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HomeMy WebLinkAbout97-04961 I" " , , ' ' " , " , , , I ' I , , ~ \! i ' , , ,"I ," , I", , , , , , , i " , , , " " h " I/i , , i I.', , , " I !' , I I .., I , I I I , , , , , I'j ,\1 " I' , , I I , " " , " , i! l' I' I , I , " I, it I' I ", . I ,I , ' I -~ , , '/ ' , , " "' '1"\ I 1/ , ' , I ' , , , I " ' , ,', ", , , , i , " , " , , " I , , " I ; ,..1 , . I , , , , '" tl"; , , ' I 0', " ' I " , , I i " " , " I, I, -I, 'I " " 1'1 , , , , , , , , , rJ. " , , ii, , , " " " " " " , , , ;,' , , " "I I' "',' ';, , ~ , II' I' ~ ~ ~ , " , \ 1,1' ,.' " ;,\ 5, On April 21, 1995, Plaintiff Michael P. Worley was the driver of a van on State Route 74 (SR 74), Creek Road in Dillsburg, Monroe Township, Cumberland County, Pennsylvania, when he was struck on the left driver's sill., I:y a vehicle, driven by Pona Sergio Ricardo, which had crossed the center line of the highway. 6. As a result of the aforesaid accident, Plaintiff Michael P. Worley sustained painful and severe inj uries, which include, but are not limited to, three (3) ruptured discs in his neck which have resulted in muscle spasm, limited range of motion and headaches. 7. Plaintiff Michael P. Worley has not undergone surgery to repair or remove the ruptured discs but does require periodic care including physical therapy when his condition becomes aggravated by his work or activities of daily living. 8. Plaintiff Michael P. Worley has been required to undergo extensive medical treatment in an effort to restore himself to health and continues to suffer from injuries arising from the accident for which he will need medical treatment in the future. 9. Defendant USAA Casual ty Insurance Company has denied continued coverage for Plaintiff's accident-related medical bills and refused to pay certain past and continuing accident-related medical expenses. 10. All of the Plaintiff Michael P. Worley's medical bills were incurred for reasonable and necessary medical and rehabilitative services for the injuries that he sustained in the April 21, 1.995 accident. 4 11. Copies of Plaint iff MJ.chael P. Worley's accident -related medical bi Us, medical records, and reports have been sent directly to Defendant USAA Casualty Insurance Company by Plaintiff's healthcare providers. 12. Said physicians' records and reports provid~ that Plaintiff Michael P. Worley's continuing injuries are directly related to the trauma he sustained in the accident, which occurred on April 21, 1995. 13. On March 20, 1996, Defendant USAA Casualty Insurance Company requested a medical review of Dr. Keith Zeliger, D.O., orthopedic treatment to be performed by Steven J. Valentino, D.O., which was completed on April 17, 1996. 14. The review was purportedly conducted to review medical treatment received by Plaintiff Michael P. Worley and listed extensive and complete medical documentation up to and including March 19, 1996. 15. On July 16, 1996, a second medical review w'as conducted at the request of Defendant USAA Casualty Insurance Company by Jill S. Galper, P. T., M. ed., to assess the reasonableness of the physical therapy that Plaintiff Michael P. Worley had been receiving. 16. Jill S. Galper, P.T., M.ed., concluded that the physical therapy and t.reatment received by Plaintiff Michael P. Worley was "reasonable and appropriate and necessary." 5 ..' 17, The review conducted on Plaintiff Michael P. Worl~y' s medical treatment had come to a contrary result on the basis of which Defendant USAA initJ,a11y withheld payment. 18. Plaintiff Michael P. Worley maintains that Defendant USAA Casualty Insurance Company had no proper basis for requesting a medical review, since they had been provided with complete copies of records and reports in support of the bi l1s submi t ted by Plaintiff Michael P. Worley's healthcare providers for medical treatment relating to the automobile accident which supported the fact that his injuries were permanent and would require continuing care. 19. Plaintiff Michael P. Worley maintains that Defendant USAA Casualty Insurance Company did not need to request a medical rev~ew to determine the reasonableness or medical necessity of his care, as his treating physicians had provided sufficient documentation in support of their treatment and bills. 20. Plaintiff Michael P. Worley, based upon information and belief, believes that Defendant USAA Casualty Insurance Company conducts medical reviews routinely as a claims management procedure regardless of the nature of the injury and information received from the treating physician justifying the need for treatment. 21. Plaintiff Michael P. Worley maintains that Defendant USAA Casualty Insurance Company did not have a proper basis for conducting a peer review and did so partly for the purpose of intimidating him from seeking further treatment, which he felt to 6 be medically necessary and appropriate and which his treating physician had recommended. 22. Plaintiff Michael P. Worley further alleges that he had to engage counsel, and counsel has had to expend considerable time in research, correspondence, preparation, etc. To date, counsel has also incurred expenses in obtaining Plaintiff's medical records and bills. Counsel will have to expend additional time and expense in the future in an attempt to obtain recovery for the medical bills as provided under the Financial Responsibility Law. COUNT I Breach of Contract Michael P. Worlev v. USAA Casual tv Insurance ComDanv 23. Par.agraphs 1 through 18 of Plaintiff's Complaint are incorporated herein by reference. 24. Defendant USAA Casualty Insurance Company has refused to pay outstanding bills owed to HealthSouth Rehabilitation of Mechanicsburg in the amount of $1,854.50 and East Shore Orthopedics Associates, P.C. in the amount of $210.99. 25. Defendant USAA Casualty Insurance Company has breached its contract with Plaintiff Mic~ael P. Worley to pay all accident- related medical bills in accordance with the terms and provisions of the aforesaid automobile insurance policy, whereby Plaintiff Michael P. Worley's first-party medical coverage is $10,000.00. 26. Be~~use Oefendant USAA Casualty Insurance Company's failure to pay Plaintiff's medical bills is without reasonable 7 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. (3) Assess court costs and attorney fees against the insurer. 30. Plaintiff Michael P. Worley avers that Defendant USAA Casualty Insurance Company has denied payment of his first-party medical expenses in bad faith and without reasonable justification given that Plaintiff's inj uries are related to the automobile accident on April 21, 1995. 31. Plaintiff Michael P. Worley maintains that Defendant USAA Casualty Insurance Company's request for an alleged medical review of his treatment was merely a pretext for denying benefits, and that the circumstanc""s or conditions relating to his medical treatment would have caused a prudent person familiar with PRO procedures, standards, and practices to believe it was necessary that a PRO determine the reasonableness or necessity of his care. 32. Defendant USAA Casualty Insurance Company's continuing bad faith warrants an award for interest equal to the prime interest rate plus 3%, punitive damages, court costs, and attorney's fees pursuant to 42 Pa.C.S.A. ~8371. WHEREFORE, Plaintiff Michael P. Worley demands judgment from Defendant USAA Casualty Insurance Company for first-party medical 9 " , , " ;!I " " I I II " " @ I i I I I a l II' II I' " ! I ,.> " i ~ '; {b.. :~ SPA ~ USAA CASUALTY I.NCE COMPANY 11 IlU' I.I~".U c...,.-.,; USAA Building - S.n Antonio, Tem 78288 PENNSYLVANIA AUTO POLICY AMENDED DECLARATIONS I ATTACH TO PREV-IOUS POLlCY) d Inlurd end Address .,. POLICY NUMBER "" 00212 62 17C 7104 5 POLICY PERIOD: ' 112:01 A.M, st.ndlrd time EFFECTIVE'APR 22 1995 TO AUG 01 1995 01 KATHLEEN M WaRleY 03 MICHAEL PAUL WORLEY 04 PAUL E WORLEY KATHLEEN M WORLEY 898'TRAVER DR. LEWISBERRY PA 17339-9774 . ..;,. ~<.... .~.;t.. . . ,; tlon 01 VehlclelJl ,,&R 1UI1' Ill'" . MODI1. IDO' nPl UWU WI . IYW W1).lf1thD~. ""W ~C tl:. .. ~ VlK un. 7 C'O 79 PONTIAC S/V SAF 81 CHEV MALlBU PU SW 40 CPE 20 CK 42 1 2N35W91718559 1G1AT27K7BB428145 9 P " B 7 W 09 5 ducrlbld herein Is princlp.lly glregld It thl .boYI .ddress unless OtlllrwiSl Iltltld. WI,.w,~II"..': ...01'.... ,.,.", ,.".... , 03 lEWISBERRY PA 17339-9774 , 11 LEWI SSERRY PA 17339-9774 I policy provldll ONLY thOI' cOVlrlglS lor which ~rlmlum I. .hown bllow. A ("Ar::v- MEANS ACTUAL CASH VAlUE! iT A ., L AB L Y 30DILY IN..JURY EA PER $ 100,00 EA ACC $ 200,00 =ROPERTY DAMAGE EA ACC $ 50,00 iT B . FIRST PARTY BENEFITS MEDICAL EXPENSE $ 10,000 WORK LOSS 5 5,000/51,000 MO FUNERAL EXPENSE $1,500 RT C - UNINSURED MOTORISTS STACKED SODILY IN..JURY EA PER 5 100,00 EA ACC $ 200,00 ,iT C .. UNDERINSURED MOTORISTS STACKED 6001 L Y W..JURY " VEH 13 LEWISBERRY PA 17339-9774 VEH VEH VEH VEH 03 6-MONTH 11 6-MONTH 13 6-MONTH o-oeo PRfMIIJM O-OEO PREMIUM O-OEO PREMIUM O-OEO PREMIUM MO I MOIJ . MO . M I 60.4 96.1 270.9 29,5 47,3 134,5 21.8 31.0 76.0 23,1 23.1 23,1 ~RT 0 .. TOWING EA FER $ 100,00 EA ACC 5 200,00 PHYSICAL DAMAGE COVERAGE AND LASOR 18.6 2.8 rR1CLE TOTAL PREMIUM 153, 58 219.22 526,16 TOTAL PREMIUM - SEE FOLLOWING PAGE(S) 'JDORSEMENTS: ADDED 04-22-95 - NONE ;~~IN IN EFFECTIREFER TO PREVIOUS POLICY)- A089(03) 5000PA(01) aaa AANER "OPA(01) 50PA(01) 60PA(01l 60EPA(03) 41PA( 10) T94PA(01) 200(02) 650CIC(04) 999PACIC(06) 5685(06) '03181 , WITNESS WHER!O, WI hive cluSld this policy 10 bt signtd by our Prtsidtnt Ind Secret.ry II Sin Anlonlo, TIIIl, OUNTERSIGNED BY , , 1.995 ~ ~ ~- PLAINTIFF'S J,L ^-'A' ~ ~..4.- P' ~ 00 '" lolL I EXHIBIT' William M,C,.. Wil.O" C. ~~_._( ~ C,. j ~ S.cr.t,rv Plflld.I'\1. A , ~ ~.,'...;., :~,. . .~..",., ':' .:-" . ~', " :'r:;."~. .,,::.~. , I~ S,AA s . . SUPPLEMENT AL INFORMATION The following premium discounts or credits were applied to your policy: VEHICLE 03 lOW ANNUAL MILEAGE DISCOUNT MULTI-CAR DISCOUNT . VEHIClE,11'.' MULTI-CAR DISCOUNT VEHICLE 13, ' MULTI-CAR DISCOUNT . ' SUPDECCW 3-9~ . '( .. . ... . " -$ 20.92 -$ 27.90 -$ 27.90 -$ 27.90 .' ..... ,/ " , ' , I' , ' .1 ',i, " , n .n ('J r::. I -! oil " ,~'rj'\ N I " nll';;/ ..-I h:'1 :~;i>i r' \, '13 hi' " tJl "1 I, .It") ~., , J ::1 " -., ,1-,' :.l."} :d ,)rn -. , ~ .~ , :') 17' .'j ,,' , .t< ,7' :.; Ii' " " ,,' ,1.1, " , , , ,', " " , " , , , " (') ;/.l (.) ~;" -.\ " ,- " ,":7) I lIb! , :") ',- ,-rl [I " .., . '," ~ . ., '('9' <' , 's ,1.1: " , ":\, jC ...., ) :fJ " ,( ,,,.. .. t.rt , ~;? i )r " .:.~- t '. '"'! ., 5] ,-, u', .... " 1(, " " , " " n ,. C ,l..) , .~::; f/' ~() j' . I j'~ \,l,U i.1 I, ',i"l , I I,' , 1;-,:' C:~ , " ) , I ';L~ " ),;. ~., ~. , '.j ,. ,. '_1 J ", ..~.. , I I,. ;1, ,. I I' " " \' "