Conway-West v. State Farm Insurance

19 Pa. D. & C.4th 84, 1993 Pa. Dist. & Cnty. Dec. LEXIS 145
CourtPennsylvania Court of Common Pleas, Monroe County
DecidedJuly 2, 1993
Docketno. 914 Civil 1993
StatusPublished
Cited by1 cases

This text of 19 Pa. D. & C.4th 84 (Conway-West v. State Farm Insurance) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Monroe County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Conway-West v. State Farm Insurance, 19 Pa. D. & C.4th 84, 1993 Pa. Dist. & Cnty. Dec. LEXIS 145 (Pa. Super. Ct. 1993).

Opinion

MILLER, J.,

On May 6, 1991, plaintiff was injured in an automobile accident. At the time of the accident, plaintiff held an automobile insurance policy issued by defendant. Under the terms of the policy, defendant was obligated to provide first-party medical benefits in accordance with the provisions of the Motor Vehicle Financial Responsibility Law, 75 Pa.C.S. §§1701-1799. Plaintiff alleges she received and will continue to receive medical treatment for injuries caused by the accident.

Plaintiff submitted medical reports and bills to defendant and requested payment. In February 1992, defendant contracted with a peer review organization (PRO) in accordance with section 1797 of the MVFRL for the purpose of confirming that the medical treatment conforms to the professional standards of performance and is medically necessary. The PRO, after an initial review and a reconsideration requested by plaintiff, found certain charges non-recoverable under the parameters established by the MVFRL. Based on this finding, defendant denied payment for medical treatment.

[85]*85Plaintiff initiated this action on March 31,1993, bringing, in Count I, a breach of contract claim under the MVFRL and, in Count II, a bad-faith claim under 42 Pa.C.S. §8371. Defendant filed preliminary objections to the complaint on the following grounds: (1) insufficient specificity based on plaintiff’s failure to attach a copy of the insurance policy, (2) insufficient specificity based on plaintiff’s failure to allege the amount of damages sought, and (3) legal insufficiency of Count II. Both parties filed briefs in support of their respective positions and oral argument was heard on June 7,1993. Defendant’s preliminary objections are now before this court for disposition.

I. Request to Strike Complaint Based on Failure to Attach a Copy of the Insurance Policy

Defendant filed a preliminary objection on the grounds of insufficient specificity in the pleading, requesting that we strike the complaint and require plaintiff to attach a copy of her insurance policy to the complaint or set forth the substance of the material portions of the policy. As defendant issued the insurance policy requested, we find this objection to be meritless and therefore dismiss this objection.

II. Request to Strike Complaint Based on Failure to Allege Amount of Damages

Defendant’s second preliminary objection alleges insufficient specificity in the pleading, requesting that we strike the complaint and require plaintiff to plead more specifically the damages she is seeking to recover. Plaintiff seeks recovery of first-party medical benefits allegedly denied by her insurer. Pa.R.C.P. 1019(f) requires that special damages must be specifically stated in a pleading.

[86]*86Accordingly, we sustain the objection and plaintiff is directed to plead specifically the amount of unpaid medical bills, the providers involved, and other damages sought so that the defendant may prepare an appropriate answer and the court may be adequately informed in any further proceedings.

III. Demurrer to Count II

In Count II, plaintiff brings a bad-faith claim under 42Pa.C.S. §8371. Defendant filed a preliminary objection on the grounds of legal insufficiency and requests that we dismiss Count II.

In ruling upon a preliminary objection of this nature, we must examine the entire complaint with an eye toward determining its legal sufficiency. County of Allegheny v. Commonwealth, 507 Pa. 360, 490 A.2d 402 (1985). The issue to be resolved is whether, upon the facts averred, the complaint shows with certainty that plaintiff is not entitled to the legal relief sought. Sutton v. Miller, 405 Pa. Super. 213, 592 A.2d 83 (1991). In examining the complaint, the court shall accept as true all well pled, relevant and material facts set forth therein as well as all inferences fairly deducible from those facts. Composition Roofers Local 30/30B v. Katz, 398 Pa. Super. 564, 581 A.2d 607 (1990). Further, if there is any doubt as to whether or not plaintiff has sufficiently pled a cause of action, this doubt must be resolved in plaintiff’s favor, and the preliminary objection must be dismissed. McGregor v. Mediq Inc., 395 Pa. Super. 221, 576 A.2d 1123 (1990).

Defendant contends that the provisions of MVFRL provide the exclusive remedy for individuals seeking to recover first-party medical benefits under an automobile insurance policy. Plaintiff contends that a bad-faith action [87]*87for punitive damages under section 8371 may be maintained and is consistent with the MVFRL regarding payment of first-party medical benefits. After a survey of the relevant case law and noting the absence of Commonwealth appellate authority on point, we conclude that under the facts as pled in this case, the detailed provisions of the MVFRL provide the exclusive remedy for the plaintiff’s claim for first-party medical benefits. We note, however, that there may be circumstances where a bad-faith action under section 8371 may be maintained consistent with the MVFRL.

An initial review of the case law reveals a split in authority as to the availability of a bad-faith claim for denial of first-party benefits under an automobile insurance policy. However, this split is difficult to define and sometimes mischaracterized. The developing case law addresses conflicts between varied combinations of effective statutes under various factual situations as well as other collateral issues. Thus, any inquiry must be fact-sensitive.

In regard to an insurer’s questioning of the reasonableness and necessity of treatment, the MVFRL, section 1797(b), provides as follows:

“(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.

“(2) PRO reconsideration — An insurer, provider or insured may request a reconsideration by the PRO of [88]*88the PRO’S initial determination. Such a request for reconsideration must be made within 30 days of the PRO’S initial determination. If reconsideration is requested for the services of a physician or other licensed health care professional, then the reviewing individual must be, or the reviewing panel must include, an individual in the same specialty as the individual subject to review.

“(3) Pending determinations by PRO — If the insurer challenges within 30 days of receipt of a bill for medical treatment or rehabilitative services, the insurer need not pay the provider subject to the challenge until a determination has been made by the PRO.

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Related

Perkins v. State Farm Insurance
589 F. Supp. 2d 559 (M.D. Pennsylvania, 2008)

Cite This Page — Counsel Stack

Bluebook (online)
19 Pa. D. & C.4th 84, 1993 Pa. Dist. & Cnty. Dec. LEXIS 145, Counsel Stack Legal Research, https://law.counselstack.com/opinion/conway-west-v-state-farm-insurance-pactcomplmonroe-1993.