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Home My WebLink About95-04316 Ii" c'{"" ';'.' 0; , ~I'<l" 1;;(1" ~'n!1 J\~" I ;'.~.' ,I L'ql !'.li~;J I';I,!, 1'/1' fi.,'." hl!I,; . .,f ;t.''!l- i""il ihi "-J !.;; g, , . ... U . ~ ~ " {5 " ,', r:f i' " 1" .' , I:, ~ ,j'. ,I, ',:,' ;;\:'1J1 Ir:_"(1.' \'\Ii I ' ':0;.','.,11 ,-, -': !,-". 'J", f.. , ' " q < , " , , " I I I " " " " , , , " ' 4. The policy of Insurance Issued by the Defendant WlIS Intended to meet the requirements of the pennsylv.mla Motor Vehicle Fln.melal Responsibility law, 75 P.S, 91701 et. seq., .IS amended, .md 10 provide flrstl).lrty benefits to Kim Gardner and her family In accordance with the law. 5. The benefits provided Included coverage for medical and chiropractic services rendered to Kim Gardner In the event that she was Injured as the result of a motor vehicle accident. 6. On July 3, 1992, Kim Gardner suffered personal Injuries as the result of a motor vehicle accident. 7. Kim Gardner sought and received care from the Plaintiff Advanced Chiropractic, Inc., which consisted of chiropractic treatments, manipulations and other modalities to aid in her recovery from the personal injuries that were suffered as a result of the motor vehicle accident. 6. Advanced Chiropractic, Ine. routinely billed the Defendant for the services performed and in accordance with the Motor Vehicle Financial Responsibility law. 2 9. The Defelldallt .llIegedly fhld .1 "peN n'vll!W" .lCcompllslwd .111[1 UpOIl the basis of the pel!r wvlew rpfuspd to fJ.\Y for .1IlY chlropr.lCtil: IW.IIIlll'llts for Kim (i.mlller after February 12, 199], The "peer rl!Vll!W" rpport W.I$ tr,lIlslllllh'd to Advilnced Chlroprilctlc, Ine. by letter dated June 4, 199:1. The peer review was not done by a competent .md qualified chlropr.lCtor .IS Is required by the motor vehicle flll.mclal responsibility 1.1W .md the appllc,lble regulations, 10, As Indicated by the peer review report dolled M.1Y 13, 1993 and the transmittal letter of June 4, 1993, Defendant WilS denying pilyment for care retroactive to February 12, 1993 for Kim G.mlner. S.lld ,lCtlon by Defendant violates the Motor Vehicle Financial Responsibility L.ilW which is set forth .1t 75 PA, C.S,A, ~ 1797 (commonly known as Act 6) and the applicable regulations, 11, In addition to the above referenced violations of Act 6, the Defendant also violated Act 6 and the mgulations In several other instances, First, on or about March 23, 1993 the Defendant initiated the peer review process. Pursuant to Act 6 and the regulations for Act 6, the Defendant had 30 days to complete the peer review and an additional five days to notify Advanced Chiropractic, Ine. of their finding, 12. The Defendant did not respond within 30 days. 3 19. 'The Defend,lI1t has .ll'ted In b.1l1 f,lith ,IS Indicated by their abuses of the peer review system as outlined "bove ,lI1d below, 20, 'The Defend,ltlt has acted Improperly bec,luse It has denied the claim of Advanced Chiropractic, Inc. on the basis of opinions r(mdered by chiropractors who were not competent to review the specialized service performed by Advanced Chiropractic, Inc. 21, 'The Defendant, pursuant to Section 1797 (bl 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 peer review organization used by the Defendant was United Medical Philadelphia. Said peer review organization has only found that treatment has been appropriate In 13,9% of all Initial determinations submitted to it in 1992 and 0% of all reconsiderations submitted to it based upon statistics compiled by the Insurance Commissioner of Pennsylvania, 22, It is believed and therefor averred, and the statistics reveal, that Defendant has violated Section 1797 (b) in that the Defendant has an express and/or Implied plan to intentionally cut off benefits in violation of its responsibility under the terms and conditions of Its contract with its Insured. 5 23. It Is averred that all bills Incurred be(ore and after the peer review, are fair and reasonable .md that said treatment was medlc,llly necessary and related to the accident. 24. The (.llr and re,lsonable sum due to Advanced Chiropractic, tne. (or their care and treatment o( Kim Gardner Is $7,878,86, tOI\(!ther with Interest at Twelve percent (12%) per ye.lr, pen.llty as provided by the st,ltute and re,lsonable and actual attorney's fees. 25. The Defendant has refused to pay the balance due under the terms and conditions of the policy of Insurance and the Pennsylvania Motor Vehicle Responsibility Law. As a result of the aforesaid, Plainti(f has been required to obtain the services of an attorney to collect the medical bills due. Therefore, pursuant to Section 1716 of the Pennsylvania Motor Vehicle Financial Responsibility law, Plaintiff is entitled to attorney's fees in the event that the insurer is found to have acted in an unreasonable manner in refusing to pay the benefits when due." 26. It is (urther averred that under Section 1798 of the Pennsylvania Motor Vehicle Financial Responsibility law, in the event that an insurer is found to have acted with "no reasonable (oundation" It is also liable for attorney's fees, 6 al", rRATICILLI , ULRICH BYI FREOERICK W. ULRICH, ESQUIRE 6400 Flank Drive, suite 900 Harriabur9, PA 17112 (717) 541-8990 Attorney I.D. No. 4485~ ADVANCED CHIROPRACTIC, INC. (Gardner) , plaintiff v. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 95-4316 CIVIL TERM CIGNA PROPERTY AND CASUALTY COMPANIES, Defendant JURY TRIAL DEMANDED ANSWIR or DIFINDANT. CIONA PROPIRTY AND CASUALTY COMPANIIS. TO PLAINTIFF'S COMPLAINT WITH NIW MATTIS 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted. 6. Admitted. 7. Admitted in part and denied in part. It is admitted that Kim Gardner received chiropractic care from the plaintiff. However, it is specifically denied that the chiropractic treatments at issue herein aided in the plaintiff's recovery from her personal injuries and were reasonable and necessary. 8. Admitted. 9. Admitted in part and denied in part. It is admitted that the within Defendant had a peer review of the chiropractic treatments of the Plaintiff. It is further admitted that the peer review physician determined that the chiropractic treatments that the Plaintiff received from February of 1993 until the date of the peer review were not reasonable and necessary within the meanin9 of the Motor Vehicle Financial Responsibility Act. It is also admitted that a copy of the peer review report was forwarded to the Plaintiff. It is specifically denied, however, that the peer review was not done by a oompetent and qualified peer review physician. To the contrary, the peer review was performed by a physician qualified within the meaning of the Motor Vehicle Financial Responsibility Law and the applicable regulations. 10. Admitted in part and denied in part. It is admitted that the peer review physioian determined that the Plaintiff's chiropractic treatments from February of 1993 until the date of the peer review were not reasonable and necessary within the meaning of the Motor Vehicle Financial Responsibility Law. The remainder of this averment constitutes a statement or conclusion of law to which no response is required under the Pennsylvania RUles of Civil Procedure and is accordingly denied. 11. Denied. This averment constitutes a statement or oonclusion of law to which no responsive pleading is required under the Pennsylvania Rules of civil Procedure. 12. Denied. It is specifically denied that the Defendant clid not respond and/or cODlplete the peer review process within the time frames set forth within the Motor Vehicle Financial Responsibility Law. 13. Denied. Thie averment oonstitutes a statement or 2 conolusion of law to which no responsive pleading is required under the Pennsylvania Rules of Civil Procedure. 14. Denied. This averment cQnstitutes a statement or oonolusion of law to which no responsive pleading is required under the Pennsylvania RUles of civil Procedure. 15. Admitted. 16. Denied. It is specifically denied that the physician who performed the reconsideration was not competent or qualified. To the contrary, the physioian who performed the peer review reconsideration was conpetent and qualified within the meaning of the Motor Vehicle Financial Responsibility Law. 17. Denied. This averment constitutes a statement or oonolusion of law to which no responsive pleading is required under the Pennsylvania Rules of civil Procedure. 18. Denied. This averment constitutes a statement or oonclusion of law to which no responsive pleading is required under the Pennsylvania Rules of Civil Procedure. 19. Denied. This averment constitutes a statement or oonclusion of law to which no responsive pleading is required under the Pennsylvania Rules of civil Procedure. 20. Denied. To the contrary, the chiropractic opinions rendered by the peer review physicians were properly rendered and within the criteria Bet forth by the Motor Vehicle Financial Reeponsibility Law. 21. Denied. After reasonable investigation, the Answering Defendant is without sufficient knowledge or information to form 3 a belief as to the truth of this averment and accordingly denies the same. 22. Denied. After reasonable investigation, the Answering Defendant is without sufficient kl,owledge or information to form a belief as to the truth of this averment and accordingly denies the same. 23. Denied. Based on the peer review opinion received by the within Defendant, the chiropractic treatment given by the plaintiff was neither reasonable nor necessary within the meaning of the Motor Vehicle Financial Responsibility Law. 24. Denied. This averment constitutes a statement or conclusion of law to which no responsive pleading is required under the Pennsylvania Rules of civil Procedure. 25. Denied. This averment constitutes a statement or conclusion of law to which no responsive pleading is required under the psnnsylvania Rules of civil Procedure. 26. Denied. This averment constitutes a statement or conclusion of law to which no responsive pleading is required under the pennsylvania Rules of civil Procedure. 27. Denied. This averment constitutes a statement or conclusion of law to which no responsive pleading is required under the pennsylvania Rules of Civil Procedure. 28. Denied. This averment constitutes a statement or conclusion of law to which no responsive pleading is required under the pennsylvania Rules of Civil Procedure. 29. Denied. This averment constitutes a stat~ment or 4 oonolusion of law to which no responsive pleading is required under the Pennsylvania Rules of Civil Prooedure. WHEREFORE, for all of the foregoing reasons, the Defendant, cigr.a Prop~rty and Casualty companies, respectfully request Your Honorable Court to enter judgment in its favor and against the Plaintiff, together with suoh other relief as deemed just and appropriate. HI. MATTIR PURSUANT TO P..R.C.P. RUtl 1030. 42 P..C.B.A. 30. The Plaintiff's cause of action is barred or limited by the provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law as set forth in 75 Pa.C.S.A. 51701, ~. ~. 31. The claims of the plaintiff for recovery of medical expenses are limited and/or barred by the Pennsylvania Motor Vehicle Financial Responsibility Law as set forth in 75 Pa.C.S.A. 51701 ~. ~. 32. The medical bills and expenses claimed by the Plaintiff are not covered as benefits under the terms and conditions of the polioy of insurance held with the Defendant and the Pennsylvania Motor Vehicle Financial Responsibility Law. 33. The Defendant has paid all of the medical bills and expenses for which the appropriate and substantiating information has been received and which are payable pursuant to the terms and conditions of the policy of insurance held by the Plaintiff with the Defendant and pursuant to the provisions of the Motor Vehiole Finanoial Responsibility Law. 5 ,i;,' " . , , ! !I"".ONwwl ' .T'/GlIIII'~'UW ,.lGOUIYlINIY .M.D". 1~J1n II M~"''''- ---~I ~I"_'" " , , ! , IIi' '! , .- ADVANCED CHIROPRACTIC, INC. (Gardner) Phlintiff IN TilE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 95-4316 CIGNA PROPERTY AND CASUALTY COMPANY, CIVIL ACTION. LAW Defendllnt . JURY TRIAL DEMANDED CERTIFICATE m- SERVICE I hereby certify that I have this day served the original and two copies of' Plaintiffs Interrogatories addressed to Defendant. First Set and the originlll of Plaintiffs Request for Production of Documents Addressed to Defendant - First Set by first class mail, postage prepaid, addressed to the following person: Frederick W. Ulrich, Esq. Law Offices of Roger T. Margolis Suite 900 6400 Flank Drive Harrisburg, P A 17112 ADLER & CLARA V AL Date: 10/18/:15' By Uor\\~ ~ ~\ \^1~~~j\J\~ DENISE I. WILLIAMS, Secretary For Robert F. Clarllvlll I'; I " 'r"> ;~.. ~. c.:n - ~.~, I:" ~':: '" , ", "- '~.' ..' '::' l/'> 1./..' ,\ ',~"') \..'., , j'-' ," I"~ ()., , , .' I'" ,.,"1 "I r ," , III .. ....., ,'J J, n. , ~ ,.,\ .~!'..:. " oJ I ,-. 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