HomeMy WebLinkAbout94-05996
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KRISTI L. CASSBLL BURXE, . IN THI COURT OP COIOlON PLIAS
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now known a. ICRISTI CASSELL I ctJHBIRLAND COUNTY,
BURD, I PBNNSYLVANIA
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Plaintift I NO. 1/r :F? 1~ (I~J~,
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-v.- I
. CIVIL ACTION - LAW
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UNITBD SBRVICES AUTOMOBILE
ASSOCIATION, .
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Detendant Jury Trial Demanded
LO TIC.
YOU HAVE BEEN SUED IN COURT. It you wi.h to de tend aqain.t
the clai.. .et forth in the following page., you must take action
within twenty (20) days after this Complaint and Notice are
.erved, by entering a written appearance per.onally or by
attorney and tiling in writing with the Court your deten.es or
objections to the claims set forth against you. You are warned
that if you tail 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 reliet requested by the Plaintitf. You may lo.e mon.y
or property or other rights important to you.
YOU SHOULD TAU THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU
DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OPPICE SET PORTH BELOW TO FIND OUT WHERE YOU CAN GET LOCAL HILP.
COURT ADMINISTRATOR
CUmberland County Courthouse, 4th rloor
1 Courthouse Square
CarliSle, PA 17013-3387
(717) 240-6200
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p....nger in was .truck on the .ide by anoth.r vehicle that
proceeded through a stop .ign.
4. prior th.r.to and at all time. rel.vant to this
action, the Defendant, USAA, i..u.d a policy ot automobile
in.urance (policy No. 00080 60 69U 7101 1) to Gary L. c...ell, in
which the Plaintift herein was a named in.ur.d.
5. The aforem.ntion.d policy was in tull force .nd ettect
on June 12, 1993. A copy of the policy i. attached her.to a.
Exhibit "A."
6. The contract tor the atorementioned in.urance pOlicy
provid~d tor Ten Thousand ($10,000) Dollar. in tir.t party
medical 10.. benetit. and a tive Thou.and ($5,000) Dollar waga
10.. benetit in accordance with the requirement. of the
Penn.ylvania Motor Vehicle Financial Re.pon.ibility law, 75 P.S.
I 1701, At aag., as amended.
7. A. a re.ult ot the accident, the Plaintitt, KRISTI L.
CASSELL BURn, .uffered .ev.re and permanent injurie., which
included cervical neck .prain, trapezius mu.cle .train, lumbar
back .traih, myofa.cial pain, and recurring headache..
8. A. a result ot the accident, the Plaintitt has been
obliged to r.ceive and undergo medical attention and car., and to
expend various .um. of money and incur various .edical .xpen.e.
properly due and allowable und.r the term. ot the in.urance
policy. She may be obligated to continue to expend v.riou. .uaa
of money tor an indefinite period ot ti.e in the tuture in order
to receive treatment for her injurie..
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i, Additionally, the Plaintitf is entitled to receive
wave loss bene tits properly due and allowable under the terms ot
the insurance policy.
10. At various time. tollowlng the accident, the Plaintiff
incurred rea~onable and nec.ssary treatment trom various health
oare providers, including:
(a) Daniel S. Rom., M.D.
Pain Reliet Center of Harrisburg
890 Poplar Church Road, Suite 305
Camp Hill, PA 17011
(b) Si Van Do, M.D.
Physicians ot Rehabilitation Medicine P.C.
1751 Lanca.ter Boulevard
Mechanicsburg, PA 17055
(c) Richard Seldow, D.C.
431 Bridge street
New Cumberland, PA 17070
(d) Earl J. Wenner, Jr., M.D
Edgar Square
1101 South Edqar Street
York, PA J.7403
(e) Clem A. Ciccarelli, M.D.
Green Hill Family Health Center
503 Bridge street
New Cumberland, PA 17070
11. The lair and reasonable charges that remain unpaid tor
her treatment are as tollows:
Daniel S. Rom., M.D. . . . . . . . . . . . . $560.00
Si Van Do, M.D.
. . . . . . . .
88.00
. . . . . . .
HealthSouth Rehabilitation ot
Mechanicsburg . . . . . . . .
. . . .
.$928.04
336.aA
1910.70
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TOTAL .
These totals are not final calculations, as plaintitt is
continuing to incur medical expenaes as a result ot the accident.
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12. The plaintiff ha. continuou.ly .ubmitted rea.onable
proot ot the amount ot 10.. .nd r.a.onable proof of the a.ount of
bill. incurred by all of her provider..
13. At various time., the Plaintitt, KRISTI L' CASSELL
BURK!, and her provider., have reque.ted th.t the oetendant pay
the aforementioned bill., .. they have been accumul.ting .ince
December ot 1993 through the pre.ent.
14. The Defendant, USAA, pursuant to 1797(b) (1) ot the
penn.ylvania Motor Vehicle Financial Re.poneibi1ity law, ..
a.ended, h.. contr.cted with a peer review organization, tor the
purpose ot allegedly confirming that 8uch treatment, product.,
.ervice. or accommodation. contorm to the profe..ional .tand.rd.
ot pertormance and are medically nece..ary. The name and .ddre..
of the atore.aid peer review organization i.1 DISABILITY
MANAGEMENT ASSOCIATES, Airport Bu.ine.. Center, Amb....dor One,
100 Diplomat Drive, Le.ter, PA 19113-2304.
CUI. ..8 TO DU. DO &lID aDlDI
15. On or about April 5, 1994, the Defendant refu.ed
payment tor treatment given to the Plaintift by Dr.. Do and Roaa
ba.ed on the conclu.ion. ot a peer review report. A copy ot the
report i. attached hereto ae Exhibit liB."
16. Under the Medical co.t containment Rule. and
Regulation., I 69.5~, "Peer Review procedure~," a "PRO'. initi.l
dete~in.tion .hall be completed within thirty (30) day. atter
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the receipt ot reque.ted information." IaI 31 Pa. Code I
69.52(d).
17. The PRO'. initial det.rmination tor treatment provided
by Dr.. Do and Roam to the Plaintitt for treatm.nt provided
through January ot 1994 wa. not compl.ted until April 5, 1994.
18. The Plaintitt believe. and aver. that the PRO h.d
sutticient docum.ntation nece..ary to make an initial evaluation,
and, i. theretore, not in compliance with the pe.r Review
Regulation..
19. The Detendcnt has tailed to comply with the
Regu1~tion. in making it. initial pe.r review tindinq., and
theretore, denial ot payment i. in violation ot the Peer Review
Procedure..
20. Although Det.ndant USAA viol.ted the Regulation. in
it. initial PRO d.termination, the Plaintift'. provider., or.. Do
and Roam, reque.ted th.t a peer revi.w r.con.ideration be
pertormed. au reque.t in Exhibit "c."
21. Thi. reconeideration request was acknowledged by USAA
until May 2, 1994. a.. USAA letter in Exhibit "D."
22. In addition to not complying with the initial Peer
Review Procedure., Detendant USAA has t.iled to properly pertora
the pe.r review recon.ideration .. reque.ted by the in.ured under
I 69.52(h).
23. Under I 69.52(1), a PRO mu.t complete a
recon.ideration within thirty (30) day. atter r.ceipt ot the
n.ce...ry information as per 69.52(k). A. per Exhibit "E," the
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recon.ideration wa. not completed until July 26, 1994, over
ninety (gO) day. after the April 21, 1994 reque.t tor
recon.ideration.
aLa.:r. U TO .aov:rD.. -..'....mD'l'll ._Il.tL:r~"''l':rO. O. "".IlInC..nII
f~.MWaLY ..~a.%e..u.a ..... .y.~..,
24. The Detendant, USAA, reque.ted a peer review of
HealthSouth on February 14, 1994. ill lett~r attached hereto in
Exhibit "P."
25. The Detendant, USAA, utilized the PRO ot Dr.. Do and
Roam to retu.e payment tor treatment provided by HealthSouth
Rehab.
26. The April 5, 1994 peer review report tor treataent
provided by Dr. Do (and Dr. Roam) was .ent to HealthSouth Rehab
Center and was uaed to terminate medical benetit. payable tor
phy.ical therapy treatment provided by HealthSouth to the
Plaintiff, KRISTI L. CASSELL 8URD.
27. Dr.. Do and Romm are not aftiliated with HealthSouth
Rehab of Meohanic.burg.
28. Even though the Detendant, U8AA, wrongfully utilized
another provider'. PRO report to withhold aedical payaent. due to
HealthSouth Rehab, the in.ured requested a recon.ideration for
phy.ical therapy a. per the April 21, 1994 letter a. tully .et
forth in Exhibit "C."
29. Moreover, even though the April 5, 1994, PRO report
vaa addre..ed and perforaed to evaluate treataent by Dr. Do, the
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Detendant, USAA, did not provide a copy to HealthSouth "vithin
tive (5) days of receipt" ot the report troa its contract PRO.
30. Under the Medical Coat containment Rules and
Regulations, a "PRO's initial determination shall be coapletecS
within thirty (30) days attar the receipt ot requested
intormation.", as. 31 Pa. Code I 69.52(d).
31. The PRO's initial determination tor physical therapy
treatment provided by HealthSouth through Pebruary 10, 1994, vas
not completed until April 5, 1994, and moreover, was denied
through a PRO report prepared to evaluate the reaaonableness and
neces.ity ot the care provided by Dr. Do. as. letter trom
HealthSouth to USAA in Exhibit "G."
32. The Oetendant finally is.ued an initial PRO report tor
treatment provided by HealthSouth R6hab on Auguat 2, 1994. ...
report attached hereto in Exhibit ilK."
33. Although the report indicates that it i. the
"reconaideration reviewer's" opinion, thia peer review report was
an initial determination for treatment provided by HealthSouth.
34. The report indicate. that the provider, HealthSouth
Rehab Center, may "request. a reconsideration within thirty (30)
days," and theretore, this report clearly was an initial peer
review report that was requested on February 14, 1994 (as per
Exhibit "r") and again on May 2, 1994. au May 2, 1994, request
for initial peer review in Exhibit "1."
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35. The Detendant, USAA, has also .ade a reterral to a PRO
beyond ninety (90) days ot their receipt ot sutticient
documentation, which is in violation of I 69.52(b).
CL&!II U IfO 1.0.., na..
36. The Plaintitt, KRISTI L. CASSELL BURKE, ha. requested
lost waqes tor her 1994 summer traininq in the Pennsylvania Air
National Guard as well as her stipend as a graduate a.sistant at
Millersville University. IAA letters dated July 22, 1994, and
Auqust 19, 1994, attached hereto as Exhibit "J."
37. On or about August 16, 1994, the Detendant USAA denied
wage loss benefits to the Plaintitt based on a "Disability
Review" pertormed by the eame contract PRO conducting its
aforementioned peer review determinations. aaa Disability Review
attached hereto in Exhibit "K. II
38. The Detendant, USAA, has used this "Disability Review"
provided through it. contract PRO to deny the Plaintitt, KRISTI
L. CASS~LL BURn, wage los. benefits she is entitled to under the
atorementioned policy ot insurance.
39. The Detendant, USAA, has utilized a peer review report
and entitled it as a "Disability Review" for the purpose ot
denying wage loss benefits to the Plaintitt, KRISTI L. CASSELL
BURKE, in violation ot 75 Pa. C.S. I 1797, and the aoco.panyinq
peer review procedure..
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...IlCJI OIlP COIITUCT U TO ..~L IIPIIOV:ID.U
40. The Defendant, U8AA, has used the atorementioned peer
review reports and Disability Review to deny payment of all
reasonable and necessary medical treat.ent rendered to the
Plaintift, as well as reasonable lost wages. Theretore, the
Plaintift has filed this act\on tor payment ot overdue medical
benetits and for reimbursement ot loet wages.
41. It is averred that all medical bills are tair and
reasonable, and that all treatment was medically necessary.
42. It is also averred that reasonable proot has been
submitted tor wage 10.. benefit. that the Plaintitf, KRISTI L.
CASSILL BURKE, i. entitled to under the policy ot insurance.
43. The Defendant has retused to pay the balance due under
the terms and conditions of the applicable policy ot insurance in
the Pennsylvania Motor Vehicle !'inancial Responsibility law. As
a result ot the aforesaid, the Plaintiff has been required to
hire the services ot an attorney to collect the medical bills and
lost waqes herein due. Theretore, pursuant to I 1716 ot the
Pennsylvania Motor Vehicle rinancial Responsibility law, the
Plaintitt is entitled to attorney's tees "in the event that the
insurer is tound to have acted in an unreasonable manner in
refusinq to pay the benetits when due." The insurance coapany
must also pay twelve (12'> percent interest.
44. It is turther averred that under. 1798 of the
Pennsylvania Motor Vehicle Financial Responsibility law, in the
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event an insurer is found to have acted with "no reasonable
foundation," it i. also liable tor attorney's tee..
45. The Detendant's retusal to reimburse Plaintitt for
medical expenses and lost waqe. arising out Qt the atore.entioned
accident constitutes a breach ot the terms ot the contract
entered into between the Plaintitt insured and the Defendant,
USAA.
46. By not complying with the regulations and otherwi.e
retusing to comply with the peer review procedures, the
Detendant, USAA, has undertaken a course ot action which has been
designed to unilaterally and without justitication, retuse clai.s
for medical benefits and lost waqes and cause the Plaintitt to
become personally re.pon.ible tor medical bills arising out of'
the maintenance or use ot a motor vehicle, in contradiction to
the term. ot the contract, The Pennsylvania Motor Vehicle
Financial Responsibility Law, The Automobile Insurance Modical
Cost Containment Requlations, and the Case Law ot the
Commonwealth ot Pennsylvania.
47. The above described actions constitute a breach of
contract by Detendant USAA with Plaintiff, KR1.STI L. CASSELL
BURD.
WJIEREFORE, the Plaintiff, KRISTI L. CASSELL BURD,
respectfully requests that thi. Honorable Court grant the
tOllowing relief:
(a) Declaratory relief that Defendant is liable to
Plaintitt under its contract of insuranoe.
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(b)
Award Plaintitt .edical benefits and lost waqes plus
interest at twelve (12') percent interest per annual
and
Award attorney's tees pursuant to 75 Pa. C.S.A. I 1716
and I l798(a), based on actual hour. expended until
the date ot final judgment in this matter.
(c)
COUIIT II - BAD nITS
48. Paragraphs 1 through 47, above, are incorporate herein
by referencft as though fully set forth at length.
49. On or about February 7, 1990, the Governor ot
Pennsylvania signed into law 42 P.S. I 8371, etfectlve July 1,
1990, titled "Actions on Insurance policie., II which provides a
private cause of action for bad faith against insurance companies
operating in the Commonwealth ot pennsylvania.
50. It is believed, and, therefore, averred that the
Detendant, USAA, has employed a peer review organization in bad
taith by knowingly attempting to utilize a PRO's services
pursuant to I 1797 of the Pennsylvania Motor Vehicle Pinancial
Responsibility law to deny payment of treatment and services that
were reasonable and necessary.
51. In addition to the peer review violations outlined in
the aforementioned paragraphs, the Defendant also displayed bad
faith and a pattern ot violations in handling the claims ot
provider Richard Seldow, D.C.
52. On or about April 5, 1994, the Defendant, USAA,
refused payaent for treatment given to the Plaintift by Dr.
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Seldow based on the conclusions ot a peer review report. A copy
ot the peer review report is attached hereto a. Exhibit "L."
53. On or about April 5, 1994, the plaintitt'. provider,
Dr. Richard Seldow, requested that a peer review reconsideration
be pertormed. iIs letter in Exhibit "M."
54. This recon.ideration request ot Dr. Seldov was not
acknowledged by USAA until May 2, 1994. iIs USAA letter in
Exhibit "N."
55. Under I 69.52(1), a PRO must complete a
reconsideration within thirty (30) days atter receipt ot
sutticient intormation as per I 69.52(k). The reconsideration
was not completed until June 16, 1994, over sixty (60) day. atter
the April 5, 1994 reque.t tor recon.ideration. iIs
reconsideration report attached in Exhibit "0."
56. The Plaintitt believe. and avers that the PRO had
sufticient documentation to perform the reconsideration at the
time of the request.
57. Although the Defendant eventually reiabursed Richard
seldow, D.C., ba.ed on the results ot a reconsideration, the
plaintift wa. forced to discontinue her treatment with hi. beyond
the March 4, 1994 cut-off date.
58. The Detendant has continuously denied payment for the
variou. .edical .ervice. and treatment rendered to the plaintiff
by deliberately violating the peer review procedures set forth in
. 1797(b), and the Automobile Insurance and Medical Cost
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Containment Regulation. which .et torth the .tandard. of
operation tor PRO'. and peer review procedure..
59. In addition, it i. believed that the Detendant, USAA,
ha. employed .aid p.er review organization in bad taith in that
it ha. utilized it. contract PRO and the peer review .y.te. to
deny waqe 10.. benetit. to the Plaintitt, KRISTI L. CASSILL
BURXE.
60. In addition, it i. al.o believ.d that the Defendant,
USAA, ha. employed .aid peer review organization in bad taith in
that .aid peer revi.w organization doe. a .ub.tantial amount of
peer review work tor Detendant, and, therefore, has a financial
intere.t in providing to Defendant a bias peer review report.
61. Moreover, the said peer review organization ha., or
may have, continuou.ly been providinq neg~tive pe.r review
report. to this Detendant, and other in.urance companie.
repeating the same language tor the purpo.e ot maintaining a
.teady .ource of busine.., thereby .howinq a patt.rn of abu.e ot
the peer revi.w proc....
62. In addition, it i. believed and averr.d that the
Detendant had ~o r.a.on to believe the Plaintitt's treatment va.
not medically nece..ary, but, in.tead, was intentionally trying
to .imply "cut ottO medical coverage and deny benetit. tor vhich
Plaintift paid a .ignificant premium. It i. believed that
Detendant USAA has a practice of atte.ptinq to "cut oft" .edical
treat.ent by quick p.er review. without rea.onable cau.e to do
14
UNrnD SERVICES AUTOMOBILE ASSOCIATION
.
IA .1I1_~ III'/I_.IICI UCH..en
USAA luilcllng - s.n Anlonio. Tex.. 78288
THE EASY READING AUTO POLICY
RENEWAL DECLARATIONS
ATTACH TO PREVIOUS POLICY
Nlm.d Insur.d and Address
PAGE
F
'.'.IIf4..
USM
POLICY NUMIER
00080 60 69U 7101 1
POLICY PERIOO: 112:01 A.M. slandard 11m.)
EFFECTIVE JAN 04 1994 TO JUL 04 1994
OPERATORS
01 GARY L CASSELL
02 DONNA J CASSELL
03 KRIST! L CASSELL
04 SETH P CASSELL
ANNUAL
M' ,
9 PONTIAC GRAN PRIX LJ CPE 20 4000 2K37Y92578439 7 P
07 86 VOLKS JETTA SED 40 10000 WVWGA0166GW390754 11 W 01 5
08 86 FORD F150 7000 1FTCF15Y9GLA53014 9 W 02 3
09 86 YOLKS JETTA GLI SED 40 15000 WVWGB0163GW636852 12 W 50 4
The V.hi~I.(s) dlS~rib.d h.r.in is prin~ipally garaged al the above address unless otherwise stat.d.' WIC.W..."...." ..."'....: "'or.; '.PI.."
GARY L CASSELL
70 RIDGE ROAD
ETTERS PA 17319-9111
Des~rl lion 01 V.hi~I.ls)
'till lURi nADI ....MI
VIM USI .
IODY TVP'
IDENTlfICAflON NUMB.N
11M
MOOU
VEH 05 ETTERS PA 17319
VEH 07 ETTERS PA 17319
This poli~y providlS ONLY Iholl cov.rages lor which
a mium i$ shown below.
LI IT Of LIABILITY
l"ACV" MEANS ACTUAL CASH VALUE)
PAA - LIABILI Y
BODILY INJURY EA PER $
EA ACC $
PROPERTY DAMAGE EA ACC $
PART C - UNINSURED MOTORISTS
STACKED
BODILY INJURY
VEH 08 ETTERS PA 17319
VEH 09 ETTERS PA 17319
VEH VEH VEH
05 6-MONTH 07 6-MONTH 08 6-MONTH
C'OED PREMIUM DoOED PREMIUM OoOED PREMIUM
AMOUN S AMOUN S AMOUN S
VEH
09 6-MONTf-
DoDED PREMIUM
AMO ,
100,00
300,00
50,00
50.85 (( 60.91 .,1 121.2' ~'P
30.25 r> 36.5 }-'I,o 74.2 J. )"
11 . 5 .(1 11.5 }of 11 .5 orl
10.61 21.0 _I 28.6 ....f
D 50 57.4 D 50 92.9 D 50
I? -l
EA PER $
EA ACC $
PART 0 - DAMAGE TO YOUR AUTO
OTHER THAN COLL LOSS
COLLISION LJSS
OTHER COVERAGES
FIRST PARTY BENEFITS
MEDICAL EXPENSE $ 10,000
WORK LOSS $ 5,000/$1,000 MO
FUNERAL EXPENSE $1,500
25,00
50,00
AC
ACV LESS
,t'
20.0
17.7 ;.1,.
34.4
......,
TOTAL PRE rUM - SEE F LLOWING PAG (51
11
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DC
)) I
5640PA(021
5801(011
485106)
.J.~':
161.5
99.4
..n.t
4-(
11. 5'
....1
64.5:
161.6
. )."1
,yJ-
44.0,
" " I
J/,&.
'/"')"(, ,
"'4/1db/~4 131 ~~
1'().1illle
" ,
..,
"
Din'.' J. Rlgon. Jr., M.D., P.A.
OIlIIHTlliE DECUTl\'i CMlPUI
l.lNCCUI OIIWIWlIT.lUrTI 100,.4
lWII. TON N.I OIOU
~OHlIOM"""3
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oJ.Old.. CM'hU.
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neck .pr.ln .nd .t~.in. A. ..rly I' July 22. 1"3. M.. C....l1 bad -.d. T.,
~nt witb b.r 'robl.... Du. to Ilos,lalnta of ndiovlU' type .)'IIpt_ of
h.r IIppe~ ..tr_l1:1.., .n IIRX 01 tb. 11'1"1111111 .pln. "I. on.red '",bich "'..
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carvio.l .t~lj,n. Ni. r.c~nd.t10n WI' . r'f,rrll to I p.ycholOfl.t. M!Ob..l
'''11:h.
On Hovllllbu' 16. 1993 HI. C....11 ".. r.fund to Dr. DO. . phl'.inrilt. who f.lt
.... ea...u bad" polt tUII..:io wII1pl.Ub injllry III\d a-.Il_~cIe~ . 11_ ....rou.
pr09r.. Ind .q~ltic th.a-.PlI"
In A'If\l1t of 1"3 .... C....11 "'.. ,,'und to Dr. '.ldow. . ell1.ro~.etO&', "'110
r.c_nd... · OOV". at tn......." 1l0nd.Un, at unllal unlpul.Uon and
~ooed1Il'... He. C....U tnn811 dtll Da-. ..lclooi t~9h r...",U'J 0' \',..
H.. C....ll "I. 11.0 ,.'urld to Dr. .iklll1', I d.nt1.t. 'o~ 7M3 dy.'"nctioa.
on .0v..".4' 16. U9J He. C....U "... "lll1lt811 Dy Dr. Do who 'alt tllat IlIr
conclJ,Uon Ilovl" lie ....t, "".OM 'larOll,b In laullh. prOf'" 1114 11: .,.. Upon....
tMt .be IIec_ 1nvolY.. 1ft I CIlI,.""Ua IIIMv...nt prOfw", .be w.. wol...w811
to pIIy.1cal tb.,.py. l4II'Uo t......PlI'. llId ocOllp.lUon.1 tlleraP)'.
AO of 3aftll..Y of 1". it "1' I.lt 'II., ft.. C....ll.. OOndltloa "'.' l.provio,.
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lil7 /2&'94 14' 34
D.M.A. + 11 ~;8~
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JYOTHl CHINTA, M.D.
o-r-CIIuI1Ir IIdlMl c,,,.
0.. IIIl11i1l c..., ..uJ.NIfI
~ I'A 11013
July 21, 1".
Jayne Mc!.auvhUn, R.N.
Di.ability Manag...nt A..ociate.
Airport lu.!ne.. C.nter, Aaha...dor One
100 Diploaat Drive
La.ter, PA 1'113
RBI Kri.ti C...ell
CLAIM I: 10-10-6'
DIIA 1& PA10ll
DOlI 8/12/'3
Dear Ms. McLaughlinl
Tbe following .edical record. are reviewed in order to perta~ .
peer review reconsideration regarding tre.tment provided on Kri.ti
Ca..elll
1. Docuaentation and bill. tro. Holy Spirit Ho.pital Clinic troa
Jun. 11, 1,.3; until June 6, 1"4.
2. Phy.ical therapy documentation and bills are tram
Mechanic.burg Rehab, date. including June 23, 1993, until
January at 1"4.
3. Con.ultation report tro. Dr. Litton, penn.ylvania Orthcpedics,
.epteaber 1, 1"3.
4. lills .nd x-ray report. tro. Septelllber 2, lU3, until Decellber
., I"'.
5. .ill. and pre.cription. tor equip.ent including TENS unit and
aquatic equip.ent.
I. DoclwIentation and bill. tro. Dr. seldov, chiropractic
phydcian.
7.
Docu..ntation and bill. fro. Dr. Do. Nov..ber 16, I"', until
'ebruary 10, 1"4.
All uneiqn~ phy.ician'. consult.tion ..eport dated Deoeaber 21,
ltt3, with Initial. -'.I.Z.-.
..
" .
paqe 2
JUly 2', 1114
aKa Kri.ti C...ell
.. Peer review reports froll Dr.. Raqone and Cavallo.
.1IIdI..Y
Tbe above .edical recorda indicate t:hat Kri.ti ca...ll i. a tventy-
tvo y.ar old f..ale who v.. invo1v.d in a .otor vehicular aooidant
.. a pa..enger on June 13, 19n. Sbe v.. examin.d at the ...rganoy
ro01l ot st. M.ry'. Ho.pital in Langhorn., Penn.ylvania and va.
di.cbarqed. She v.. th.n seen by Dr. ciccarelli .t Cre.nHlll
PaaUy Health Centar on June 18, 1913. H.r diaqno.iI included
cenical .train and .pr.in.
POl' treat..nt .h. received outpati.nt phy.ical th.r.py at
".chanic.burq R.hab Systa. consistinlJ of hot: 1l1lC'llcll, ult1'..ound .nd
.....g.. Th. pat:ient v.. .e.n three tille. . ve.k with reli.f. Sh.
wa. di.cbarq.d on July 25, 1993 troll phy.ical therapy .nd va.
re.tartad on Augu.t 2, 1"3 tor luabar para.pin.l pain. Record.
indicaced i.provement in pain. She va. followed by Or. Ciccarelli
who d..cribed .nti-intl....tory ..dication, lIu.cle relax.r., eto..
Work up included x-ray. ot the cervical .pine, a C'l' .can of the
head, an MRI of the necJc, and bone .c.n which vera all
unr...rkable.
Dr. Litton troll Penn.ylvani. orthopedic. .av h.r on sept..ber 1,
1913 vho felt that Ms. C....U ba. had a cervical .train. His
ex..ination tinding. are indic.ted of full ran~.. ot motion in her
n.ck and tend.rne.. 1n tbe thoracic and bilateral trepeaiu. area..
He advi..d bel' Co be .. physic.lly active a. po..ibl. and al.o
reco_ended a p.ycholoqi.C tor con.ultation and treablent tor .elf-
bypno.i..
Pollow up nota. ot Dr. CiccueUi indiQated noraal neuroloqic.l
exaaination t!ndinqa throughout.
Ms. C...ell va. .een by Dr. Seldov, a chiropractor, for chiroprac-
tic tberapi.. troa Augu.t ot 1"3 until February of 1"4.
Ihe va. refen:.d to Dr. Do, a phy.iatri.t:, vho ..v her on Ifoveaber
1lI, un, vith cOllpla1nt. of love" baok pain. Dr. Do noted nonal
raftCJe. of IIOtion in b.r lev back area .nd t.ndem... on IM'llM'tion
around '1'4, '1'5 .id-.pinou. arsa and greater trochanteric and gluteal
r.,ion.. "tl-~ndaUon. included a reconditioning/roqra. to b.r
baok throu9b phy.ical ~enpy, aq\laUo thll'lPY en occupat:ional
ther.py. H1. follow-up noU on .January 23, 1"4, incl10ated th.t:
.... Ca...ll'. baok pain condition va. i.proved with no lvielence of
tender .re.. which doctor had noted durinq . pr.viou. exaainaUon.
'he v.. cU.cbuqad by Dr. Do on J.nulIry 33, 1914, with in.uuG1:10M
to continue the pre.oribed ...rci.e..
',ve 3
.rilly 36 1"4
RII KrI.t! C...ell
A ~eyiev ot the the~apy not.. t~om January 3, 1"., until 3anu.r,y
34, 1"4, Indic.ted no .dditional modalitie. b.ing offe~ed othe~
than What vere given to h~ du~in9 her early th.rapy pr~.. f~oa
Juns until Augu.t of 1"3. She va. seen 1n fOllov-up, again! by
Dr. Do on rebruary 10, 19'4 with . tla~e-up ot bel' .yapt~ . noe
.h. h.. return.d to school. She va. refe~~ed tor .urt.ce DIG
.valu.tion and p.ycholoqical coun.eling va. recomaended.
D~. Ro.. .aw the patient on M.~ch " 1"4, tor .n initial evalua-
tion for co.plaints at h..d.che and low bao~ pain and po.t.rior ara
pain. Hi. i.pr...ion. inoluds a collhin.Uon at ayot..cial pain and
dapr...ion. He ..v the patient in tollow-up, aq.in, on March 11,
April 1, Ap~il 15 to April 27, and M.y 30, 1"4, tor adju.t.ent at
anti-intl....tory medication and anti-depre...nt..
IDIl..8IOII
AClQordinq to the above .edic.l record., Ms. Ca..ell ie a tventy-two
y..r old taaale vho va. Injured in the motor vehiole acoid.nt ~n
June 12, 19'3. I aqree with Dr. RaCilon." opinion. expre...d in his
p..r revi.w a. follow.:
1.
The treataent inoludinCil phy.ical therapy and diagno.tic
t..ting were appropriate throuqh December ot 1"3. Con.ulta-
tion by Dr. Do and follow-up vi.its through 3anuary at 1"4
w~e approp~iate a. they r.lated to the injuries .ub..quent in
tha actor vehicl. .ccident.
Record. review.d do not provide ju.tification tor ongoin9
phy.ic.l ther.py beyond December. 19'3, and physioian follow-
up. beyond January of 1994.
Medical note. reviewed beyond Janua~y ot 1"4 are not ,uppo~-
tive of t~..taent a. th.y relate to the injuri.. .u.tained on
Jun. 12, 111U.
A telephone di.cus.ion at the ca.. in .cco~dance with Act 6 wa.
carried out with D~. JIo_ on July 1, 1'94, .t 1:30 p... The above
..cUcal opinion. were reaobed attar the ca.e va. dbcu..ed vith Dr.
~.
2.
3.
Sinoera~y" ~()J
~,~I fn.'P'-
loard certUied, Phydc:al "acHaine ,
Rehabilitation
.1C/A,.,.l
1I.;i;t:Il\i~af
1l.1'I.1I. . ....
. .
PHVIICAL TNI..A'Y ..IV.I. '."VlCI', INC.
'.0.101" WOOD&. "N, "NNIVl.VAN,A ,.....
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Schmidt and Ronca PC
109 sua. seree.
Kanlsbu.... 'ennsylvualA 17101
717 / 131-4300 fa. 717/ln......7
y~a ~...!Wt.D Ma!~
"~IIU He.!" ..onw....D
Attorneys uad Counselors at Law
July 22, U94
Ms. Melanie Miller
USAA
Northea.t aegion
USM lIuUdinq
P.O. Box 33UO
S.n Antonio, Texa. 7126'-34tO
ael Kri.ti e...ell
elaia NOI 10-60-6t
Date of Accidentl 6/12/t3
Dear M.. Millerl
I .. .endinq this letter a. a tollow-up to .y recent telephone
conv.r.ation with you. At that time, you and I di.cu..ed at
gr.at length the .tatu. ot this c..e. You told me that USAA i.
not willing to pay the work 10.. tor Kri.ti C...ell becau.e of
your pending peer rev1ew ot the aedic.l tre.tment by Dr. Ro_. I
advi.ed you at that tiae that in my view, peer review i. not for
the purpo.e ot di.continuing wage 10... You, your.elt, aqreed
that an adverse peer review doe. not ..an that your in.ured i.
not injured, it only me.n. that the aedical treatment wa.
inappropriate. Accordingly, I would a.k that the wage lo..
retlected in the attached documents from her .ummer jOb in the
Penn.ylvania Air National Gu.rd be paid in .ccordance witb the
Financi.l Re.ponsibility Law. I have also encloeed drug
pre.cription. for which .he .hould be reiabursed. No one ba.
indicated that .he .hould not be taking the.e drugl. I have al.o
induc1ecl. the 1.te.t'-y,U"'''irz:el15'rt trom a reviewing phy.ician. I
.. not .ure you ha' ~ .. . ur _oJ -rT'ul.~Y, that will
belp YO~to evalua. .'
,," PS f'orm 3100 J
Thank you . ..... 111111"-_/ I 1 1110 willi 10
. foI'owl ,-=..~ ...
, ' t I f 't A"Ie" .. form Ih., we GM, ng MtVIC" (101 1ft '.Ir.
1~.rY t l.VV;YO\lr. I ~. "0' """It. tl) tl\t 'ron. c), ,/'I. "'.'CQae, or QtI tn._tt , "J;
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AND.PR 3, A~JCI' Add"..~ I ' "........,--...- C 2. 0 ...."'Ct""O"I"..,
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Charlatl I. 'oui l)<'"" ~A Ol~ 537 ~a
Attorney .t Law ~^~I~ t!j'"S",,'cIType
...) /-1 OQj.t_ 0 I........
CUI." 0 ~ 3~'t-90 &CIrtJIIod Ol:llP
balo.ure. . Sctn '/I ; ~ "-1"7 ..,..,.<' 0 ........ ""'" 0 '"..," ......,. lor
GOa ... ~i.ti' ," , '-'V..> ) I X I 7, 0." 01 0",-, """,.~-..
5, SJlc'otur. IAddI",", \lUL 2 5 1994
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"J Ips,,,,,,, Jill ,'.
I . 1. O~,,"Oe' 199'
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Schmidt and Ronca PC
vIa e..~!.!.D MA%L
..~u.. ..e.r~ "OU..~.D
109 StAte seree.
tI&n1sburs. rennsylYlUlLa 17101
717/ Ul.63oo foUl 7.7/ UJ-6467
Augu.t U, 1n4
Attorneys &lid Counselors at L.\w
M.. Melanie Miller
USAA
Northea.t R.gion
USAA Building
P.O. Box 33490
San Antonio, Texa. 78265-3490
Re: Kri.ti L. Ca..ell Burke
Claim NOI 80-60-69
Date ot Accident: 6/12/93
Dear M.. Miller:
A. you knov, I repr.sent Kri.ti L. Ca..ell Burke due to an
accident she wa. involv.d in on June 12, 1993. M.. Ca..ell va.
an in.ured operator on a policy ot in.urance is.ued by USAA to
Kri.ti'. tath.r, Oary L. Ca..ell. The in.uranc. policy included
a Pive Thousand ($5,000.00) Dollar wage 10.. benetit, payabla up
to at least One Thousand ($1,000.00) Dollar. per month. In
October ot 1993, your company paid Kri.ti Seven Hundred and
Thirty and 45/00 ($730.45) Dollars for ber vaq. lo.. benetit.
re.ultinq trom her inability to perform her .'maer job in the
pennarlvania Air National Guard. (See USAA vaqe 10.. payment
verit cation and insuranc. policy attach.d in Exhibit MA.M)
On July 22, 19'4, I submitt.d documentation to USAA reque.tinq
that Ms. Ca..ell be reimbursed lo.t wage. tor her training in the
penn.ylvania Air National Guard. (See attached letter and
accompanyinq vage veritication in Exhibit MB.M) At that time, I
al.o submitted a reque.t that .he be reimbur.ed tor various druq
pre.criptions. CUrrently, -r client has Three Hundred and four
and 04/00 ($304.00) Dollars n outltandinq medical expen.e. tor
pre.cription. related to h.r treatment. (See attached r.ceipt.
in Exhibit MC.M) In my July 22, 1994, corre.pondence, I advis.d
you that USAA'. pending pe.r review tor medical treat.ent .hould
not be u.ed tor the purpose ot discontinuing her vage lo.. or
d.nying r.imbur.e.ent for pre.cription..
As ot July 22, 1994, a recon.ideration vas already r.quested tor
treat.ent provided by Dr.. Do and Ro.. and Dr. RiChard Seldov.
On June 16, 19'4, the insur.d received a copy ot the
reconai~eration on Dr. Seldov. (Se. reconaideration attached in
Exhibit--D.-) Sub..quently, on July 26, 19'4, I received a copy
ot the recon.ideration tor ..dical treat..nt provided by Dr..
Do and Ro... (See reconsideration attached in Exhibit -..-)
6
~
M.. Melanie Mill.r
Auqu.t 19, 1994
page Two
Finally, on Auqu.t 2, 1994, I received a copy ot the peer review
r.port on phy.ical therapy treatment my client received trom
HealthSouth R.hab Center (torm.rly M.chanic.burq Rehab sy.tem).
I am aqain r.que.tinq th.t you reimburse Kri.ti c...ell tor waqe
lo.. benetit. a. follows:
June iI-June 30, 1".
.a ai~ .atlonal ou.rd
Jul! 1.-July 17, 1114
.a ai~ .ational Guard
.tipen4/'a~t-tlme Graduat. a..i.tant
caU9U.t 30, 1113-Hay 13. 1".)
tuition .elabu~.".Dt
caugu.t 30, 1113-..y 13. 1"4)
, 117.21
, 171.24
, "7.01
. .'l.~i
TOT~L
'2,230.10
I
,
i
A. you c.n ..e, USAA has . contractual waqe lo.s liability ot
approxim.tely Two Thousand, Two Hundr.d and Thirty and 90/00
('2,230.90) Doll.r. to Xri.ti C...ell. The Six Hundred .nd
Sixty-Seven and 01/00 ('667.08) .nd the Pour Hundred and Seventy-
One and 33/00 ('471.33) are compen.ation .h. would h.ve received
h.d she not be.n torced to di.enroll from Millersville Univer.ity
due to her injurie.. (See w.ge verification letter trom
Mill.rsville Univer.ity in Exhibit Mr.M) The other waqe los.
benetit. are due to the lo.t wages Kristi would have received h.d
.he been .ble to p.rticipat. in her training with the
penn.ylvania Air Nation.l Guard. (s.e w.ge loss veritic.tion in
Exhibit M8M, supr..)
pir.t, plea.e note th.t the stipend and tuition r.iabur.e.ent wa.
owed Xri.ti betore any of the recon.ideration. w.re pertoraed.
cert.inly, I bope th.t you were not utililing the peer review for
the purpo.e of denyinq waq. lo.. benefit.. IAI Danlev v. S~a~.
Farm Mutual Auto. In.. Co., 101 F. supp. 399 (M.D. ,.. 1992)
(allowinq bad faith claim for deni.l ot waqe 10.. benetit.) and
Lah.an v. state ra~ In8. Ca., 140 P.L.J. 71 (Alleqbeny County
1990) (holding that .ection 1797 applie. only to clai.. for
medical benetit.). In tact, you never co..unicated the ba.i. for
your d'nlal ot any waqe 10.. benefit.. The reconsideration ot
Dr.. Do and Ro..'. tr.atment va. .ub.tantiated tbrouqh January of
1994. Moreover, Dr. Seldov'. treatment wa. .ubltantiated throuqb
. .
o
.
Melanie Miller
st 111, 111114
qe Three
arch 4, 111114. On what basis could USAA deny her waqe loss
benetits tor the stipend and tuition reimbursement tor the period
ot August 30, 1993, throuqh May 13, 1111141 Siqniticantly, the
peer reviev report tor HealthSouth Rehab (Auq. 2, 19114) and Drs.
Do and Roam (July 26, 111114) were received atter her 1994 summer
training dates in the Pennsylvania Air National Guard. Quite
trankly, I do not see how you could ccntractually deny allot the
above outlined waqe loss bene tits to my client. Perhaps, the
reports tro. Dr. Ciccarelli will convince IOU ot my client's
riqht to waqe loss and other medical benet ts. (See medical
records attached in Exhibit "G.")
As an aside, you should also be awa~e that USAA has violated
several peer review procedures in this matter. por example,
under the law in Pennsylvania, an initial peer review
determination shall be completed within 30 days atter receipt of
the requested intormation. 31 Pa. Code 1611.52(d). You requested
a peer review tor treatment provided by HealthSouth Rehab Centsr
(tormerly Mechanicsburq Rehab System) on February 14, 111114 and
May 2, 111114. (See requests attached in EXhibit "H.") However,
you did not provide an initial report until Auqust 2, 111114,
nearly 110 days atter your second request and 168 days atter the
tirst request. This and several other tlagrant violations ot
mandatory peer review procedures are evidence ot the bad taith
you have di'played towards my client. Also, please con~ider this
letter a tormal request tor reconsideration ot the Auqust 2, 111114
peer review report tor treatment provided by HealthSouth Rehab.
It is my desire that we can ~esolve this matter amicably,
however, I am tully prepared to prepare a bad faith and breach of
cont~~et action in the event that this matter ~emains unre.olved.
Your prompt attenticn would be appreciated.
.
,
It'yOU' have any questions, or need additional information, plea.e
do ,not hesitate tl ccntact me.-----
,.' / \ .' ' , 11110 wl.h to r'Cli". the
Very t~llt--~uJs, 'i : ....,.. 2" ........01 ..,..1..., 100lo..lng .."Ie.. 110' .n IX'"
e: : / I . Compl" .tlfftl 1 tnd'" la. wi all' tM): ~
HMI rp .... 0 ."'NT"" P,' Corn~'lttm' 3, . on 11'11 ~"'..... l)' 11'11, form '0 1"" Add .,,
fU' /......, .., r . II',ln' vOUf ,,"'" .net ..... . ,. 0 Addr.....' r
~ "r' rllNf'l ttlt. ctfd to ,ou. , tM mlllplIC', ot on tN ltHk It IIMC
./..;.... eo-;;" ~ ..- I' 11 . AttlGl'l 11'111 to"" to IN 'ront a IIftUmW 1 0 "lI8ulcttd O,UVefV
.". '..... , dOflnOllMl'''''t" Md'.ont""m..lptltG.blIOWlltt'lti...... f f
Charles I Schmidt' I . ..........."'........- _...................-......- Con..." ,mllll' Of ..'
. I.." RtGelptwlllilNWtO'IlI
Attorney at Law 1:":::':- '. .., Artl';,'JN)f"'~.!J6l)
3, Artie" Add..'MCl to, ~ ,d-
\ y'KIJ. ~ . ~'II~=~ype D In...,ee1
,,,"clJn -~. DcCO
~;;'AJ~ L!l""f;;trtlfleel lIecllptlof
'l/J~_' D ..p.... Mil' D
CCI Mrs. Itrhti L. C ~ ~~' 7, O..tOIO'"'~UG22 '994 _I
~ I Addll.-'. Ad<I....IOnly if ,--,eel 1
II Illddr.....1 _ ' ""d ,.. " pt.dl II
CIS/lll9
Inclosures.
, "
_... OOM.'TIC 1IITU"N "'CI''''
.u.a.QItOIl
"
.
,
. .
nOTBI CHINTA, M.D.
a.r "I rdt~' JI c.r
0.. VI !t'-' "'* I r.-
u",.., r.. IItlJ
.
A\l9'l.t 12, 1114
o1.yna ICGLaU9hlin, .... '
Di..bility Kana9..-nt lasoci.te.
Ais'poR luain... CantU', &abas.ador one
lOa Diploaat Driva
Le.tel', 'A 1'113
01 II'i.ti C....U
CLAIM II '0-10-1'
DNA , I .A140.
DOli '/12/'3
Deal' M.. JlCLAU9hlin:
The fol1owinq ..dical reGords .re reviswed in order to perfora a
Di..bUity ..pol"C on the above patient, lri.tJ. C....ll I
f
1. Lett.rs troa Darliel S. Rou, M.D., to Ronald Milclau., M. D.,
v1th d.t.. Jun. ao, 1"4, and July 13, 1"4.
a. .hy.ioian" report'l
. Cl.. CiooU'elli, R.D., datsd June 26, 1"3, and
. D.n1.1 .. ao.., M.D., dat.d March " 1"4.
3. I.lary verifioation .tat...nts.
4. Office r.pol"C fl'oa "1'1 J. lfeMeI', Jr., D.O., dated June 21,
19U. '
--.Y
Aocol'di"9 to Che I'sClOns I'evie".d, ... calle1l i. a a2 YMI' old
f...l. Who va. lnvolyed ln alIOtoI' .,.Ilicl. accidsnt on J\IIle 12,
1113, a. a se.tbeltad passullIer ot a CU'e that v.. -.ielaswiped- on
the dZiwl'" I1d.. III. C....ll va. s..n by Dr. CioGaI'.lU on June
11, 1113, wha clla9ftOled cervical, lUllDar w.ol. .tl'.in and ve.teII
bel' with therapy .....Utie.. H. eetiMt.ad that .... ca..aU w111
return to VClS'1I soaeU.. in July, lit'. R.. cas..U v.. ....loy.. a.
an ada1n!atl'athe ..dstant for the 'ennsylvania Ail' 1f.t1GMl
'usl'd.
. .
..........
.
."
.
.
,
',q.3
A\lfUat 12, lf14
HI ltI'iat:! C....u.
IWlaIqlllftUy, lib. v.. ...n by ..verl1 pbYMcian. lnal\1di", Dr..
Lit.ton and Do and, on ....rab " ",,,, Dr. ..., a pain ..,aa,-.nt:
.,.ai.U.t Who ooaUna. to treat bar with anU-intl...tory
....icatiolUt. lia ...t noat not., c1atH .naly 13, "114, inclicatad
pl'uenae 01 MCIJl tandftM" with ...... VU'.1I8 trinv point.
An ottio. note by ~. Wenner, dat.d ,Jun. 37, 1114, indiGate. 1Cs.
ca..eu. he. . biltozy ot . previou. utor vatUcl. .ccident,
OCCUJ:rift9 in l'.., 1n wbicb .h. IUatainad carvical .train Whicb
took tour (4) y..r. to re.olv..
Hi. di.vno... inoluded.
· 'o.t-tnWllltic fibl'ay.lqia and .dju.taent dbaI'. with
depr...ed .oad ~r8U' d.pre..ion.
h. ca",U'1 ..dication. 1nolud.d C (100 119 daily), Ilavil (l00 119
'daily), ICsclaaan (100 ar 4 ti.../d.y), and V1codyn.
Dr. VeMer'.r.couandat1onl included \lllnq flexibility and condi-
tioni"" cue.rei.., p.r.n. u.e at ICld.Uti.., and r.tu.rn to .
.ad.nt.ry job avoiding exce..iv. overlo.dinq of tbe au.culatur..
nnta...rOll
Accordinq to th. reoord. provid.d, it .P....I'. that th. claiaant
.ult.rld purdy .ott tis.u. injud.1 on Jun. 12, 1113, which Mould
bav. r'lolVad with a p.dod at thr.. (3) to lix (I) unthl foUow-
inq th. injury. At which tiae, MI. ca..eU .hould hav. been .ble
to r..uaa ot productiv. lit.ltyl. and qaintul eaployaant.
The record. provided do not jUlt1fy tbe ,rolon9" p.dod of d1..-
~ility beyond January, 1194, re.ultinq frOl injul'ie.. d.ted J\lne
12, 1113.
In ay opinion~ .... ca..ell could have nl\lMCl .t. l...t Utllt duty
work by the end of January ""4, with a ~adWll return to full tiM
ap1oylMnt.
.1.... contact .. tor any que.tion..
lincenly,
~ ~)mf)
~1 Qint.., R.D. CS
loU'cl c.I'tU1ac1. 'by.ic.1 ..cUdn. ,
..habUitation
.. I. .
Pip 2
Kriltl CalleD
putt"8- in a motor vehicl.. In tun! another motor vehide ItnIck lhe vlhicll elal......t WII
traveliDaln 011 the driverslide, caulina the vehicle claimant wu travellns in to strike a hip QItb,
Accordlna to the documentation, this claimanl prlSll1ted 10 the emeraency room of Sa.illl Mary
HoIpita1. where the claimant wu examined IIId released. There exist no doculllOQtalion ltltilll
that thia c1aimlUlt cxpaienced lilY Iou of colISCiousness, nor sustained any fractures &om the
incident in question.
Accordina 10 the records, this claimant presenled to Holy Spirit Hospital Fanwy HeaItb Clnter on
what appears to be 6/18193, where it wu noted that this claimant wu examined by Clem
CiccareW,MD, Upon evaluation, Dr, Ciccarelli diagnosed this c1aimant u havillllUstaiMd a
cervical sprain, In turn Dr. Ciccarelli referred this claimant to physical therapy at Holy Spirit
Hospital in 61'93 through 1193. Also this clailllllll underwenl an exercise program It
M...hUliesberg Rebabilitarion System. 00 1/5/93 this claimlllt wu referred for a cervical MRl
study which 1QUIts were esaentially nonna!.
011 8IJ 1/93 lhis claimant underwent orthopedic evaluetion by Jason Unon.MD. UPOD evaluation
it wu Linona' impresalon that tbis claimant had a cervical strain. However, it was stated by Dr.
Litton. · I cannot define what is th.u is StTained.' Dr, Litton stated that this claimaat did not have
a dlll8vous condition. It wu ~nunended by Dr. Utton that thiJ claimant be u phylically
aeUvt u polllol, with activity not causina any increue in the severity of tbc il\iwy DOr any ,
permanent damaae. Dr, Linon also recommended that this cll.imaat unclqo psyeholoiPcaI
evaluation with Mitchell Smith. On 11/16/93 thiI claimlllt underwent evaluation by 5i Van
Do,MD, physical medicine and rehabilitation specialist, where i1 was noted thai upon examiIIatiOD,
it was Dr, Do impression that Ibis claimantlUltained a po.t-trll1JD&tic whiplu/l injury resullin8 in
neck and back sprain. Dr, Do recommtlldecla hOID8 exercisl proFam with aquatic dlanpy and
occupatiollll therapy. Dr. Do also .tated that chiroprlC1ic treatments were helpA1l However, only
provided temporarl ",liel This cllimant also underw=nt a Cerebral C1 study on 1218/93 which
raults were normal,
SubnqullIlIy, this claimant presealed to the olllCl of Dr. Richard Slldow, c.hiroprldor oa
8IJ 1/93, IJYfI two and one half months post.IIIUma, where i1 was aoted upcn examiJlation, Dr.
Seldow Irri~ lithe followinJ diaanoses: arsde 2 ccrvitalllld thoRde sprain, secondary lumbar
spnln, myofascitis and vertebral inslibility (subluxation.). Sa&ed upon the above dillOOscs, Dr,
Seldow impln.nted a count of utluneal cOrWtina of adjunc:tivI proceclurtl and manual
manipuJalion of th. spine.
From I revitw of !he records, this claimant initiated care under the auidance or Dr. Seldow on
1131/93 and continued lhrouah 2/14/94, It appears wouah the tICOrcla submilled for my miew
that till. c:laimam comlnued 10 receive can WId. tIM auldlllCl orDr. S.ldow beyond 2/14194.
"
.' ,
.... )
Krilti CUIIII
IMPRESSION
Upon revicwina the documentation IUbmlttcd for my rmew. It iI my proCllllional OpinioD tbat
thII claimant aul&lined lOft tissue injuria to lhe wvic:al and thorac:ic: Iplne conslstiD. of
Iprain/strain.
DISCUSSION
It should be noted that lreatmenl for soft tissue injuries consistina of palli.tiv.: Iherapia inI:IudiDa
,"am tal awlipulation, is usually juJtitied for a three moolh period oftlm., Al which poinc, a home
baed prosrun consistina oflheraplUtic screlch.. and exercises could be inc:orporued effectively
to inc:reue strlllsth, flexibility and IIIduranCf a well a to prCVeDC aur'VltiOnlexaurb&&ioo.
There exist linle compellins evidence suppbnina that continued ooa0in8 use of pusive modallti..
anellor manipulation is more aftlclcioUI than a home bued prcaram utilizins Ileal, sttetcha and
exerciaes. In fact, litCl'llure IUllesls lhat the prolonaed utilization of pusive IIIOdaIiti.. IIId
manipulation may actually promole chronicity of symptoms, seconduy to disuse, decoaditioaiDa,
IIld patient expectations ofunresolvable disability (Ven Mooney,MD. The Journal of
Musculoskeletal Medicine, September, 1989), If significanl fUnctional disability peniscs, the most
appropriate course of treatmenl is an active and aagressive exercise and stretchina prosram.
Baed upon lhese principals, a10na with the dot;Ulllllltation submitted for my rmew, it is my
prol'asional opinion that this claimant reached I point of maxilllWD medic:al irDllfO'I'DISDt or
achieved maximum beneflt under the suidanu oiDr. Seldow on 11/1193. II is my professional
opinion that this claimant necasillted tOlal care lor over three months due 10 the a11'led MVlrity
ofinjurles sUllaioed on 6/12/93. which wa diqnosed by Or, Seldow a . arade 2 ceMcal and
donal Iprain. PropCSl nota IUbmined for my review &om th. treatiDI chiropractic: phy.ician
throup 10 my rccommtncled MMJ d.led faila 10 document thu thia claimant wu makina any
further imr-rovemem wilh the treatment reJimCII which was bcin. L'tIplcmcnted, Furtbcrmore,
records submined for my review iDdicales that this c1aimanl had exp.;enced numerou.
exacerbatioll.l due to school work a10na with prolonsed drivin8. Acc:ordinS 10 the report
lubl1litted by Dr, Do dated 11116/93, it wu Sllled that it wun't uncommon (or thi. claimant 10
trave140 to 80 miles rOl school U . lTadual. stud.nt. It is my p'ofessional opinion that b41yond
1111193. home based proaram coll.listins o(ther1p<<ltic stretcha and exercises. coupled with
home beasin. lechniqu.., would have been Ippropriate in and o( itMlllo incraMlltrenph.
flexibility and enduranca a well u to help prevent ..liNt any agrlVltiOnlex&c:lrtlltiOD. Ther.
exIl1l1O ftuther objec:ti" c1inic:al documentation IUbmined rOl my rllli"" suPportina 1M oeceeaity
and/or need 01 continued c.hiropractic car. beyQad 11'1/93. In l'Act U llat.d previOlU, cervical
MJU study pcrfonned in 8/93 wu CSI.ntially 110111III. lbet.lor., any aad all care rendered to tlli.
clalmw by Dr, Seldow beyond 11/1/93 ClIlIIOt be conSlt\/ed U .pPlOpri.... reuonable 01
ncelllll)' lor lb. lnItmMlt oltlle aD.,ed injuries sustained on 6112193, Additionally, in thai thia
'"
. .
~ ,
. .
1lE: Kriati Cauell
Oalm II: ~
hae 2
anoeher vehicle and chen puahcd head on ineo a curb. She was wearinr a seal belL The patienc
was Men in che Emerpncy Iloom of St. Mary's HOIpical where she was x.rayed. created and
released. 5he WaI provided a cllqnOIia of a neck sprain.
The patient lOulht care at Holy Spirit HOIpical beslnnlnr June 18. 1993. She had chiel
complalnu of neck pain. She reponed chae her neck hura with liflinr an~nr wich her arms.
The padenc WaI dlqnOMd wich cervical neck scraIn. uapezllll mUlde scrain and mild lumbar back
sUlln. Cervical spine MlU SlIICII... Aupc5. 1993. were nepdve. She was provided medlcadona
and physical therapy WaI recommended for the nexc month. The omce note of Aup 20, 1995
swes thae the patl.nc haa been u,M1 physical therapy for the Iaac couple of monlha. The patienc
haa be.n referred to a Dr. Uuon. an onhOpedlaL The padenc was manqed ac lhIa faciUcy co
approximately Febnwy 1.1994.
The patienc was seen by Dr. Juon Uuon. an onhopedlsc. Aupsc 31. 1993. He diamONd a
cemeal scrain. Dr. Liuon's report of September 1. 1993 scaees chat he could not define what Ie
II chae is strained. He recommended retelTal co a plYCholopc for consuJwion. He aiIO
recommended chatche padenc be II physically active as pouible.
The patient wu also Men b~ a Dr. 51 Van Do. a specialist in ph~ical medicine and rehabilication.
on ~ovember 16. 1993. He dJacnoeed POS" traumatic whip\aah injury resultinl in neck and back
sprain. He recommended ph,ucal ther"p~. aquatic therapy and occupatiunal th.rapy. The
patiene was se.n apIn by Dr. Do apin onJanuaty 23. 199-6. The patient's myofasc:lal back pain
condition had improved with che Q'QUIIent prescribed. He recommended cOlllinuadon of the
prescribed exercises. He aIIo provided IOme home baaed exercises. The report of February 10.
199-6 from Dr. Do scates thac the pacienclw had a flare up since her recum to school. He did .lot
any additional recommendaciolll al thae poinL
The patient was also ~uaced by a Dr. Daniel Romm. a pain management specialis&. on :'<tarch
9, 199-t. The padent reponed back and neck pain. He dIal'losed myofaacial pain. He
recommended ph,ucal therapy, a TL'l5 unie and occupadonal therapy.
The recordl lubnulled for revI_ include documencadon for physical therap~ provided ac
Mechanicsbu'l Rehab s,scem (rom December 1995 throulh .\pril 1994. Ie appan thae the
ueaunent protocol at thlI facility incorporaced water exercise.
The padene coNulled for chitopracdc care on AulUK 31. 1993. approximaeely cwo and one-hall
monlhs aiter che acddene occurred. She presented with chief complainu of neck pain and plUn
into che upper uapezllll _ She abo repora oMte of headaches. The !*iene wa provided
a dlapOlis of gncie 11 cenlcal and thoracic sprain with seconda.ry lumbar sprain.. m,ot.ucicil and
vanOUl levels 01 ~nebral subluxaciol1l.
-
The padene NIl provtded approlUma&eIy'" vlsia over a 27 week period duoUlh March -t. 1....
The "acmene frequ.ncy proftded was _ncially once co ,:wice weekly throUlh ~owlllber j. 1",.
The" was a three ....k in..M! (ollowed bY crncment as a frequencY 01 _ncially twice _1cIy
Ihroullh JanIWY \-t, 1994. Mer a one ,"ek iUlerval. the paDent __n approlli.malely once
....klv to once _IV cwo _u throu,h the remainder of the ue:wnene period throUCh ~
.
\0
RI: Kristl Cauell
Clalm" ~
Page 3
".199-1, A report 0(Feb~21. 1994llaees thae the pallene's condlllon it (ar (rom resolved and
baa noe yee reached ~I.
Ccrebnl CT scan. December S. 1993. was nonnal. X'I"iY studies. .~ugu.se 3. 1993. indicated
satisfactory !"&IIle motion and no e'lidence o( (raceure.
PUR RlVlf.W DECISIONS:
..\ peer re'liew W'U perfonned by Dr. Mark Cavallo. daeed March 16. 199... He concluded chae the
patiene reached maximum benelle from trnaIIene with Dr. Seldow on Sovember 1. 1993. He
ltlted chac thlI uaanenc alan, with the r-hysical therapy l'ro'lided initially W'U sulllclenc (or the
injuria o(June 12. 1993.
PRoytDr. CONSULTATION:
I spoke with the auendinl chiropraaor. Dr. Richard Seldow. onJune 6. 1994. He swcd chae the
patiene had a hiIcory of a mocer vehicle accidene in 1989. He seated chac the patiene was a (rone
seae passenscr in a vehicle thae had several angles of impact. She had a lacenl flexion injury and
then a f1exion/ exeension injury with rocation. He explained thae these mechanism of injul'l' seems
co have contribuced co the patiene's relatively slow and limieed prOll'CII rrom cradltional oucpatiene
crcaunene lDethocb.
Dr, Seldow seated thae the padene was an AJl.Scaee Gymnasc and was in excellene physic:al condition.
He (ele chac her condition had pcniseed (ar beyond expcCEations. considerinl her physical
condition and her ace. She had received ueaanene (rom multiple physicians including
eemporomandlbular joinc care rrom Dr. :'olic:IrJau.s. She had twO separaee COUM of physical therapy
which did noc seem co produce any significane cliniaJ benefic, His ucaanenc plan included hoc
moise pules. ulcruound and myolascial relnsc. He tried usinl high vole therapy ce reduce the
inflammation which did noe help. He also had her doinglOme range of motion and isometric
exercises. He:&lso melTed her ror water exercises.
Because o( the patiene's slow clinical PfOlRll and pcniscene complaincs. h. ref.rred the patienc
(or some ~holosical counseling with a Dr. Sharon Scurbin.
Dr. Seldow mentioned the occunence on Febnwv 28. 1994 which i.t ouc1ined in his records. The
patienc was eakin,lOlD' dllI'erenc medicacion and she (alnced in hiI omce. She had vowled and
_ sene home with her brocher. He i.t noc cunendy ueacing the patienc. I am UNUte of the IaN
dace o( MMce. He swa chac he has been in concacc wich her ramI1y. To hiI know1edsc, a
specialisc in rheWlWolosY has placed her on complee. bedtes& (or three monchs.
CONci:uSIONSJUnONAII"
I. Cb.iropncdc cu. ~ r_ubi. aad a.c-.y cbrou,b Mud! ... 1994.
Ilaaonal.: I do noc arre' with the inicia1 peer review decisions. I do lend co ..,.. wid'! elM
iPn.nl concepc rtptdlnf th. limica&ion in clinical .ffecMness 01 pasU" chenpl'. Tbla is 1I
~ ,. '"
...
.
..
RE: Krilc.l CalleU
Claim': so.6().69
Pace"
reasonable ,eneral IIIldellne. but I do not Ceel that Ie applies specillcally in chis aM. The recorcb
document many complications and unwua1ldes 01 thJs case.
Clearly. a 22.year-old (onner IYI1lIWC would be expecced co have a re1adve1y ullCompUcaced
recovery from a scn.:n/sprain injury. The Cact that she had an acddene several years lacer may be
a Caccor. How!lYer. her rate of recovery was much slower chan would be expected. The recorcb
did noe seem co document any identiftable complications such as disc bulle or hemlacion which
would explain her limlced PfOllelL
In my opinion. the records prOYided for review document condnuacion 01 chlropracdc care alker
Sovember 1. 1993. The padene went approximacely Cour weeks wlthoue uncmenc. She WII Fin.
to school ac the time, She was becominl dbenchanced wich her prosreu. The recorcb alker
November 1. 199~ documene many flare up' 01 her condition. The padent WII also refemd Cor
ocher therapy. Active therapy was introduced. The patient was doinl home based suecchln, and
exerdses. She was also referred for wacer exercises. Therefore. reasonable efrons were mad. co
try co rehabillwe the patiene's condidon.
Several dlBerenc physicians saw and ereaced che patient aleer Sovember 1. 199~. She WII beln.
manased with medications as lace as April 1994. All 01 the physidaN aareed that lI.lm. Conn of
pain. inllanunacion and muscle spasm concroWnl therapy was indicaced. The padene had some
cransiene rellef Crom chiropractic care. Therefore. in my opinion. It WII reasonable co manap the
patiene wlch pauive therapy. Active therapy was belnl provided. Pauive cherapy would be
indicaced in chis aM co cry co conerol her flare up'.
When the patient's condition did not respond in an adequae. manner. relemll were mad. for
a1eernative ereaanent considerations. .\ddltional dJasnoecic INdies were performed. The padene
was relerTed for evaluation oC possible psycholOlical and/or emocional overlay. Therefor..
approprlaee clinical lIWIaIemenc of the condition had occwred. Durin, chis period. che only
option i.s co concinue therapy which has produced ac 1_ Cl'lIIIIiene cherapeulic benefic. Ie would
noe be appropriace co simply dlscondnue any unanene while punuin, ocher _ne options
or evaluacin, the condition tunher. The creacment frequency was not excesUve. Therelore. in my
opinion. unanent has been jusdfted chroUlh the Iaa& dace at aMce in the records. ~tuch ...
1994.
Very uuly youn.
~~,(v-./
Jell' ^' Behrend. D.C.. r.-\.c.o.
JAB/jl ~
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JOIZB'J'Z L. CASB.LL al7JlJ., . IN 'J'H. coua'J' 0' COIIIION P.L.UB
.
1I0W baWD a. DZB'J'1 CABS.LL . Cl7IGI.RUHD cornrrr, PDlNSYLVANZA
.
auau, .
.
:
PldntUt : CIVIL AC'J'ZON " LA"
v. NO. 94 CIVIL 5996
:
UNZ'l'm1 S..VIC.' Al7TOJIOaIL. .
.
ASBOClA'J'ZON,
:
netendAllt JURI' TRIAL nDAND.n
pDII1'.TIfl'~DJ" ~C'J'IOJIB 0' ImP...........
NO" INTO COURT, through ullder.1gned cOUII.el, came. the
netelldant, who, pre111D1n.rlly objecU to the Campl.1l1t ot the
Pla1nt1tt, 1n the tollow111g part1cular.:
n_DmI
1. Pla1nt1tt 1:Ia. alleged, 1n COUDt II at the Campla1l1t,
a cau.e ot act1011 under 41 Pa.C.S.A. 18371. However, the Campla1nt
ta11. to .tate a cau.e 01 acUon UDder that SecUon, becau.e
acUoll. on 1D.urance po11c1e. under that Sect10n tor bad ta1th
cOllduct, are not app11cable 1D act10n., .uch .. the ODe here1D,
aga1D.t jn.uraDce compaD1e. lor the nOD "payment at lDed1cal b111e
UDder the Kotor Veh1cle '1Danc1al Jle.poD.1b111ty Law. ID.t.ad, 15
Pa.C.S.A. 11797 1. the e~clu.1ve remedy.
94-5988 CIVIL TERM
As Q result, Plaintiff flied this Instant action against Defendant for breach of
contract and bad faith conduct for failure to pay Plaintiff medical beneflts and lost
wages pursuant to the terms of the Insurance polley. Defendant responded by
flllng preliminary objections In the nature of a demurrer to count II of Plaintiffs
complaint, which Is a claim for Interest, punitive damages and attorney's fees
pursuant to section 8371 of the Judiciary Code, 42 Pa. C.S.A. 58371. Defendant
argues that Plaintiffs exclusive remedy Is found within section 1797(b) of the Motor
Vehicle Financial Responsibility Law, 75 Pa.C.S.A. 1701 et seq., and consequently,
Plaintiffs section 8371 claim must be denied. We dIsagree.
DISCUSSION
In Pennsylvania, the standard for ruling upon a preliminary objection In the
nature of a demurrer is well-settled. Arst, a demurrer will be sustained only when
on the tacts averred, the law says with certainty that no recovery Is possible.
~, 530 Pa. 366,369,609 A.2d 147, 148-149 (1992). In ruling on
a demurrer 'the court must accept as true all well-pleaded material facts set forth
In the complaint, as well 8S all Inferences deduced therefrom.' ~
.417 Pa. Superior Ct. 316,321-22,612 A.2d 500,
502 (1992). In addition, 'a demurrer Is not to be sustained and the complain!
dlsmls.ed until the law says with certainty that no recovery Is possible.' ClantrIDl
:l
9ot~5988 CIVIL TERM
505 Pa. 294,
297, 479 A.2d 468, 469 (1984). Finally, any doubts In ~he determination should be
resolved by overruling the obJection.
fbJlIdIJgbIa, 439 Pa. 501, 267 A.2d 867 (1970).
Section 1797(b) of The Pennsylvania Motor Vehicle Ananclal Responsibility
Law sets forth the Peer Review OrganlzatlCln (PRO) process an Insured party must
undertake to challenge a denial of a claim for medical beneflts. The relevant
provisions, for purposes of this opinion. are as follows:
(4) Appeal to court.- A provider of medical treatment or
rehabilitative services or merchandise or an Insured may
challenge before a court an Insurer's refusal to pay for
past or future medical treatment or rehabilitative services
or merchandise, the reasonableness or necessity of which the
Insurer has not challenged before a PRO. Conduct considered
to be wanton shall be subject to a payment of treble damages to
the Injured party.
.. .
(6) Court dettnnlnatlon In favor of provldtr or Inaurtd.- If,
pursuant to paragraph (4), a court determines that medical
treatment or rehabilitative services or merchandIse were
medically necessary, the Insurer must pay to the provider the
outstanding amount plus Interest at 12%, as well as the costs
of the challenge and all attorney fees.
75 Pa. C.S.A. H 1797(b)(4) and (6).
However, 42 PI. C.S.A. 58371 Is the more general statutory provision which
covers 'bad faith' actions on Insurance policies. This section provides:
3
94-5988 CIVIL TERM
In an action 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.
(3) Assess court costs and attomey fees against the
Insurer.
42 Pa.C.S.A. 58371.
In the Instant case, Plaintiff, by Invoking section 8371, seeks Interest,
punitive damages and attomey's fees against Defendant for the bad faith denial of
her medical and wage loss claims. However, Defendant argues that Plaintiff Is
precluded from relief under that section because It Is Inconsistent with section
1797(b), which provides Plaintiffs sole remedy for nonpayment of medical bills
through use of the PRO process. Therefore, our analysis must begin with the rule
of construction to be applied whenever provisions In statutes purportedly conflict.
Whenever a general provision In a statute shall be In
conflict with a special provision In the same or another
statute, the two shall be construed, If possible, so that
effect may be given to both. If the conflict between the
two provisions Is irreconcilable, the special provision shall
prevail and shall be construed as an exception to the general
provision, unless the general provision shall be enacted later
and It shall be the manifest Intention of the general assembly
that such general provision shall prevail.
4
I .'
94-5888 CIVIL TERM
1 Pa. C.S.A. 81933.
Accordingly, we must first construe section 1797(b),lf possible, 80 that both
section 1797 and the more general provision of section 8371 may be given effect.
Pennsylvania courts have had the opportunity to consider the Interplay of
Sections 1797 and 8371 on a number of occasions. However, we note that casel
which address the possible conflict between these sections In both the medical
beneflt and wage loss context have been sparse. We are guided, however, by a
federal district court d&clslon which addresses both Issues. SII ~
Q... 808 F. Supp. 399 (M.D. Pa. 1992). In~, the court
concluded that a section 8371 claim for punitive damages could be sustained for
a bad faith denial of wage losses based on the rationale of Its earlier decision In
$~.r v. AU"tllte Ins. Co., 776 F. Supp. 986 (M.D. Pa. 1991). In Seeger.
however, the Issue Involved section 8371 and section 1716, as opposed to section
1797, of the Vehicle code. The Seeoer court held:
We 888 no conflict between section 1716 and section 8371.
Section 1716 provides that overdue beneflts . benefits not
paid within thirty days after the company receives reasonable
proof of amount . shall bear the Interest at twelve percent,
and that a company shall be liable for attorney's tees If
benefIt, have been withheld because a company 'acted In an
unreasonable manner.' This section does not provide that thl'
,hall be the company's only liability.
e-.r at 991.
~
. .
94-5996 CIVIL TERM
The ~ court explained that Seeo~r stood for the proposition that section
1716 and 8371 are not Inconsistent because those sections penalized Insurer. for
different transgressions - 'unreasonable' conduct under the former and 'bad faith'
conduct under the latter. ~ at 402. The ~ court then applied this
rationale to the wage loss Issue before It and concluded that a punitive damage
claim could be sustained under section 8371 for a bad faith denial of a wage loss
claim. 1d.
However, we do not agree with the QaOO court's conclusion that sections
1797 and 8371 conflict when applied to the area of medical benefits. As previously
noted, Pennsylvania state courts have had few occasions to distinguish between
wage loss claims and claims for medical beneflts In the context of the above-stated
statutory sections. Yet, several of our courts have adopted the exact rationale that
~ used In the wage loss context as applicable In the medical beneflts area.
In Werle v. ~rQDerty and Casual1X....lnsur.. Co., 425 Pa.
Superior Ct. 396, 625 A.2d 663 (1993), the Superior Court also found Seeoer.
SUDra. Instructive In reaching Its conclusion that section 8371 can coexist with
sections under the Motor Vehicle Financial Responslbllty Law. While the QJmI.[u
court recognized that a potential conflict may exist between the two statutes with
regard to damage provisions, It held that the statutes are not Irreconcilable
6