Erie Insurance Exchange v. Dzadony

39 Pa. D. & C.3d 33, 1986 Pa. Dist. & Cnty. Dec. LEXIS 362
Pennsylvania Court of Common Pleas, Alleghany County·Decided March 21, 1986·No. no. G.D. 86-266·Published·Cited by 9 cases

Opinion

WETTICK, A.J.,

Joseph S. Dzadony and Iris Dzadony have filed claims with their insurance carrier for payment of medical bills covering treatment for injuries allegedly sustained in an automobile accident. Erie Insurance Exchange (which insured Mr. and Mrs. Dzadony) filed a petition to compel a physical examination by a physician selected by Erie.

Section 1796(a) of the Motor Vehicle Financial Responsibility Law, 75 Pa.C.S. § 1796(a), permits a court to order a person to submit to a physical examination by a physician for good cause shown. A petition for a physical examination may be filed pursuant to section 1796(a) even though no legal proceedings have been instituted. It is the submission of a claim to the insurance carrier and not the institution of legal proceedings which triggers the insurance company’s right to petition the court for an order requiring the insured to submit to a physical examination. State Farm Mutual Automobile Insurance Company v. Morris, 289 Pa. Super. 137, 432 A.2d 1089 (1981).

In the case of Nationwide Mutual Insurance Company v. Fandry, 12 D.&C. 3d 65 (1979), this court concluded that the purpose of the “good cause shown” requirement (which was also contained in the Pennsylvania No-fault Motor Vehicle Act, 40 P.S. §1009.401) was to protect persons against unreasonable invasion of privacy, unnecessary inconvenience and examinations sought in bad faith. Thus, this court held that the “good cause shown” [35] requirement requires the insurance company to show that the information supplied by the insured in support of his or her claim does not eliminate reasonable doubt as to the validity of the claim, that the proposed medical examination may assist the insurance company in evaluating the claim, and the amount of the claim justifies a court order compelling claimant to submit to a physical examination. To satisfy this “good cause shown” requirement, this court generally requires the insurance company to show that it has given the insured the opportunity to provide more complete and updated information from the insured’s treating physician and that either additional information was not provided or that the additional information which was provided did not eliminate reasonable doubt as to the validity of the claim. Also, .unless it is clear that the information of the treating physician is insufficient to support the claim for payment of medical and other rehabilitative treatment which the insured received, the insurance company shall submit an affidavit from the physician whom the insurance company wishes to perform the examination stating that he or she has reviewed the information submitted in support of the claim and explaining why this information is insufficient and why the examination is necessary.

In the present case, Erie’s petition contains no allegations that the information supplied by the insureds in support of their claims is inadequate. Consequently, this court will not compel the insureds to submit to a medical examination pursuant to section 1796(a) of the Motor Vehicle Financial Responsibility Law.

Erie contends that this court should grant its petition because the Dzadonys agreed to submit to examinations under their insurance policy with Erie. [36] In support thereof, Erie cites condition C on page four of its insurance policy with the Dzadony’s which reads as follows:

“C. Medical Reports; Proof of Claim

“The person we protect shall submit to mental and physical examinations by physicians selected by us when and as often as we may reasonably require. We will pay the cost of such examinations.”

For several reasons, we reject Erie’s contention. First, the policy provision upon which Erie relies should not be enforced because it is inconsistent with the obligations imposed upon an insurance company to pay benefits under the Motor Vehicle Financial Responsibility Law. The Motor Vehicle Financial Responsibility Law is comprehensive legislation governing the rights and obligations of the insurance company and the insured under liability insurance policies covering motor vehicles. This legislation specifies the benefits that must be provided and the benefits that must be made available (75 Pa.C.S. §§1711, 1712, 1715, 1731); it requires various exclusions (§1718); and it provides for payment of benefits within 30 days after the insurance company receives reasonable proof of the amount of the benefits (§1716). Provisions within an insurance contract which impose additional burdens on an insured before the insured may recover these benefits to which the insured is statutorily entitled, are inconsistent with this legislative scheme. Thus, we will not enforce a provision within an insurance policy that would make payment of benefits dependent upon the insured appearing for a physical examination that the law does not require.

If the Motor Vehicle Financial Responsibility Law had not dealt with the issue of when an insured may [37] be compelled to submit to a physical examination, this matter could perhaps be governed by the insurance contract. But through section 1796(a), the Legislature has balanced the interests of the insurance company in obtaining more complete information in support of a claim through a physical examination . by a physician selected by the insurance company and the interests of the insured in having claims paid without being subjected to the inconvenience and invasion of privacy that such an examination imposes, by providing for an examination pursuant to a court order obtained by the insurance company based upon good cause shown. The necessity for protecting this legislative balance was recognized in State Farm Mutual Insurance Company v. Morris, süpra:

“However, the No-fault Motor Vehicle Insurance Act contains no requirement that the insurer pay the fees of an attorney who accompanies his or her client to the examination. Indeed, despite the broad discretion vested by statute in a court of common pleas, it is difficult to conceive of circumstances which would warrant a court in requiring an insurer to pay counsel fees as a condition precedent to a physical examination of an insured. Upon good cause shown, an insurer is entitled to an order directing a claimant to appear for a physical examination. That right should not be impaired by the imposition of unnecessary and unreasonable conditions calculated to discourage insurers from using a procedure intended to aid in the prompt and fair compensation of accident victims in Pennsylvania.” 432 A.2d at 1092.

Thus, we conclude the clause which Erie seeks to enforce is inconsistent with Erie’s obligation to pay [38] benefits whenever the insured submits reasonable proof supporting his or her claim.

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Erie Insurance Exchange v. Dzadony, 39 Pa. D. & C.3d 33, 1986 Pa. Dist. & Cnty. Dec. LEXIS 362 (Pa. Super. Ct. 1986).

39 Pa. D. & C.3d 33 (Erie Insurance Exchange v. Dzadony) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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