Bacstrom v. State Farm Insurance

40 Pa. D. & C.4th 330, 1998 Pa. Dist. & Cnty. Dec. LEXIS 52
CourtPennsylvania Court of Common Pleas, Franklin County
DecidedJanuary 26, 1998
Docketno. A.D. 1997-219
StatusPublished
Cited by2 cases

This text of 40 Pa. D. & C.4th 330 (Bacstrom v. State Farm Insurance) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Franklin County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bacstrom v. State Farm Insurance, 40 Pa. D. & C.4th 330, 1998 Pa. Dist. & Cnty. Dec. LEXIS 52 (Pa. Super. Ct. 1998).

Opinion

HERMAN, J.,

This case is before the court on preliminary objections of defendants State Farm Insurance Companies and State Farm Mutual Automobile Insurance Company to the complaint of plaintiffs Shirley M. Bacstrom and Douglas J. Bacstrom.

A. FACTUAL BACKGROUND

On May 18, 1993, plaintiff Shirley Bacstrom was injured when an automobile driven by Kathleen Ham-man struck Mrs. Bacstrom’s vehicle from behind. At the time of the accident, Mrs. Bacstrom was covered by an automobile insurance policy issued by State Farm which provided for $10,000 in first-party medical benefits. As a result of her injuries, Mrs. Bacstrom sought treatment from several physicians, and the bills for the services rendered by these providers were submitted to State Farm for payment. Sometime in early 1995, State Farm contracted with Laurel Rehabilitation Services, a peer review organization located in Blackwood, NJ, to review Mrs. Bacstrom’s medical records and to offer an opinion as to whether the treatments received by Mrs. Bacstrom were medically reasonable and necessary. Four doctors associated with Laurel submitted reports stating that at least some of the treatments received by Mrs. Bacstrom were not medically reasonable and necessary. Based on these reports, State Farm decided to discontinue payments for medical treatment to Mrs. Bacstrom.

[332]*332Following State Farm’s decision to deny coverage, the plaintiffs sued to compel State Farm to continue to pay for Mrs. Bacstrom’s ongoing medical care. In their two-count complaint, the Bacstroms set forth a claim for breach of contract and a second claim for bad faith under 42 Pa.C.S. §8371. They claim State Farm reneged on its contractual obligation, under the policy of automobile insurance issued by the company, to pay for medical treatment in connection with the May 1993 car accident. Additionally, they assert that State Farm acted in bad faith when it submitted Mrs. Bacstrom’s medical records to Laurel for a reassessment of the medical necessity of the treatments being rendered to Mrs. Bacstrom. The complaint alleges that Laurel is a “sham” PRO and a “captive reviewer” providing findings favorable to State Farm in order to secure a steady stream of business. (Complaint, ¶¶34 and 36.) The Bacstroms seek to recover the amount of the medical benefits they have not received from State Farm and additional awards of interest, court costs, attorney fees, treble damages pursuant to 75 Pa.C.S. § 1797(b)(4) and punitive damages under 42 Pa.C.S. §8371.

State Farm filed preliminary objections in the nature of a demurrer to the bad faith claim under section 8371. The insurer claims that under the circumstances of this case, the Bacstroms have failed to state a claim upon which relief can be granted. In the alternative, State Farm asks this court to strike Count II, the bad faith count, from the complaint for failure to conform to law. Briefs were submitted by both sides, oral argument was held on January 8, 1998, and the matter is now ripe for disposition.

B. DISCUSSION

The issue to be decided by this court has produced a deep division among courts throughout this Com[333]*333monwealth. We are asked to determine whether an insured who has been denied first-party medical benefits under an automobile insurance policy following peer review can seek punitive damages against her insurer under both the Motor Vehicle Financial Responsibility Law and the bad faith provisions of the Judicial Code. State Farm, in its brief, presents the question thus: “Do the specific procedures and remedies set forth in the Pennsylvania Motor Vehicle Financial Responsibility Law preclude a claim for damages under 42 Pa.C.S. §8371 in the context of an action for first-party medical benefits?” For the reasons set forth below, we answer State Farm’s query in the negative and overrule its preliminary objections.

Initially, we note that the test for preliminary objections which would result in the dismissal of a claim is whether it is clear and free from doubt from all the facts pleaded that the pleader will be unable to prove facts legally sufficient to establish his right to relief. Bower v. Bower, 531 Pa. 54, 611 A.2d 181 (1992). In the review of preliminary objections, facts that are well pleaded, material and relevant will be considered as true, together with such reasonable inferences as may be drawn from such facts. Mellon Bank N.A. v. Fabinyi, 437 Pa. Super. 559, 650 A.2d 895 (1994). Any doubt as to the sufficiency of the pleading must be resolved in the plaintiff’s favor. MacGregor v. Mediq Inc., 395 Pa. Super. 221, 576 A.2d 1123 (1990).

State Farm argues that the bad faith claim in the Bacstroms’ complaint should be dismissed or stricken because section 1797 of the MVFRL provides an exclusive remedy to insureds aggrieved by an insurer’s denial of payments after a PRO has determined that the treatment received by the insured is not medically reasonable or necessary. The relevant provisions of section 1797 of the MVFRL provide as follows:

[334]*334“(b) Peer review plan for challenges to reasonableness and necessity of treatment.
“(1) Peer review plan. Insurers shall contract jointly or separately with any peer review organization established for the purpose of evaluating treatment, health care services, products or accommodations provided to any injured person. Such evaluation shall be for the purpose of confirming that such treatment, products, services or accommodations conform to the professional standards of performance and are medically necessary. An insurer’s challenge must be made to a PRO within 90 days of the insurer’s receipt of the provider’s bill for treatment or services or may be made at any time for continuing treatment or services. . . .
“(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.” 75 Pa.C.S. § 1797(b).

State Farm contends that the procedures for challenging the propriety of medical bills under the above-quoted section constitute an exclusive remedy, and once the insurer has availed itself of the peer review process, the insured has no grounds on which to claim that the insurance company acted in bad faith. According to State Farm, the Bacstroms cannot assert a bad faith claim under section 8371 of the Judicial Code because the remedies provided by section 1797 of the MVFRL are the only avenue of vindication for State Farm’s failure to pay the Bacstroms’ medical bills. Section 8371 reads as follows:

[335]*335“In an action arising 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:

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Bluebook (online)
40 Pa. D. & C.4th 330, 1998 Pa. Dist. & Cnty. Dec. LEXIS 52, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bacstrom-v-state-farm-insurance-pactcomplfrankl-1998.