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2. Defendant State Farm Insurance Company (hereinafter
"state Farm") is a mutual inourance company existing under the laws
of the State of Illinois with its principal office in Bloomington,
Illinois, and doing business in Pennsylvania with offices at 115
Limekiln Road, New Cumberland, Pennsy~vania 17070-0257.
3. On or about November 23, 1990, Barbara Vagnerini was
involved in a motor vehicle accident.
4. Prior to November 23, 1990, Defendant issued a policy of
automobile insurance to Barbara Vagnerini. Said policy was in
effect on November 23, 1990, the date of the accident.
5. As a result of the accident, Plaintiff suffered various
injuries, including neck ~nd back injuries and chronic pain
syndrome.
6. As a further result of the aforementioned accident,
Barbara Vagnerini 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 Barbara Vagnerini incurred
reasonable and necessary treatment from, among others, Plaintiff,
for chronic pain syndrome, low back pains and accident related
injuries. The fair and reasonable charges for this treatment are
$37,558.25 for in-patient and out-patient services as set forth on
a copy of the bill which is attached hereto, made a part hereof and
marked as Exhibit "An.
8. The bills for Plaintiff's servicel!l were submitted to
Defendant for payment. The balance remaining unpaid is $24,427.04.
2
9. Defendant, pursuant to Section 1797(b)(l) of the
Pennsylvania Motor 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 and address of
the aforesaid peer review organization is Omni Medcorp. A copy of
the peer review reports is attached hereto as Exhibit nBn and "C".
10. 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.
11. On or about September 28, 1992, 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.
12. It is averred that all 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. A copy of James W. Williams, M.D. letter is attached, Exhibit
"D".
13. Dofendant has refused to pay the balance due under the
terms and conditions of the policy of insurance and tho Pa.MVrRL.
As a result of the aforesaid, Plaintiff was required to hire the
.ervices of an attorney to collect the medical bills due.
3
14. It is averred that the Defendant has acted in an
unreasonable manner by refusing payment of Plaintiff's invoices.
Pursuant to Section 1716 of the Pa.MVFRL, Plaintiff i8 entitled to
attorney's fees plus interest at the rate of twelve percent.
15. Barbara Vagnerini 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.
16. It is further averred that the Defendant has acted with
no reasonable foundation.
Pursuant to Section 1798 of the
Pa.MVFRL, Defendant is liable for attorney's fees for such actions.
17. 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 dccidents
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 $24,427.04 plus reasonable attorney's fees,
costs and interest on said overdue benefits.
COUNT II . BAD PAITH
and INTERPERENCE WITH CONTRACTUAL RELATIONS
18. The foregoing paragraphs are incorporated herein by
reference as though set forth in full.
19. All treatment was provided to Plaintiff after the
effective date of Section 8371 of the Judicial Code, 42 P.S.
Section 8371, effective July l, 1990.
20. It is believed and, therefore, averred that the Defendant
4
has employed said peer review organization in bad faith in that
said peer review organization does a substantial amount of peer
review work for Defendant and has a financial interest in provident
to Defendant a biased peer review report.
21. Moreover, said peer review organization has, or may have,
continuously been providing negative peer review reports to this
Defendant and other insurance companies repeating the same language
for the purpose of maintaining a steady source of business, thereby
showing a pattern of abuse of the peer review process.
22. It is believed and therefore averred that the Defendant
regularly refers claims to peer review organizations for review
without a basis to do so.
23. In addition, said peer review organization gave its
opinion that the injuries were not related to the accident, instead
of determining nmedical necessityn or nconformance to standards",
all in violation of Section 1797(b)(I).
24. In addition, it is believed that the Defendant had no
reason to believe that Plainti f f' s treatment was not medically
necessary, but instead was intentionally trying to simply ncut of"
medical coverage for which Plaintiff paid a significant premium.
25. It is believed and, therefore, averred that based on the
allegations set forth above, Defendant is guilty of bad faith.
26. Defendant's unlawful, malicious, unreasonable and
unjustified conduct has interfered with Plaintiff's contractual
relations with its patients by making it more expensive and
burdensome for Plaintiff to perform its contractual obligations and
,
WRIPlCATION
I verify that the statements made in the foregoing pleading
are true and correct to the best of my knowledge, information and
belief. I understand that false statements herein are made subject
to the penalties of 18 Pa. C. S. 4904 relating to unsworn
falsifi~ation to authorities.
Date:
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Mark Smith
Chief Financial Officer
Healthsouth Rehab Hospital
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April 3, 1992
HARRISaURG
APR 6 1992
R E C E.L'lE..P
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Mr. Matthew OWens
State Farm Insurance Co.
115 Limekiln Road
P.O. Box 257
New Cumberland, PA 17070
REI Barbara Vaqnerini
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CL.: 38 6421 077
D/A: 11/23/90
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Dear Mr. Owll!ns:
This letter contains the initial detex
and medical neceseity of care pursuan
Company's challenge in the case cited al
is certified as a comprehensive peer : .
Pennsylvania Insurance Conunissioner, and this determination is
rendered pursuant to the provisions of PA Act Six of 1990.
State Farm Insurance Company challenged the reasonableness and
medical necessity of care rendered to its insured by The Rehab
Hospital in Mechanicsburg, based upon State Farm Insurance
Company's receipt of one or more bill(s) for treatment rendered on
or after April 15, 1990.
We note that all documents provided by the respective health care
provider(s) pursuant to our request by certified mail of 1/24/92,
were forwarded to Craig A. Soskin, M.D., for review and made part
of the permanent record of this determination.
On the basis of Dr. Soskin's peer report and telephone conversation
with Dr. Williams, and the medical documentation made available for
review by the insurer and the heal th care provider ( s ) ,
respectively, we have determined the followinq;
, 1) The psychological therapy and vocational therapy provided
by The Rehab Hospital in Mechanicsburg was not reasonable and
nece..ary as defined by PA Act Six of 1990 as related to the
11/23/90 HVA;
2) The Biofeedback treatment provided by The Rehab Hospital
in Mechanicsburg ",as reasonable and neceseary as defined by PA Act
Six of 1990 as related to the 11/23/90 MVA.
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Commonweallfl (~(IfIII', 100 Toumam.nr Drive. Sui" 212. Hanham, PA 19044
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February 17, 1992
Omni Medicorp
Attn: Odette Sanders
Medical Investlgator
Commonwealth Corporate Center
100 Tournament Drive
Horshan, PA 19044
RE: BARBARA VAGNERINI
Dear Ms. Sanders:
I take strong exception to the statements that the referral
of Ms. Barbara Vagner i ni for management of her chronic pain at
Mechanicsburg Rehab Hospital is unnecessary medical care. It seems
that most of this is b~sed on an oplnion by a Dr. E. James Kohl
that she had reached maximum medical benefit on May 23, 1991 with
regard to her neck injury she sustained In a motor vehicle accident
on November 23, 1990. In my cilnical experience and my knowledge
of the literature concerning Gervical trauma there is no basis for
such an opinion. It is well documented in the medical literature
that lO-15~ of all people with flexion-hyperextension injury to the
cervical spine failed to achieve good recovery for as long as two
to three years. We do know that 50\ of the people tend to recover
somewhere within the first year and 25' more over the next six
months.
In one sense I have to agree with Or. Kohl In that she was not
deriving any benefit from the medical treatment she was undergoing
ie. chiropractic adjustment and modality therapy. Certainly the
modalities are useful in the fIrst few weeks after significant
musculoskeletai trauma but after that they are of little use and
therefore it should come as no surprise that she continued to have
pain and progressive decrease in her functional abilities on and
after May 23, 1991. I find it very difficult to figure out how a
physician can arbitrarily make this decision when a patient has had
such a limited treatment ~pproach and continues to have progressive
paln and disability.
There seems to be some question about Dr. Ronald Lippe' 8
referral to Physicians of Rehabilitation Medicine. What actually
occurred was Dr. Lippe as an experienced and competent orthopedic
surgeon referred Ms. Vagnerini to the Mechanicsburg Rehab Hospital
Musculoskeletal Injury Rehabilitation unit for evaluation to see
if the chronic paln program would be useful.
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Page 2
Barbara Vagnerini
I am Medical Director and attending physician of the patients
in the chronic pain program so that is how I became the treating
physician. I certainly think the referral was appropriate and from
my vantage point now knowing that she completed the program
successfuily and is back to work and managing her problem very well
I can certainly say it was an appropriate referral.
I take exception to the statement by Dr. Kohl that there is
no cause of the relationship between the conditions that I treated
Ms. Vagnerini for and the November 1990 motor vehlcle accident. It
is well known from physicians with clinical experiltnce in neck
trauma and in the medical literature that there is a very
characteristic symptom complex that follows fleXion-hyperextension
injuries of the cervical spine. One of the most extensive studies
was done by Balla, who studied 300 people, who noted the common
complex of headache, neck ache and stiff.ness, arm pain and
tingling, dizziness, blurring of vision. There was a little
diffp.rence in this symptom complex from six months to two years.
If the pain persisted for greater then six months, psychological
symptoms of anxiety, irritability and depression become part of the
symptoms complex of cervical trauma. Likewise it is commonly known
by physicians experienced in managing this disorder that there
tends to be posity of physical and neurological flndings apart from
pain and tenderness in the affected muscles and decreased range of
motion in the cervical spine and upper body.
Ms. Vagnerini certainly exhibits this classlcal pattern. At
the time of the accident she had immediate pain radiating into the
occipital area which 15 conslstent with a compression occlpital
neuralgia of the greater occlpltal nerve. This can only occur when
there is extreme hyperextens ion of the cervical spine. As is
generally the case radiological studies were unremarkable for bony
abnormality. As with any such injury it occurs with a speed and
force that overwhelms the normal protective cervical neuromuscular
reflexes and the damage occurs to the soft tissue and joint
structures before the nervous system can react. Thi~ results in
strain or tear to the anterior and posterior longitudinal in the
ligaments, interspinal ligaments and annular fibers of the
intervertebral discs. Such force can certainly Impact the facet
joints which can result in capsular strain and even cartilaginouB
damage. We generally sec stretching, tearing and/or hemorrhage of
the longus colli, longus capitis, scalenes, upper trapezluB and
sternocleidomastoids. One can note throughout her various
examinations that she exhibited paln to palpatlon of all these
structures and any dynamic movements particularly repetitive ones
such as she performs in her job as a dental assistant continue to
aggravate these muscles. She had accompanied numbness and tingling
bilaterally In the fi~gers which likewise is part of the common
symptom complex that we in spinal medicine see on a daily basis.
Page 3
Barbara Vagnerini
The treatment she received likewise is well documented in the
medical literature partlcularly if one were knowledgeable in the
work of Drs. Teasall and McCain who are national authorities In the
management of cervical trauma. Thls involves an extensive education
of the patient as to the nature of the injury and the factors that
may continue to aggravate the problem. Therapeutlcally it includes
the use of graded stretGhing exercises that must be performed by
the patient on a regular basis. We titrate in strengthening of the
related musculature with attention to very good posture. Since the
majorlty of people with spinal pain tend to have a decrease in
aerobic f i tnees it has been well documented that promotion of
aerobic fitness not only decreases the disability but definitely
increases the success of the spinal pain program. Pain is a great
stressor and (I student in basic sciences learns this in the
physiology labs. The more stress, the more pain therefore in order
to learn good pain management skills one must use relaxation
techniques and psychological stress management tools in order to
keep this under control. It is Imperative that the patient and
staff understand the patient's personality and emotional state in
reaction to the injury in order to successfully bring this about.
At the same time the patient has to learn how to deal with
aggravating environmental factors which can increase stress and
pain levels. There must be a consideration of work modification and
retralnlng in order to return them to a fully functional lifestyle.
Overall the emphasis is on improved function and pain control as
opposed to pain relief.
The role of movement, stretch and strengthening cannot be
overemphasized. This Is one thlng that Ms. Vagnerini never received
in her treatment protocol befol'e coming into this particular
program. The aspects of this program which I will describe is based
on the known pathophysiology of soft tissue injury and the natural
course of its repair. Strong connectlve tissue has a very limited
blood supply and few cells therefore the repair of these tissues
is quite slow compared to other more vascular tissues in the body.
Nutrition to many of these structures are obtained by means of
extravascular diffusion which is enhanced by motion and is delayed
by inactivity. Extensive research on animal models has shown that
activity speeds a slow repalr process and organizes the soft
tissue. Spontaneous repair with inactivity tends to allow for
random collagen allgnment and the potential for segmental
shortening as a result of collagenous cross linking. Guided
acti v ity such as lie prnv ide in our stretching and strengthening
programs has been demonstrated to align the collagen and enhance
tissue compliance thus avoiding the contractures due to cross
linking and random flber orientation.
Page 4
Barbara Vagnerini
We addr.ess all the above issues through the various aspects
of our program. In physical therapy we work with stretching and
strengthening exercises particularly with great attention to
dynamic body posture. ^chieving proper bio-mechanical body posture
is imperative in order to decrease abnormal stress forces on the
involved tissues. In occupatlonal therapy again we work with
endurance, s trengthenlng and range of motion exercises particularly
geared toward repetitive use of the upper extremities using well
designed upper extremity exer.cise activity and the BTE work
simulator. At the same time we use the Valpar task tolerance
program to begin job simulation activities. Therapeutic recreation
is specifically directed toward improving general aerobic fitness
which consists of twice daily walking program and an aquatics
program. We make extensive use of dynamic EMG bio-feedback. We
certainly work with stress management and relaxation techniques but
we have found it very Ilse ful to be able to use the dynamic EMG
feedback to quanti tate abnormal muscular contraction. In people
with acute or chronic pain we find characteristic patterns of
increased static and dynamic ':ension as well as abnormal co-
contraction patterns. In Ms. Vagnerini's case there was a 20' and
greater imbalance in the left sternocleidomastoid, left scalene,
right pectoralis, left upper trapezius, left low back and the left
lumbar musculature. This particular pattern was consistent with
that reported in the literature indicating a soft tissue injury
consistent with Ms. Vagnerini's particular injury in the automobile
accident. With this information we are able to quantitatively
define the abnormal cont.ractiol\ patterns and correct them. We find
that if it is not corrected adequately even what we once thought
to be good exercises are generally done with muscles that have
adopted a poor contraction pattern and therefore do not seem to
work. We have had good success through the EMG bio-feedback to
correct these abnormal contraction patterns and bring about much
more ordered movement that is therapeutically beneficial.
We do psychological assessments and management as it is well
documented that after six months of cervlcal spine injury that the
symptom complex includes anxiety, irritability and depression which
is directly related to that injury. These problems can be a
stressor in and of themselves and tend to impair the development
of good psychological and emotional pain coping skills and stress
management. There is a wealth of clinical knowledge and literature
that well documents that treatment of chronic pain without
psychological intervention is generally doomed to failure. We also
perform vocational counseling to the extent that our counselor did
attend Ms. Vagnerini's job site for specific recommendations about
how she can return to her previous employment as a dental
technician who needs to do chair side assisting for the dentist.
Page 5
Barbara Vagnerini
This postur~lly ia a very difficult position and with that
information gathered she was able to work in occupational and
physical therapy with certain movements and postural techniques in
order for her to be able to return to that position which in fact
she has been able to through our treatment program.
In summary I think the opinion that she had reached medical
benefits by May 23, 1991 has absolutely no basis in fact. I do not
believe anybody with strong cllnical experience in cervical soft
tissue pain and with a basic knowledge of the literature regarding
cervical trauma could make this assumption. I could word that a
little bit more differently for the reviewer in that it appeared
that she had derived no benefit to that point from the medical
treatment that she was receiving. What this would mean to me is
that we need to re-look at how she is being treated and come up
with a more logical treatment protocol in order to develop a good
result. If that date however is just based on an arbitrary six
month cut off that certainly is not supported by any of the mo~ical
literaturo nor cl1nical experience. Likewise to say that the
treatment that was performed in the program had no connection to
her motor vehlcle accident is without any medical basis and in my
opinion solely reflects a lack of knowledge of chronic pain
treatment and more disturbingly a desire to find any excuse, no
matter how trivial and medically undefensible, to deny payment for
appropriate and necessary medical care. I also think one may wish
to look at the outcome of this medical care which has been
successful.
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Ja~es W. Willl~ms, M.D.
Physical Medicine & Rehabilitation
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CERTIFICATE OF SERVICE
I, Richard Oare, Esquire, hereby certify that I have this
11-th day of October, 1995, Bent a true and correct copy of the
foregoing documents: PRAEC1.PE TO SETTLE, DISCONTINUE AND END to
the following individual, via United States Mail, postage paid,
addressed as follows:
Rolf E. Kroll, Esq.
Reynolds & Havas
101 Pine Street
P.O. BOX 932
Harrisburg, PA. 17108-0932
Richard 0 re, Esquire
Attorney ID: 18631
1776 South Queen Street
York, PA 17403
(717) 846-3000
Attorney for Plaintiff