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Mechanicsburg, Cumberland County, Pennsylvania 17055.
2. Defendant The Travclers Companies (hereinafter "Travelers") is a mutual
insurance company with its principal office located at One Tower Square, Hartford,
Connecticut, and doing business in Pennsylvania with offices at One Mellon Bank Center,
500 Grant Street, Pittsburgh, Pennsylvania 15219-2502.
3. On or about October 12, 1988, Christine Dunn was involved in a motor
vehicle accident.
4. Prior to October 12, 1988, Defendant issued a policy of automobile insurance
to Christine Dunn. Said policy was in effect on October 12, 1988, the datc of the
accident.
5. As a result of the accident, Plaintiff suffered various injuries, including
cervical and lumbar strain and sprain and various other injuries.
6. As a further result of the aforementioned accident, Christine Dunn has been
obliged to receive and undergo medical attention and care and to expend various sums of
money or to incur various expenses for which medical benefits are payable.
7. Following the accident Christine Dunn incurred reasonable and necessary
treatment from, among others, Plaintiff, for her accident related injuries. The fair and
reasonable charges for this treatment is $8,913.50 as set forth on a copies of the bills
which are attached hereto, and made a part hereof and marked as Exhibit "A".
8. The bills for Plaintiffs services were submitted to Defendant for payment.
9, Defendant, pursuant to Section I 797(b)( I) of the Pennsylvania Motor
2
Vehicle Financial Responsibility Law, as amended, has contracted with a peer review
organization, for the purpose of allegedly confirming that such treatment, products,
services or accommodations conform to the professional standards of performance and are
medically necessary. The name of the aforesaid peer review organization is Tri State Peer
Review Organization, Inc. A copy of the peer review report is attached hereto as Exhibit
liB".
10. It is believed and therefore averred that the above peer review procedures
set forth in Act 6, viz., Section 1797(b)( I ) do not apply to this case since the policy of
insurance was entered into and the accident occurred prior to the effective date of Act 6.
See, McKeen v. Slate Farm Ins. Co., No. 90-SU-05089-01 (CP York, October 29, 1991).
II. In addition to the above, if the Peer Review provisions of Act 6 do apply,
then, Defendant has, in violation of Section 1797(b)( 1), attempted to use said peer review
organization to determine the causal connection between the accident and the alleged
injuries.
12. By letter dated December 12, 1991, the Defendant refused payment for
certain medical treatment, including the treatment provided by the Plaintiff, based on the
conclusions provided in said peer review report.
13. It is averred that a'l medical bills incurred both before and after the peer
review and reconsideration are fair and reasonable and that said treatment was medically
necessary and related to the accident. Moreover, pursuant to Section 1797 (a), all bills
were to be paid unless submitted to peer review within 30 days.
3
14. Defendant has refused to pay the balance due under the terms and conditions
of the policy of insuranc~ and the Pa.MVFRL. As a result of the aforesaid, Plaintiff was
required to hire the services of an attorney to collect the medical bills due.
15. It is averred that the Defendant has acted in an unreasonable manner by
refusing payment of Plaintifrs invoices. Pursuant to Section 1716 of the Pa.MVFRL,
Plaintiff is entitled to attorney's fees plus interest at the rate of twelve percent.
16. Christinl1 DUlin assigned to MRS the right to receive monies otherwise to
be paid to the patient under any insurance plan and to pursue her claims for such monies.
17. The Defendant did not provide timely notice of the Peer Review decision
not did they provide the Plaintiff with an opportunity to discuss the treatment rendered.
18. It is further averred that the Defendant has acted with no reasonable
foundation. Pursuant to Section 1798 ofthe Pa.MVFRL, Defendant is liable for attorney's
fees for such actions.
19. Defendant has undertaken a course of action which has been designed to
unilaterally, and without justification, refuse claims for medical benefits arising out of
motor vehicle accidents and for which the Defendant has contracted to provide insurance
coverage.
WHEREFORE, Plaintiff demands payment of the full medical bills due in the
amount of $8,913.50 plus reasonable attorney's fees, costs and interest on said overdue
benefits.
4
PATIENT NAME
"':'I1~" rtaS~ iT.1L
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III 7I,n JI~I.
PATIENT NUMBER
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MEDICAL RECORDS NO
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1'.)0; LJ
DATE OF BIRTH
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ATTENDING DOCTOR
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'.J 7/11 ""hAd ROO~ I. C.h<c 1 3110%01 )95.~ ') Jq; .t~1
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v 71 L 7 ':dd'(C-,L T",~Cilu~1 1 l1..; ,;.) I.:;;.. 2'1.:, 2 f~ e l'
.: 71 ~j ht(..-I:f.IJLt..\TJ~ ~:-.... \ l J : ," jl; ~J) ];. ;':j ]:i .1,
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0) 711,1 M YCj\\,j~Jl.L' fL.", tI.\l;,\ 2 )lZIj~l~) j~h~C ] j .1'
u71 J. ~ 'E;.. v I C.I~ TkACT1".' 1 J1.lt~.H')" ':-:;.1';: N.l
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o 7/lJ .: ok 'il CI~ T"' C T 1 ul, 1 3l..r.J1J. ~q.l'-" 2Q.ll
" ~7J 2" rlYU"OCJ~L"T,)R ?C, l H~OOLOJ ]~.lC ); .11
"07121 Co~HCA~ Tk.\ C II O.~ 1 3l..uCl'J.. Zq.l; Z<l.I'
07/21 h TO< U'J~~A f1J~ ~ ~C,< ~ lllCJLJ3- 35.Ln J~.l !
o 71 ~, ~c~..tC.\L Tk,\C T l,jl' 1 )Llt~Jtv" lQ.1S 2').1 '
l. 71 i:.l .;.:~, ll~ \L T~.H':Tl:Y"4 1 H.:ll'J" lQ.1.5- U.I'
C 71 ~~ n'f-:"uCdLL.\TUk. P..~\ 1 312 C'.! LJ J 17. ;'; 17.S'
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.31
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: :.:~E;~: ',CE." ,.:.:: :~ARlfR' 00 '10' ~u ~'H e,,1. :. ."11 ",...ou~n SHO\~'I
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. . .' .! TOTAL '
$UII"'f~TCAII
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PATIENT NAME
PATIENT NUMAEA
MEOICAL ReCOROS '40
........ ~..
CUI .,,..
LtlKI lT1Nt ~'J;j~
lOtdZJ
CATE OF BIRTH
1..,jh9~ )-i J'J::S
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ATTENDING DOCTOR
11) j~ C711.,!I~1. q l.'~H~ )blLlt/bl. 1ttl'i4;]~!j
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~A
T~AVELE~S
"G~jE
STATE FA ~ IkSu~\I.C[
NO~E
S"~b')50
L5 Jo
H-blQ]-07i
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; 71~; ,J rl"",;l:'CY L of }~ 0:JlJ'; l.7.50 147. :-
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')7/lu ,... 'JI -; r .\I~ L :,) 1':1:' JiJ.) bl.70 61. i
I'j 11 ~o ~ r c'J.\L )/- rl,'( : It) 7 ':'lb~'J 1.2 i. tot,' l2l.~
':;711b oJ CL.' [l~ T 1\ ole r i')~.. 1 t,) 7':;Z'JG 1 :i~.1"" 5lt. i
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J 71lb "~T/~1YJ'~(uLL~i'J~ ,. 1 -]7,)2101 lb.51j Ib.~
J7I Lb '1 ~i 'i.\GE l 41713,00 1'0.20 )....?
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,.
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_'Jlll::l~11I.tll"I!::I:__ :~l:"':~.~ :,~~:;1i:1"1";' '.of I>OSl!D ."~IH "lIl all~ ,~'S PRtP'HID ..,. I'H'IUIUHCI,
_~~;;".~_, .~.,., C.lIIIlIIII\~O"OfP"U".AA,:,n'Il.l.I,IOU"n\HO','H .
~";,r'-:~"'~"J"""~'~'~ ..,.
., . I I'TOTAL
f I rl~L
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PATIENT NAME
(.,1<1 ~T~!'lC: l)U~lrl
P4T1ENT ~IUM8ER I.4EOICAl RECC'A05 NO
.....N .a
~u , "'...
L)~HZJ
DATE OF BIRTH
tI)":(ll]-~ h)o
A S
'A. '"
'<\'U ..
ATTENDING DOCTOR
)" 01121111 ~ 2~': ;,ll.le2 lJ75.S)ljd
Gti r;QI-1",~" t.1J vC E
l)]d
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DUQtlPnOH OP UoaPlTAL SOMCE
1J7/17 .HSS4GE
Oll7 n 11'0 rl~
v7/17 n In Hol
G7/1j ~J~ATIC G~? 1 HK
Cl/l<j ~'~LI\T(C GiO? 1/2 illt
u7/11 ,vi H ~I<
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'J71,,1 ':Lc:'; ~T( MvL.... TI-J~~
~111~ hJT/1'J~0~~LL~TJ~ p~
07/L.J ~",~'::"t,;~
-; 711.:' ,l T LI ~ ;1 (
,)7/1~ F.LE"; 'iTI'-iJL.\TIJ-,
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l.J7/1" 1u(~T "(,,
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'J7/1~ "'ljf/l,1:"~:':']LL~TG" p..\
v7/1~ -AS:iAt:C
071 ~'I r1 T :./, IH
1J1I2u .1GI'iT ~IQ
.'01120 C.'dC.L r~.\Crl)1I
'07/2u .L.r. ~Tl.uL.rIJ~
07/l~ N~T/HY~~'JCJLLATI1~ ~~
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_~_.. ,....;, ._ :"-~~:',CI,,;p::;'.:,C - .' .or "OSHO ,y"t~ -"1'1 J'L~ 'tU Pllt,.1l10 uN' ,"IU'U,lOtl
::t\::,o:;= :',CE'.':: C..IlIlIIIlI:l0 I.ot'lf ""'<1" 'lllr:,;' ....t "..OllNTS SItO~~'t
~~"""'\"l'2i!:I.'i"'''''''''''~'''''':'~[':''''"".~ ...
i K 'ib') 5')
m;-':":;-- "'I,
. _.:lUL_
1 ~]70J500 ].,21
1 4170],,00 ':'...1.')
1 .17lJlolJ /H.iv
1 .HOloN 11,).25
1 .H01~2~ ;'i,L,
1 .370LJ,)O b 1. 71)
l 't J 1:)1 -,~O 5...11
l .11C21IJJ 't7.J?
2 4H~2)OO l';C}.Iotu
Z "t:! 7r}l7tJO JJ. :.':
l ..)1,1),0-) J~.,"
1 .. 37'j]ol J ~ d. ~'1
, .J7J2]CIJ l~? "I)
-
l "J70ll00 ..,J.tS;
1 ")7v.'~0) ~-1. 7r.
l :,) 7~ t lt1,:l 1'11.10
l .. j'1~l ')J J 11~.~'J
1 ")111'l')~ '.l ';;.1-;
, It) 7 '~ll'j,~ ]).11
'.
. itJ7C)';~,} lit.le
.
1 4J7CJolv ~a.,o
l 4J7:ll'j1 01.70
l '" 7 0 L-IO 0 5".70
l .J7G2JOO 5",.10
2 4J7D27J.'; _ )],1~
1 ..,) 7lj l'~l),) 5..7')
t "J;:~JJ~ 5",.11)
l ,,) 1':~ 7:)u 1/:.;5
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".. ,..;ciW"". ,o,irrui.iir.,-
., .. 1 ' . TOTAL '
lH:ttMI ttDSPITAL IN "ELIi,IL
175 L.\NCASTER dLYll. t:
/lECIlANCI\RG ,PA l11155 ,- ~
7\ 7/&'11/370,.
;rnTl"_TI,lir~ IOII'~+-
lHAYELHS
P. o. nox t5JI\
PlllSnURG PA 1~23J
,.....-.....
CLlNIl.
lOTAL CII AR GES
. lRA YELERS
.STA1E FARft INSURANCE
.UUN~, CHRIS1INE
.UUNN, CHRISTINE
,.
-.
'. ...~.......o"''''._IoIOOU'llIlL.'''''''
CEHYICAL SYNUHUIIE rile
:', I" .__.H. ~~T..........'l;;v;jrn-;T"""..;J......,
..
UIHI21.crA-',j~O
PAYER CO?Y
.ltlll '"o.q.
23-2~14175
I
:.,
'.un"'......'.... '''''''__'
510 'I Hlb. {O
'"
t01 l~lb ,7u
.' ,.".. !-:
".
F 01 SR 5&05')
F 01 38-6293-075
.. ,~..,..,.., 'y'..
'.1....".1110
'I '''...')!lhOC'O.....
I'A~OO 25(171L
.1....,'''....
."'.'''.'..01
....',...
............,.. x
" NO
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o
...
50b802-;;J08
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.~"Ad Ha~~ITAL IN "~CHANICS~U~G
"...IlW.NfDATt P ,) '_'UX 20.....
~ HAL oll~/ 1 MHHAHICS~\ .. PA. 17055 (
OILL 1717Ib913700
ll-lOlH 1~
PATIENT NAMe. PATIENT NUMBER MEDICAl. R!.COROa NO, ~ ::..
CHR15T1N~ DUNN ~D73b7 5083b7-~)08 A 0
O'lIlC/'ll 2 lJ lUIl5/91
lJA T1! OF BIRTH
Ob/l~lb2 l87545308
1538
TUVELER
NONE
STATE FA M INSURANCE
NONE
NONE
NONE
PA
,\~,~': O[SCJUPfIOH OF 1I0SP'fAl. 5EI1VICE
1m
ATTENDI~G DOCTOR
5R50050
)0-&29)-075
. .
'2D TWO HOUR5 WORK HARDE L bH0050Z. 110.25 110.2~
'ZO ULTRASOUND Z bH0050b 88.20 88.20
'20 MAS s...GE L bH00510 H.I0 H.I0
'23 rwo HOURS WORK HARDE 1 bHOO50Z 110.25 LlO.B
'2.1 ULTRASOUND L bH0050b H.IO .....le
'l.l HOT/COLD PACK 1 bUUO~09 L1.!J~ 27.55
'23 MASSAGE 1 bU00510 ...10 H.I0
WORK PERFORMANCE CE NTER ~be.55 ,.68.55
TOTAL CURRENT CHARGES 'b8.~5 A63.55
~ALANCE FUR"A~D CHARGE S
ru-DAfE PAYHENH AllJS.
UcDUCTI3L~ AHUUNTS
ACCuUNT BAL.HCE 4b8.55
a
,
~
250 MT. ~eBANoN BLVO. .
~ITTSBURaH_ PENNSYLVANIA '5234-1247
(4121531-8440
rAX(4121531.8410
CALLS AFTI!R 5:00 P.M. (4121 531.8410
Travelers Insurance Company
P.O. Box 1538
Pittsburgh. PA. 15230
T/R
fb
tml/ 2 5 \lEIl
TijI~~~E~.RIl'!f!ftW ORGANIZATION, INC,
Attention: Ken Hafner
Re: Claimant: Christinu Dunn
Claim No.: 5R56050K
Reviewing Physician/Specialty: Dr. John Lehman, Orthopedic Surgeon
T/PRO No.: 91TPR0091815230
Date of Injury: Octobcr 12. 1988
Claims Reviewer: Krista Dunlap, BSW
.
As you will recall, .the above captioned claimant was referred to Tri~State Peer Review
Organization for the purpose of a Peer Records Review. A detailed letter specific to the
concernS of this': file along w:rch .al t 0 f the avail ab 1 e medica t documents and chose person-
ally secured, .were forwarded to this profeSSional for his review/determination.
. MEDICAL. PEER RECORDS' REVIW REPORT
OUTLOOK
Upon completion and completa review 0 f the "va iI al> III recordu. the ahove professional reportl
his deteruU:nations: to che undel1signed'.
1. Treatment received after May of 1990 cannot be attribut.ed directly to the MVA.
2. No add~tiona1 treatment is necessary.
.,
Please refer to the enclosed re'l'ort for t~lis Rl.!villwllr' H compl ete recommendations and
determination:;, .
Thank you for chis: interesting referral. Our fil e -.i 11 now be pl aced on a thirty day diary
date sysLem from. Novembe~' tJ, t999 t to Decl.!mbllL' 1 J, 1991 in the eVl.!nt a cha llenlle to this
review' is received'.
Sincerely,
J~~:ll:=C ~uc no~ ~ead
Enctosuret Dr. Lehman's report
Smart Corp.. invoice for
records (not paid by T1
T/PRO invoice
<.-:, :O'~,O ";~..
IU .i -
tONf\DEN\\P-.l
Tri-State Peer Review' organization
KD t:1.llP :dc
CCt Dr. George Roth
Rehab .Medicine AssoC.
Rehab Hos~ital oe Mechanicsburg
Harrisburg Orthopedic Assoc.
~r. Bruce Goodman
Jr. ::d Violago
.,
JO'"iN W. LEHMAN, M.D.
. .--..
ORTHOPEDIC SURGERY
AND SPORTS MEDICINE
November 7, 1991
Tri-St'ate Peer Review Organization, Inc.
~SO Mt. Lebanon Blvd.
PI ttsburgh, PA 152H-1247
RE:
TRG :-10.:
amlSTIHE DUNN
91 '!"PROO 91815230
Dear Ms. Dunl apl
The following Is report of the peer review done on the above
patient, Chrls~lne Dunn, at your request.
MEDICAL REOJRDS REVIEWI
and which have been listed on
wer e r evl ewed.
A'11 the records whl ch you subnl Hed
the second page of your cover letter
SUi\MARY AND ASSESSMENl':
the following ls my oplnlon In
ralsed.
Based on review of that Information,
regard to the ques tlons you had
1. 'It ls my opinion that the diagnosis as related the motor
vehicle accldent Is an acute cervical and low back strain.
2. WI thout any records or documentation as to exactly what
treatment she had In the period of time following the accident, I
am relylng at thl's time to a sreat extent on the history that was
done by Dr. Dalunus at the time of his examination InMayof 1990.
It would appear from that history and his examination that this
patient Indeed had recovered from her acute injuries that she had
sustained In her motor vehicle accident certainly by that period
of..tlme and that alot of her ongoing complaints could not be
justified by objective findings and that she had already had an
excessive amount of' treatment by dl rferent providers. There ls
certainly no reason to suspect any permanent dl sablllty or any
reason ror her ongoing complalnts that could be related directly
to that accident. Therefore, it would be my feeling that the
treatment she had In Harrisburg specifically by Dr. Roth and Dr.
.'ylolago, HarrIsburg Orthopedics, Dr. Oooeinan and Rehabilitation
Systsns were not neeessltated or medically necessary as result of
any Injuries that she sustained in her motor vehicle accident.
"
Krist'a Dunla~'
ru:: OIRISTINE DUNN
Again, I make this s.tatement based on the records that were
provided and indeed IC there Is other addl'tlonal InCormatlon Crom
prevlous"treatlng physicians' that would Indicate ot./1erwl'se I would
be glad to re-revlew hIs records in light oC addl.tlonal
'Informat Ion.
'I do Ceel, however, Crom readlngall.the histories that were
given on these records' that the treatment she received Crom at
lea~ ~ Mav oC 1990 on cannot be attrLbuted dl rectly to her
automobile acclden.t. 1 certainly do not feel that the admission
to the Rehabll'i tatlon Hospital was medl cally necessary or
appropriate at least as Car as her motor vehicle accident Is
concerned.
3. I do not Ceel' .there I s any reason Cor any cant I nued
treatment as related to her motor vehlcl e accident. I' Ceel' that
thi's Is a situation where a case manager would be oC great benefit
and certainly an IME may be Indicated IC there Is a disagreement
wi.th this report and LC-she does have ongoing symptoms.
4. .l't Is my opinion w'ithln a reasonable degree oC medical
certainty that this patient Is essentially reQovered Crom any
Injuries that she sustalned In her motor vehiCle accident and that
her ongoing complalnts cannot be attributed directly and
unequivocally to that accident. I am certainly unable to give you
a recovery date based on the records ,that 1 received.
5. "As I noted above, I do not Ceel any addl.tlonal treatment
I s necessary.
6. .l't certainly appears that the.-patient Is capable oC
returning to work and Indeed she did return to work aud why she
stopped I am not qul.te sure. 'It appears. that she could have kept
on working and still had sane treatment Cor her low back problems.
Thank you Cor the opportunity to participate In this peer
review process wi th you. TC 'there are any further questions,
please do not hesi tate to contact me.
Sincerel~
JOffLehman, M.D.~ Orthopedl c Surgeo,
Board eert I CI ed In Orthopedl c Surgery
JWD/kaa
NOY 8 1991
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
HEAL THSOUTH OF MECHANICSBURG,
INC.
175 Lancaster Boulevard
Mechanicsburg, P A 17055
Plaintiff
CIVIL ACTION - LAW
v.
DOCKET NO. '1~- L. Y S 'I
THE TRAVELERS COMPANIES
One Tower Square
Hartford, CT 06183
C " II: L t ~ II J\'\
JURY TRIAL DEMANDED
PRAECIPE TO REINST ATE COMPLAINT
TO THE PROTHONOTARY:
Please reinstate the complaint in the above.captioned mailer.
1/25/95
Date
. ohn D. Bri g. s
Oare & Briggs
Attorney ID 52987
1776 South Queen Street
York, Pennsylvania 17403
(717) 846-3000