA SS 1716 and 1798, 75, Plaintiff believes and, therefore, avers that there was no reasonable basis to deny payments to any medical providers, based on Dr, Goodman's insurance medical examination report. The insurance medical examination did not consider Plaintiff's prior health, specific injury, mechanism of injury, or his current medical condition, before reaching its conclusions, 76, Plaintiff further avers that Dr. Goodman exhibited bias, circular reasoning, and arbitrariness in portions of his analysis, Defendant's acquiescence of such action is violative of 75 Pa, C,SA SS1716 and 1798, 77 To date, Defendant has refused to pay the balance due the aforementioned providers, under the terms and conditions of the applicable policy of insurance and the Pennsylvania Motor Vehicle Financial Responsibility law. Page -16- ~ j-'"- - -~ As a result of the aforesaid, Plaintiff, James E, Bonn, has been required to hire the services of an attorney to collect the medical bills herein due, Defendant's course of conduct in this case has been unreasonable and without reasonable foundation, Therefore, pursuant to 75 Pa, C,SA SS1716 and 1798, respectively, Plaintiff is entitled to attorneys' fees, as well as 12% interest on the unpaid bills, COUNT I BREACH OF CONTRACT 78, Plaintiff incorporates Paragraphs 1 through 77 herein as if fully set forth at length, 79, By withholding payments with no authority to do so, unnecessarily and improperly referring bills to a PRO, not adhering to the several temporal, procedural, and substantive requirements, as set forth in law, and acquiescing in the PRO's failure to do so, Defendant has undertaken a course of action that has been designed to unilaterally, and without justification, refuse claims for medical benefits, causing Plaintiff to become personally responsible for medical bills arising out of the maintenance or use of a motor vehicle, in contradiction to the terms of their contract, the Pennsylvania Motor Vehicle Financial Responsibility law, the medical cost- containment regulations, and established case law of this Commonwealth, 80, Plaintiff believes and, therefore, avers that the above-described actions of Defendant are unreasonable and without reasonable foundation, 81, The above-described actions constitute a breach of contract by Defendant, State Farm Insurance Co., with Plaintiff, James E. Bonn, Page -17- -""~I ~~~ -,-- 82, Pursuant to 75 Pa C,SA SS1716 and 1798, in the event that the insurer has acted in an unreasonable manner in refusing to pay the benefits when due, the insurer shall pay the benefits owed and interest of twelve percent (12%), costs, and all attorneys' fees, WHEREFORE, Plaintiff demands judgment in his favor, in an amount in excess of twenty-five thousand dollars ($25,000,00), including the benefits averred, interest of twelve percent (12%), and all attorneys' fees, COUNT II BAD FAITH 83, Paragraphs 1 through 82, above, are incorporated herein as though fully set forth at length, 84, On or about February 7, 1990, the Governor of the Commonwealth of Pennsylvania signed into law 42 P,S, S8371, effective July 1, 1990, titled, "Actions on Insurance Policies," which 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 amount equal to the prime rate of interest plus 3%: (2) Award punitive damages against the insurer; Page -18- "'- 1'-'" '-eo -, - (3) Assess court costs and attorney fees against the insurer, 85 All treatment was provided to Plaintiff after the effective date of the above Statute and the alleged bad faith occurred after the effective date of the Statute, 86. It is believed and, therefore, averred that the Defendant insurance carrier has employed the reviewing organization, DMA, in bad faith, Said organization does substantial review work for the Defendant and, as a result, has a strong financiaL interest in providing a biased review report to the Defendant. 87, Moreover, said review organization has, or may have, continuously been providing negative review reports to this Defendant and other automobile insurance carriers for the purpose of maintaining a steady source of business, thereby showing a pattern of abuse of the peer review process, Defendant's acquiescence of such action violates the law and constitutes bad faith 88, DMA is a sham PRO, invariably providing Defendant with findings that medicallreatment is not reasonably necessary, 89, DMA is a "captive" reviewer that is known by the Defendant to issue favorable reports to Defendant, so as to induce Defendant's continued use of its organization, Page -19- ~"""""T""""" 90, Defendant, through its representatives, agents and/or employees, has breached its its duty to act in good faith and conducted said peer review for an impermissible purpose by the following actions: (a) Representing that the Plaintiff, James E, Bonn, would be covered by the full amount of the medical benefits purchased under the above-referenced policy, when, in fact, said promise was wholly illusory; (b) Purporting to offer a specified amount of medical coverage, when, in fact, defendant had no intention of providing coverage to said extent; (c) Charging a premium, based on a specified amount of medical benefits, when, in fact, Defendant purposely avoided fulfilling its contract to provide said amount of benefits; (d) Denying Plaintiff, James E Bonn, medical benefits and/or payment of medical benefits without a reasonable basis; (e) Refusing to pay the Plaintiff's claim without conducting a reasonable investigation based upon all available informalion; (f) In failing to use DMA to evaluate the reasonableness and necessity of medical treatment, but, rather, in using said PRO in form only as a pretext for denying Plaintiff's first-party claim; (g) In employing DMA due to said PRO's financial interest in providing Defendants with biased reports; Page -20- ,'~-r- . ~~ (h) Not attempting, in good faith, to effectuate prompt, fair, and equitable coverage of claims, once the Defendant's responsibility under its policy of insurance had become reasonably clear; (i) Failing to evaluate and determine Plaintiff's entitlement for treatment rendered,based upon the terms of the policy providing coverage to Plaintiff, James E. Bonn, thereby compelling Plaintiff to institute litigation; (j) By intentionally ignoring Ihe authorized peer review process of the Act 6 amendments to the Motor Vehicle Financial Responsibility Law; (k) By inlentionally ignoring the clear language of the aforementioned peer review reports and advising Plaintiff that future medical bills would not be honored; (I) By referring all bills, incurred by State Farm policyholders who have purchased extensive first-party medical benefits like Plaintiff's policy of $100,000 in medical benefits in the case at bar, to PROs; (m) By allowing a person unfamiliar with peer review procedures, standards and practices to determine thai peer reviews were necessary, in violation of 31 Pa. Code ~69,52(a); and (n) By advising Plainff's medical providers to bill and/or contact Plaintiff individually for bills it was denying on the basis of a peer review, in violation of 75 Pa, C,SA S1797 and 31 Pa Code S69,52(n), Page -21- '!"""'!"I""-I~- WHEREFORE, Plaintiff demands judgment in his favor in an amount in excess of twenty-five thousand dollars ($25,000,OO), including interest, punitive damages, costs, and attorney fees, COUNT III DECEIT 91. 'Paragraphs 1 through 90, above, are incorporated herein as though fully set forth at length. 92, The conduct of the Defendant, State Farm Insurance Co" constitutes misrepresentation, fraud, and deceit, in that, inter alia, Defendant knowingly, willfully, and/or recklessly refused and failed to comply with the terms and conditions of the subject insurance policy, including, but not limited to, the policies, implied covenant of good faith and fair dealing, the Statutes of the Commonwealth of Pennsylvania, and the regulations of the Insurance Department of the Commonwealth of Pennsylvania, and in otherwise violating its fiduciary, contractual, and statutory duties in dealing with the Plaintiff, 93, The Plaintiff justifiably relied upon Defendant's representations in the policy and sales presentations by the Defendant's agents and/or public advertising that all claims would be fairly and promptly paid, which representations were false when made, which Defendant knew and intended that those representations would be relied upon, which Plaintiff did rely upon, to his detriment, and, therefore, the Defendant's conduct constilutes the common law tort of deceit, for which Plaintiff seeks compensa- tory and consequential damages, Page -22- '''~~ r""'~-' "~ ,< . WHEREFORE, Plaintiff, James E, Bonn, demands compensatory, consequential, and punitive damages from the Defendant, State Farm Insurance Co" in an amount in excess of twenty-five thousand dollars ($25,000,00), including interest, punitive damages, costs, and attorney fees. Respectfully submitted, Date: z-) l '1/ 7.CJrr7> , HANDLER, HENNING & R?)G By Matthew S, Crosby, Esq. Supreme Court 1.0. # 69367 319 Market Slreet P,O, Box 1177 Harrisburg, PA 17108 (717) 238-2000 Attorneys for Plaintiff Page -23- ~ r- VERlFICA nON THE UNDERSIGNED hereby verifies that the statements in the foregoing document are based on infonnation that was gathered by counsel in preparation of this lawsuit. The language of the above-named document is of counsel and not of my own. I have read the said document and, to the extent that it is based on infonnation that I gave to counsel, it is true and correct to the best of my knowledge, infonnation and belief. To the extent that the contents of the said document is that of counsel, I have relied upon my counsel in preparing this Verification. THE UND ERSI GNED also understands that the statements therein are made subject to the penalties of 18 Pa,R.C.P, 2252(d), relating to unsworn falsification to authorities, DATE: 2,20CJO ..... - Q,~ e:B&t~ c;:i'AMES E, BONN --"""'1-" , ~ r" (' " " STANLEY R. ASKIN, M,D, Hand & Orthopedic SUllIery Telephone 215-635-5997 Fu 115-635-6114 YORK AU6 02 1999 RANCOCAS HOSPITAL PROFESSIONAL Bun.DING EAST #106 1113 HOSPITAL DRIVE W1LLINGBORO, NEW JERSEY 08046 8080 OLD YORK ROAD #201 (ELKINS PARK SQUARE RlE 611 AT CHURCH ROAD) ELKINS PARK, PA 19027 July 29, 1999 .~- '.:~C.C."JI ' -"!:D -...// :; , -, 9 i9;'} . ',' ! ~,.! . -',~,., "~t ~",'~""""'~- . ,.\~/~' ".- '". . Ms. JudithF. Evans, RN., C.D.MS., C.C.M Disability MlInagement Associates 1489 Baltimore Pike Building 200, Third Floor Springfield, P A 19064 AUG 0 6 1999 RECEIVCLiJ RE: James Bonn Oaim #: 381023-737 DMA#: CPA6297 Dear Ms. Evans: A review of submitted medical records was requested of me. Additionally, I was asked to contact the attorney, Mr. Crosby, and such did occur on July 19, 1999. Mr. Crosby was mainly interested in insuring that I had been provided with all of the records. Inasmuch as I do not have a list ofwhat would constitute the entirety of records, I merely observed that I was provided with about three or four centimeters worth of records which sounded about right to Mr. Crosby insofar as the bulk of the records should represent. The request to contact Dr. Wolf; Mr, Bonn's current physician, seems to have been engendered by Mr. Crosby as well. Even so, I did contact Dr. Wolf on July 20, 1999, and he shared with me his thoughts regarding Mr. Bonn. To paraphrase, Mr. Bonn has been recommended to submit for "thenna! ablation of the disc" which Dr. Wolf considers the source of Mr. Bonn's symptoms. Dr. Wolf apprised me that he is aware of Mr. Bonn's large girth, and he does not look favorably upon the prospect of perfonning surgery upon Mr. Bonn. I did understand, from Dr. Wolf; that surgery would be conducted, however, if Mr. Bonn continued to complain despite treatment short of surgery. Provided for my review are the following records: L The letter from Mr. Crosby dated June 3, 1999. 2. The Service Request Fonn and letter of referral requesting this review. '--r- ~~ ., .r', (' Page 2 July 29, 1999 RE: James Bonn VORK AUG 02 1999 3. The application for benefits dated June 23, 1998. As of that date, the self described injury was "lower neck, lower back and numbness in feet". 4. MRI scan of the lumbar spine dated December 28, 1998 which was subsequent to surgery upon the IA-5 disc. 5. MRI scan ofJune 30, 1998 of the cervical spine revealing disc abnormalities characterized as "bulging and at C5-6 moderate, large sized, herniated nucleus pulposus. . . " 6. MRI scan of lumbar spine July 2, 1998 describing disc pathology at 13-4 and L4-5. 7. MRI scan of April 26, 1999 of the cervical spine cbaracterizing the findings, in so many words, as a degenerative type of process at C3-4, C4-5 and C5-6, 8. Electrocardiogram of September 9, 1998, 9. EMG ofNovember 20, 1998 by Dr, Lupinacci for both upper extremities finding "moderate to severe peripheral neuropathy, mixed motor sensory with both demyelinating and axonal components". Dr. Lupinacci's report references past surgery upon the nerves of Mr. Bonn's left upper extremity, "many years ago", ''"1;.-''"'' ....'. ' Also provided were billing invoices for the foregoing imaging studies, electr~ogram and EMG. 10. Pain management records ofDr. MoDlin beginning July 22, 1998 and describing epil\tI@. 0 6 1999 injections that had been perfon1ted with billing invoices. 11. Physical therapy records of Russell Poole to include billing invoices for same. RECti V t: 12. The office notes of Dr. Malin beginning July 28, 1998 with attached billing advice. b 13. Records from Pinnacle Hospital dated March 17, 1999. 14. Records of Dr. Wolf beginning March 11,1999. 15. Records of Dr, Michalek, a neurologist. 16. Hospital records from Holy Spirit Hospital. These include the emergency room record of June 12, 1998 describing the mechanism of injury being that Mr. Bonn was a seatbelted driver who was hit from the rear and pushed into the car in front ofhim with complaints ofhis back and neck hurting, Within the same sheafis the record ofhis surgical treatment by Dr. Malin noting a past history of depression and hypertension, and that he is reported to be neurologically intact insofar as his history and physical examination would reveal. Enclosed with these records is the operative report of September 30, 1998 which will be discussed below. 17. Chest x-ray performed on September 30, 1998 and an intraoperative x-ray of the lumbar spine were provided without significant infonnation contained therein, 18. Laboratory reports for the perioperative testing. A clinical synopsis is that Mr. Bonn is a gentleman characterized at the emergency room and by Dr. Wolf as being obese. He was involved in a motor vehicle accident on June 12, 1998 when he was approximately 48 years of age. He had the onset of neck and back pain associated therewith, The MRI studies revealed what MRI studies usually reveal for people in the middle years of life which is multiple levels of disc abnonnality, Such abnonnalities are variously categorized by radiologists as bulges, protrusions, or herniations without any apparent distinction insofar as the choice oftenninology .-.,- /'-" , , I " YORK AU6 02 1999 Page 3 July 29, 1999 RE: James Bonn (the fact that MRI scan revealed disc herniation has no significance inasmuch as any number of asymptomatic individuals can be felt to have "disc herniation" by MRI scan criteria. If someone with no symptoms can have disc herniation, the "diagnosis" of disc herniation is meaningless.) The EMG that was reported as revealing peripheral neuropathic changes might have some relationship to the prior history of nerve surgery in the left upper extremity referenced by Dr. Lupinacci. However, the features were observed to be bilateral. Bilaterality was not reported by disc on the first cervical MRI scan, and insofar as bilaterality on the second cervical MRI scan, it was by osteophyte fonnanon characterized as "mild". The operative report dated September 30, 1998 carried a preoperative and postoperative diagnosis of herniated nucleus pulposus at US on the left. Revealed in the operative report is that "a cruciate incision was made into it and disc material was removed". Please observe that if an ~o,n had.tobe... made into the disc to remove the disc material, the disc had not been herniated, ),' While I do appreciate that there was an initial report to Dr. Malin of improvement after thA~ 1999 that improvement seems not to have b~n long-lived leading to Mr. BOM's ultimate representation to Dr. Wolt RECEI\lE/.b Dr. Wolt's materials beginning on March 11,1999 descnbe "evaluation by Dr. Janton who felt that he does have Charcot-Marie- Tooth". Please observe that such would be an explanation for the features noted in Dr. Lupinacci's EMG. Dr. Wolf characterized the findings on Mr. Bonn's x-rays and MRI scan, and he considered Mr. BOM's symptoms due to "probably painful internal disc disruption in a lumbar spine with some spinal stenosis. ..". The clinical findings described by Dr. Wolf include a nonna! neurologic evaluation of the lower extremities at insofar as any suggestion of sciatica. On April 22, 1999, Dr. Wolf reported that Mr. BOM "was sent for a cr scan of the cervical and lumbar spine because we could not get the myelogram due ofhis size" referencing his obesity. Dr. Wolf referenced the discographic infonnation showing "a markedly provocative test at US. This reproduced his back pain completely". The report of the May 24, 1999 study was provided. I was charged, in the letter of referral, with providing an impartial and unbiased opinion and a thorough analysis. Please consider that there are schools of thought in the practice of medicine, and that the opinion which might be proffered regarding a particular case certainly depends upon the school of thought held by the reviewer. The following opinions are offered by me to a reasonable degree of medical certainty based on my appreciation of the pathoanatomy of back pain. "'1"",...,... I...."'" n - ;'" /'" ( '. VORK AlI6 02 1999 Page 4 July 29, 1999 RE: James Bonn Assessment: 1. The source ofbacle pain is controversia1. There are those who may hold that the disc is a primary or proximate source ofback pain. Different thoughts abound as to the potential neuroanatomy which might explain back pain. Concepts such as "internal disc disruption", disc bulging or disc protrusion or disc herniation are all frequently invoked. It is due to the focus on the disc as a primary or proximate source of back pain that various surgical procedures are reconunended and perl'ormed, These can include percutaneous type of procedures, such as thennal ablation, or percutaneous discectomy, or open surgical procedures such as 1aminectomy and <jiscectomy. I do believe that most surgery on the intervertebral disc for back oain has been thoroughly discredited. Such does not mean that the surgery does not routinely occur, merely that when one carefully analyzes the results of such surgery, patients ordinarily are not pll}Y not improved, , but are frequently worsened.' 2, Please observe that back pain and neck pain are conunon travails among human kind, and I do believe that the disc is indirectly respollSlble. AUG 06 1999 Basically, the intervertebral ~, when we are young, is 80"10 water, and when the disc is "fullY inflated" it holds the space between the vertebral bodies which is important for ndYiC EI" t: k functioning of the facet joints. As we age, the ~ loses its water content, the disc deflates, the space is lost, and the facet joints can no longer work without "friction" causing arthritic changes. The sequence then is that the disc first loses its water content and deflates, the joints become arthritic, but such does not necessarily mean that pain will be present. However, one can slip on ice, pick something up in an awkward fashion, sleep uncomfortably, or get rear-ended in a motor vehicle accident, and move an already arthritic joint in a painful fashion, which is, in my considered opinion, the actual proximate or primary source ofback discomfort. This sort of exp1anation for back or neck pain is tenned "mechanical" and for my own patients I characterize this as if there were a "rusty binge" within the spine, with the provocative event causing motion of the "rusty hinge" making symptoms. It should be understood implicitly that when resolution does occur, and it ordinarily will occur ifleft to its own devices, it is not to a pristine status but to a status of someone who is middle-aged and with degenerative changes. 3, Mr, Bonn's obesity is a double edged sword. In one respect, it does contnbute to pain experienced at arthritic joints, especially considering that the low back is a weightbearing part of the body; however, being swathed in an exuberant layer of "padding" also suggests the likelihood that the skeleton is actually protected from trauma in much the same way that packing beads protect a fragile structure being shipped in a box. Please observe that I would not, in any manner, dispute the possibility of significant discomfort experienced by Mr. Bonn, merely that the analysis of his back and neck pain seems to me to have been tangential to the actual source and predicts that the more treatment that he gets the worse he will be, . 1 1 ''l'WPl'"'''''''''''' .. - -, ~ ~- - t- ~0Fm: AU6 02.;S99 Page 5 July 29, 1999 RE: James Bonn 4. So long as Mr. Bonn pursues treatment of an invasive nature, it would be my considered opinion that such lIWI8gement is not reasonable nor DeC"..''Y, and it is likely to be incrementally hannful to him. TI1ece is not any treatment that a doctor could do to or for Mr. Bonn that would improve upon the natural history oflow back pain which is for spontaneous resolution. The various tests that are performed upon Mr. Bonn are focused on the intervertebral disc as a source of his discomfort, and as been indicated above, such is not ordinarily the case, especiaI1y not the case in someone who does not have sciatic tension signs, reflex abnormalities or the like. It does seem to me that common sense, as well as good medical advice, that Mr, BolUl should lose weight. A man who is so heavy that he exceeds the capacity of the imaging study table is too heavy and potentially is perpetuating his low back symptoms. It is my bottom line consideration that Mr. Bonn's treatment, orthopedically, in the setting described is contrary to his best interests and should be discontinued forthwith. He will not proffer from surgery, no matter what surgery, and no matter how capably performed. The diagnostic tests are likewise irrelevant in this setting, He has had sufficient testing to make sure that nothing dangerous was present, and now all that is being sought are reasons to penonn surgery, Insofar as medications, the use of mild analgesics, such as Tylenol or Darvocet-N, would be appropriate pending his cooperation with an appropriate weight loss ,~ In summary, it is my opinion that the care provided by Dr. Wolf from April 22, 1999 iYX\.. ongoing would not be considered reasonable or necessa'Y for injuries sustained on JufWPz,O 6 19q() 1998. REC .t::,.~_ I hope this information proves helpful to you, Again, such was offered to a reasonable degree of medical certainty, and I hope my ratiocination proves helpful in your consideration of this information. 5. 6. 7, Sincerely, ~~ C?~ /J;,AJ, &acl~yRA#M.D, ~ SRA/36 HS 36A 724 "~ . :,~--!' "'" ,._::;-_:::,'":".:"!~_!_":'._'~~~:n.....,..~ -. r , " ( YORK AU6 02 1999 ... " , ~,.~",~'''''-' "'-rn.. . HEALTHSOU7H .. DISABILITY MANAGEMENT ACT 6 TRACKXNG LOG PATXENT 1mME: CLADl I: DMAI: TYPE OF .REVJ:E1f: PROVI:DER: JAMES BONN 38-J023-737 CPA6297 PRO STEPHEN B. WOLF, MD AUG 0 6 1999 Rl:CEAVE.l.J, DATE RECEIVED: June 04, 1999 DATE ACKNO~EDGEHENT LETTER SENT: 6/4/99 DATE PROVXDER LETTER SENTI June 04, 1999 DATE PROVXDER RESPONSE: 6129199 RECORDS SENT: YES DATE COMMENCED: June 29, 1999 DATE COMPLETED: July 29, 1999 REVXEWER: STANLEY ASKXN, MD 1489 Baltimore Pike, Building 200, Third Floor . Springfield, PA 19064 800388-7877 . 610604-0450 . Fax 610 604-0461 -,,,,,,'1"" .~"I~~-~ -~'" - ~~ f ,.c- \ S tat e Far m "n sur a nee AUgust 4, 1999 James E. Bonn 967 W Trindle Rd Lot 24 Mechanicsburg, PA 17055-4056 RE: Claim Number: Date of Loss: Our Insured: Patient: Dear Mr. Bonn: 38-J023-737 June 12, 1998 James E. Bonn James E. Bonn ;r, \ Co m pa n les STATE FARM .1iL' ~ INSURA.NCE ~ Medical Claims Unit PO Box 14007 York. Pa. 17404-0867 1-888-236-8672 'l!;.l...-.of""-....................-.......;,..... AUG 0 6 1999 RECEIVED Pursuant to Section 1797 (b) of Act 6, your medical file was submitted to Disability Management Assoc, a Peer Review Organization (PRO) approved by the Insurance Department of Pennsylvania, for review of the medical records, This review concerns treatment rendered by Dr. Wolf, Enclosed is a copy of the PRO's determination, Based on this report, we will not be issuing any payment for services rendered on 4/22/99 & after. Section 1797 (b) of Act 6 states: "If it is determined by a PRO or court that a provider has provided unnecessary medical treatment or rehabilitative services or merchandise, or that future provision of such treatment, services or merchandise will be unnecessary, or both, the provider may not collect payment for the medically unnecessary treatment, services, or merchandise"... HOME OFFICES: BLOOMINGTON, ILLINOIS 61710-0001 ;~~r- ,.,.'-0- r James E, Bonn Page 2 August 4, 1999 r' _--~..,:J ,~",~....-,,,, , AUG 0 6 1999 REC~IVt:l.P An insurer, provider, or insured may request, in writing, recon- sideration of the initial PRO determination within 30 days from the date the initial determination is effected. This request for reconsideration should be submitted directly to the attention of the Disability Management Assoc. state Farm will advance the cost for this reconsideration. If the reconsideration is against you, you will be responsible for its cost, Should you have any questions concerning the above, please contact me. Sincerely, Audrey B. Crilley Claim Specialist (717) 767-8121 State Farm Mutual Automobile Insurance Company Enclosure cc: Matthew S. Crosby j~,~i!f,~~,:l,i,r,,"'r.llr~'~?i'l!;,., .y- .::.::t~;~~~:~~:: ~111Jll':' ::'::'::::::::~:::::: V ~-r- , -- r- ( , .J (- DANIEL B. LOPRETO, PH.D. CLINICAL PSYCHOLOGY Diplomat.. Ammcan Board of Quality Assurance and Uhtk:ahon Rrui"" Physicians P.O, BOX 2601 . BAIA CYNWYD, PENNSYLVANIA 19004 . PHONE I FAX (610) 668-8553 PA UC It PS-005042-L NJ UC It S 1-02307 BCIAC It 3477 August 17, 1999 Eloise Manning, RN, BSN, CCM HealthSouth 1489 Baltimore pike Building 200, Third Floor Springfield, Pennsylvania 19064 P,ECE.\~O t;.IJG l. J. \999 e't'oM^ Claimant: _ DMA: DOl: James Bonn CPA 6298 6/12/98 Provider Reviewed: Holy Spirit Hospital 2/22/99 and ongoing Records Reviewed This peer review is based upon careful examination of all available records as they pertain to the claimant's medical and psychological status, including: 1) Application for benefits, dated 6/22/98, and disability statement, dated 7/14/98; 2) Emergency room records, dated 6/12/98, 8/23/98, and 9/9/98, subsequent treatment notes dated 7/1/98 to 7/6/98, and 9/30/98 to 10/3/98, and bills for services rendered by Holy Spirit Hospital; 3) MRI report, dated 6/30/98, from Open MRI, and MRI reports, dated 7/2/98, 12/28/98, and 4/26/99, from Magnetic Imaging Center; , 4) Initial evaluation report, dated 7/22/98, progress notes, dated 7/22/98 to 8/25/98, and bills for services rendered 7/9/98 to 8/25/98, by HealthSouth Rehabilitation of Mechanicsburg; 5) Treatment notes, dated 7/28/98 to date illegible, 1999, and bills for services rendered 7/1/98 to 4/7/99, by Orthopaedic Surgeons of Central Pennsylvania, Ltd.; YORK AUS 3 1 1999 '~~_1~ - ' - (- ''-- j .> , Bonn / 2 6) Evaluation report, dated 9/14/98, and bill for services rendered on that date by Todd Samuels, M.D., of Neurology Center; 7) EMG/NCV testing report, dated 11/20/98, and bills for services rendered on that date by Michael Lupinacci, M.D.; 8) Notes from pinnacle Hospital, dated 3/17/99; 9) Treatment/assessment notes, dated 3/11/99 to 6/3/99, and bills for services rendered 3/11/99 to 4/22/99, by Steven B. Wolf, M.D., of Orthopedic Institute of Pennsylvania; 10) Lumbar spine assessment, dated 3/22/99, and bills for services rendered on that date by The McKenzie Institute; 11) Treatment notes, dated 1/11/99 to 6/16/99, and bills for services rendered 1/11/99 to 3/15/99, by Rudi Crider from Holy Spiri~ Hospital; ** I had an opportunity to discuss the case with Rudi Crider by telephone, as per his request, on 8/17/99. We spent approximately 45 minutes reviewing the case. Discussion According to the records reviewed, the claimant, James Bonn, was the restrained driver of an automobile that was rear-ended by another vehicle on 6/12/98. A police report of the accident was not contained in the file for review. The claimant presented at Holy Spirit Hospital following the incident, with complaints of neck, upper and lower back pain. There was no loss of consciousness. Documentation revealed an .obese" individual, with a history of depression, hypertension, bone spurs, and left shoulder surgery due to a rotator cuff tear. The c~aimant was also taking a number of medications for his pre-existing condition, including Prozac. He was examined and discharged the same day with a diagnosis of back strain. MRI of the cervical spine, conducted 6/30/98 at Open MRI, revealed mildly bulging discs at C4-5 and C6-7, with a mOderately-sized HNP at C5-6. MRI of the lumbar spine, conducted 7/2/98 at Magnetic Imaging Center, revealed a moderately large disc protrusion at L4-5, and a small central disc protrusion at L3-4. YORK AU6 3 1 1999 ;1,~_,"," ".."'" , if ,- Bonn / 3 On 7/1/98, the day following his MRI, the claimant returned to Holy Spirit Hospital with complaints of severe pain in his neck and lower back. He was admitted to the hospital under the care of Dr. Malin, through 7/3/98, where he received oral steroid therapy. On 7/22/98, the claimant presented at HealthSouth Rehabilitation of Mechanicsburg, with complaints of .severe pain in his lower back, left leg, as well as chronic neck pain.. He was evaluated on this date by Malik Momin, M.D., who recommended and subsequently provided two epidural steroid injections on 7/22 and 8/7/98. The claimant also participated in physical therapy at this facility. He was last seen by Dr. Momin on 8/25/98. On .7/28/98, the claimant presented for follow-up with Dr.' ,. Malin after his recent emergency room visit. Notes of this date indicate that .steroids do make him have a bizarre personality apparently. His personality is very difficult for 2-3 days.. The claimant subsequently continued under Dr. Malin's care through at least 4/7/99, according to the most recent progress note reviewed. This note reveals continued complaints of .pain to his back without leg p~in.. On 8/23/98, the claimant again presented at the emergency room of Holy Spirit Hospital with complaints of posterior headaches following an epidural steroid injection approximately two weeks earlier. Admission notes of this date indicate an .adult male of average build., and a psychiatric history .within normal limits. He was diagnosed as experiencing a cervical traction headache, was given an injection of Demerol and released. On 9/9/98, the claimant again presented at Holy Spirit Hospital fOllowing a fall in which he reportedly struck his head and lost consciousness for 3 to 5 minutes. This brief syncope was secondary to severe pain in his lower back. The claimant was examined in the emergency room, given Fioricet, and released the same day with a diagnosis of closed head injury and chronic neck and back pain. Neurological evaluation, conducted 9/14/98 by Todd Samuels, M.D., of Neurology Center, resulted in a diagnosis of migraine headaches, and a recommendation for continuation of Fioricet PRN. On 9/30/98, the claimant was admitted to Holy Spirit Hospital for excision of a disc on the left at L4-5 (decompression laminectomy). The procedure reportedly occurred without incident and the claimant was discharged on 10/3/98. YORK AUG 3 1 1999 ,~~ c-- Bonn I 4 EMG/NCV testing; conducted 11120/98, by Michael Lupinacci, M.D., revealed moderate to severe peripheral neuropathy, mixed motor-sensory with both demyelinating and axonal components. It appears that the claimant was admitted to pinnacle Hospital on 3117199. Notes from this provider were illegible. I was unable to find documentation of this episode of treatment in the notes submitted by other providers. On 3/11/99, the claimant presented to Steven Wolf, M.D., "for a second opinion of his lumbar spine problems." The claimant reported to Dr. Wolf that he has gained over 100 lbs. because of his back problems. This suggests that his "back problems may have pre-dated the incident of 6/12/98, as he had only gained approximately 25 Ibs. since the accidenC -In: any" case, the claimant continued under Dr, Wolf's care through 6/3/99, according to the most recent treatment note reviewed. On 1/11/99, the claimant presented at the Community Mental Health Center at Holy Spirit Hospital. An initial evaluation report was not submitted for review. Notes of this date, as well as subsequent sessions tqrough 6/16/99 are somewhat difficult to read. I had an opportunity to discuss with Rudi Crider, by telephone, on 8/16/99. We spent approximately 45 minutes reviewing the case, as well as clarifying the content of handwritten notes. Mr. Crider, who is an unlicensed provider, reported that the claimant had been involved in therapy previously at Ho~y Spirit Hospital, for problems with depression that seemed to have some paranoid features. At that time, the claimant was under the care of a psychiatrist, as well as Mr. Crider. At the present time, the claimant's diagnosis was "depressive disorder NOS". This was a provisional diagnosis rendered at the initial intake. "Problems" identified at intake, reportedly included, "depression, wife dying, no interest in activity, and auto accident". Mr. Crider provided nine sessions of individual and couples therapy from 1/11/99 to 6/16/99, according to the treatment notes reviewed. (A session dated 5/18 was absent from the file but was discussed during the telephone conference). Review of these notes reveals an approach that utilized an active, directive, and cognitively-based approach to assist the claimant in better managing his pain, regulating his emotional outbursts, and achieving some level of functionality. The claimant does have a history of depression with substance abuse, and the concurrent stressor of his wife's YORK AUG 3 1 1999 x_~ r- , . . Bonn / 5 terminal illness. Mr. Crider stated that this was difficult for the claimant because "his wife is his life line." Summa" and Conclusions Based on my review of the records submitted, and my conversation with Mr. Crider, it appears that the claimant is demonstrating symptoms indicative of a Pain Disorder Associated With Both Psychological Factors and a General Medical Condition. (DSM IV 307.89). I would include Back Pain as the Axis III diagnosis, without being more specific regarding the claimant's medical condition. Although the claimant has a history of depression and was taking Prozac at the time of the recent motor vehicle accident, he appears to have been functioning adequately. His wife's terminal illness represents an extreme stressor which certainly would impact upon his depression, but again the claimant appears to have been able to cope with this stressor through various means. I believe that the claimant's current level of depression, which appears to render him dysfunctional, is partially attributable to. his chronic and severe level of pain. Pain is by definition subjective. Hence, the claimant's own perception of pain is effected by his own subjective state. I believe, based upon the information provided, that the claimant's pain is influenced by his depressive state and his medical condition. In the case of Mr. Bonn, as is typical of most chronic pain patients, a vicious cycle of pain - depression (anger) - pain is operating. It is necessary to interrupt this cycle if the patient is to achieve some degree of resolution. Psychotherapy becomes a reasonable and necessary treatment for this type of problem. More appropriate, in many cases, than continued medical intervention. The psychotherapy must be active, directive, time-limited, with specific goals and objectives. The focus must be on functionality rather than subjective pain. The therapy as provided by Rudi Crider and Holy Spirit Hospital meets these criteria, In summary, based upon my review of the documentation submitted, as well as my conversation with Mr. Crider, I view the services provided by Holy Spirit Hospital, from 1/11/99 through 6/16/99, as being reasonable and necessary for injuries sustained in the motor vehicle accident of 6/1.2/98. Tbis consultant report remains advisory in nature only. Final determination regarding tbe assigneY6~1{'ility in this AU6 3 1 1999 ,- -~~ " , /.-.... ; ",,", , Bonn / 6 case, given the indirect etiol.ogy of the symptoms, is sol.el.y the responsibil.ity of the insurance carrier. ~~ PA Lie # PS-005042-L; NJ Lie # SI02307; Fellow, Biofeedback Certification Institute of America Diplomate, American Board of Quality Assurance and Utilization Review Physicians Diplomate, American College of Forensic Examiners, Board of PsychOlogical Specialties, Psychological Disabilities Eva}.uation " ~~ YORK Aut; 3 1 1999 ~1rnI!fW-r- '. - ,..- .:r""",~ ( , - ~ . .r;,'~lf~.~j;,i:::,:~~~;~~!:~,'-':::.Jl~~a~", . ;J4~i,..._1t--;~.~_... .... .,<(,....,;!f?.-~-. :'f;r;~~;.~~:':~i.I~.: ',-','''." , . . 'HIIAL'JH80UTH .. ~-;.. -. DISABIUTYMANAGEMENT ACT , '1'9ll.CB:X.G LOG PAT:I1D1'1! ItUBI t!T.ll.TlI #1 mm.#1 TYPB 01' JlBVXnl PROV:IDBll: JAD8 BOD 38-J023-737 OPA'U8 PRO HOLY Si'DlZT ilOS1?:i:'riU.-'.-e DATB RBCBXVBDI JUDe 04, 1999 DATB ACDTOWLBOOBKDlT LBTTBll 81D1'1!1 '/4/99 DATB PROV:IDER LBftBll 81D1'1!1 JUDe 04, 1999 DATB PRO'TIDER RBSPO.8BI 7/8/99 RBCORDS S1D1'1!: y DATB COMMBHCBD: July 08, 1999 DATB COMPLBTBD: August 25, 1999 " . RBV:tB1fBR :.. DAJl:IBL LOPRBTO, riiD YORK 'AUG 311999 1489 Baltimore Pike, Building 200, Third Floor. Springfield, PA 19064 800388-7877 . 610604-0450 . Fax 610 604-0461 ,.~ ~, - '~ \ State Farm 'Insurance August 31, 1999 James E, Bonn 967 W Trindle Rd Lot 24 Mechanicsburg, PA 17055-4056 RE: Claim Number: Date of Loss: Our Insured: Patient: Dear Mr. Bonn: 38-J023-737 June 12, 1998 James E. Bonn James Bonn -- ( , Companies STAll fARM &' INSURANCE . Medical Claims Unit PO Box 14007 York, Pa. 17404-0867 1-888-236-8672 Pursuant to section 1797 (b) of Act 6, your medical file was submitted to Disability Management, a Peer Review Organization (PRO) approved by the Insurance Department of Pennsylvania, for review of the medical records, This review concerns treatment rendered by Holy Spirit, . Enclosed is a copy of the PRO's determination. Based on this report, we will not be issuing any payment for services rendered on 6/17/99 & after. section 1797 (b) of Act 6 states: "If it is determined by a PRO or court that a provider has provided unnecessary medical treatment or rehabilitative services or merchandise, or that future provision of such treatment, services or merchandise will be unnecessary, or both, the provider may not collect payment for the medically unnecessary treatment, services, or merchandise",., HOME OFFICES; BLOOMINGTON, ILLINOIS 61710-0001 '~-r-1\l!Il ~ James E, Bonn Page 2 August 31, 1999 ( ,.~""" ( An insurer, provider, or insured may request, in writing, recon- sideration of the initial PRO determination within 30 days from the date the initial determination is effected, This request for reconsideration should be submitted directly to the attention of the Disability Management, state Farm will advance the cost for this reconsideration, If the reconsideration is against you, you will be responsible for its cost. Should you have any questions concerning the above, please contact me. Sincerely, Audrey B. Crilley Claim Specialist (717) 767-8121 state Farm Mutual Automobile Insurance Company Enclosure cc: Matthew Crosby '~ ,~ . . . ;.- , -'~ . .. ""'" . "1" , RECEIVED SEP151999 IiY[)tM :"":'1:' ; September 15, 1999 ";' , , Ms. Ju<li~ ~y~;~~~ . :.:~: ";~'u, Peer Review :C6ordinatcir " _l[,~,". - '+:', -~" ., So .l.,~,~ I' :,'~. '. - 7 . J J " DisabilitY,M#.~ew~t ~sosiaies ': ;~. 1489Bal1iilloie~Pik&'!-'''_L".'c'' , . . -";;'" 'L. i', ,~ , . '",-, ; .,' . :.!: . ;,.:-!Z, --: - ~ :. k.-~ "f/._t~f~'j i ~ -:'~i~\~~-~ -'f. q~'f'~~.~\'t 1~J:} '~I,:-:"j~;~,(.. ...' . .-::'1_.. ......11. r. ~.f!-.... '"1.>,.' \ '::f..lj ';f.ij':.7."::' 0' ';,'"'.i" I ~.....~~. l::-'f-r:~ - ~~~f'<"'~;" : .~~ .Iltri ~.. " , . I- ,,~,f~$~}i~~W~,'''~;i*~w;''' rt.;:_~~ ..~~;:_:~':'~~~:~ ~ !"'?"~"":1~~~1~l);1' l -; Dear Ms. Evans: I have been asked to prepare a supplemental report regarding the use ofProzac, an antidepressant medication, being prescribed by orthopaedic surgeon, Thomas Malin, M.D. Please observe that Prozac is not a medication used to treat an orthopaedic malady, but certainly there are those affected by orthopaedic maladies who might require an antidepressant. The provided records (previously enumerated in my report of July 29, 1999) do not yield sufficient medicaI or psychologic information that would permit a thoughtful consideration of the need for an antidepressant medication. That is to say, it is not specifidilly described that the patient is psychiatrically affected by any orthopaedic malady. YORK SEP 2,0 ml . .Pag.lJ 2. ,~ . I , ",,"" -. I " S'~plel11ber15, 1999 RE:Jan\cs llon{\ '",,: ~: ..i:,~,,,, ;-..,' ',.; r, ,',I' !. he botl~1l11m~ \h!:nl!;"tllC1tlf),:kI~qDI\ ISd."PN,~litl1~'~'~!L, ,,' '..~~.,. Pro~aC, i~ ~~c~lt:f~~~~~I~,#i~~r~~~~a~RM??,~~~\Em~~~,,,~~;, "tJ;~~.~ ,I>falm 'srecoro.~ thai doclll11eilL~ IMt hiS comlitlollllc!iliill " ants'arrllnt! p.resc'rri~ 'l)~?'w,l: 6i41i4I;~~C(i f~-;~ii);~idi~~~~~ , -z~t::~.~,:Y:;~: ',:;V'1;t' .,. ~~J:fj~}~:~~~~'r.1;~!F!W~i~lr k""' .' ~ ,,- ,:...; I... ';. c.. .:, ::; ~' ~'<~:;t?-:_:., . >:,_,;- ~ : ~ ::~~~K.t,:,,'l:~';c:;~-in ~_:;::'~~~::::' ~ ~-~'~: '!:,,' "':~:- ~i--_!t:."i -~: _f':::~'1T:~\~'1:~:,;:." ;f.~":~.;..,~~1:~-; "fh,~reforc, loased on the medical re,~oi-'d3, U,,, pr<,scriptions for)>rb:.aic ,;'hidl are,~'i1tt~iiby;pr. " Mailn and are being supplied by W<:i~ PhaITnacy would UC)i:.b.1 rcr\--<;oimble or necessaJ'y for the' irJurks sllstalned in the motor vehicle accident of June '12,1998,; , , :';"><,\...0:'.7.:_: >~'\'.::~"'.'<!:.T,; ::,;',:r:"':~,'.' '-~!:';': ", ... 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