Evans v. State Farm Insurance

39 Pa. D. & C.4th 193, 1997 Pa. Dist. & Cnty. Dec. LEXIS 7
CourtPennsylvania Court of Common Pleas, Elk County
DecidedOctober 3, 1997
Docketno. 95-100
StatusPublished
Cited by1 cases

This text of 39 Pa. D. & C.4th 193 (Evans v. State Farm Insurance) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Elk County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Evans v. State Farm Insurance, 39 Pa. D. & C.4th 193, 1997 Pa. Dist. & Cnty. Dec. LEXIS 7 (Pa. Super. Ct. 1997).

Opinion

ROOF, P.J.,

Presently before the court for disposition are defendant’s preliminary objections to plaintiffs’ complaint.

[195]*195STATEMENT OF FACTS/ PROCEDURAL HISTORY

Plaintiff Maureen Evans received medical treatment after she was injured in an automobile accident on February 6, 1993. Payment for her medical care was to be provided by defendant pursuant to the first party benefit coverage in plaintiffs’ insurance policy. At some point during Mrs. Evans’ treatment, defendant requested a peer review and received a determination from the peer review organization that any medical care rendered to Mrs. Evans after January 1, 1994, was unnecessary. According to said peer review, Mrs. Evans had regained her pre-injury condition by that date.

On February 2,1995, plaintiffs commenced this action against defendant requesting that the court direct defendant to pay all fees for medical treatment, services and merchandise on or after January 1, 1994, to the present as the same were reasonable and necessary and, further, to direct defendant to pay punitive damages and attorneys’ fees, interests and costs presumably pursuant to 42 Pa.C.S. §8371 which provides for special damages when an insurer acts in bad faith.

Defendant filed preliminary objections in the nature of a demurrer asking that the court dismiss that portion of plaintiffs’ complaint alleging bad faith or punitive damages, as the Motor Vehicle Financial Responsibility Law, 75 Pa.C.S. §1701 et seq. is the exclusive remedy for an insured. Final ruling on said preliminary objections was stayed by order of court dated April 17, 1995, pending decision by the Supreme Court in Barnum v. State Farm Mutual Automobile Insurance Company, 430 Pa. Super. 488, 635 A.2d 155 (1993), which decision would have a direct impact on this court’s ruling in the above-captioned case.

[196]*196The defendant filed a petition to lift the stay on August 14, 1997, as the Supreme Court had issued a ruling in Barnum. Argument on defendant’s petition was held September 22, 1997, at which time the parties also argued the merits of the defendant’s preliminary objections. At time of argument, defendant also raised, and the parties argued, the issue of standing with regard to plaintiffs’ ability to bring this action as an insured. Defendant’s petition was granted and the stay lifted on September 23, 1997, and for the following reasons, the defendant’s preliminary objections are granted.

DISCUSSION

We find not only that the MVFRL is the exclusive remedy for first party medical claims and that section 8371 is inapplicable to the instant matter but also that the plaintiffs lack standing to bring an action against the defendant.

Section 1797(b) of the MVFRL allows insurers to • utilize PROs to determine if medical treatment provided to a person injured in a car accident is reasonable and necessary. Subsection (b) further provides for the following:

“(2) PRO reconsideration. — An insurer, provider or insured may request reconsideration by the PRO of the PRO’S initial determination. Such a request for reconsideration must be made within 30 days of the PRO’S initial determination. . . .
“(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. The insured may not be billed for any treatment, accommodations, products or services during the peer review process.
[197]*197“(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 payment of treble damages to the injured party.
“(5) PRO determination in favor of provider or insured. — If a PRO determines that medical treatment or rehabilitative services or merchandise were medically necessary, the insurer must pay to the provider the outstanding amount plus interest at 12 percent per year on any amount withheld by the insurer pending PRO review.
“(6) Court determination in favor of provider or insured. — If, pursuant to paragraph (4), a court determines that medical treatment or rehabilitative services or merchandise were medically necessary, the insurer. must pay to the provider the outstanding amount plus interest at 12 percent, as well as the costs of the challenge and all attorney fees. . . .” (emphasis added)

Under subsection (b)(4), an insured can only bring a court action requesting payment of first party medical benefits when the insurer has not challenged the reasonableness or necessity of treatment before a PRO. Instantly, the defendant (insurer) did challenge Mrs. Evans’ (insured) medical treatments before a PRO, which determined that any treatments after January 1, 1994, were not reasonable or necessary. Therefore, it appears that under the terms of the MVFRL, plaintiffs [198]*198lack standing to challenge defendant’s failure to pay for medical services provided after January 1, 1994.

Further, we also adopt the reasoning set forth in Kuropatwa v. State Farm Mutual Automobile Insurance Co., 29 D.&C.4th 494, 497-500 (1994), affirmed, 454 Pa. Super. 714, 685 A.2d 1050 (1996), where the court stated the following:

“[A] person who is not adversely affected in any way by the matter he seeks to challenge is not ‘ aggrieved’ thereby and has no standing to obtain a judicial resolution of his challenge. . . .
“The requirements of the formulation of the standing test are that an interest be ‘substantial,’ ‘direct,’ ‘immediate’ and ‘not a remote consequence of the judgment.’ An evaluation of the presence of these elements will determine whether the interest asserted renders a litigant ‘aggrieved.’. . .
“In the present case, [plaintiff] has alleged no facts which demonstrate that she has or will have a direct, immediate, and substantial interest in [defendant’s] denial of payment of her health care provider’s bills. . . . According to the amended complaint, the only parties aggrieved by the nonpayment of the medical bills are the two .named providers ....
“Plaintiff also has no standing to challenge decisions made pursuant to Act VI of the . . . (MVFRL) . . . The current statute completely removes the insured from the billing process. Specifically, section 1797(a) of the Act states:
“ ‘Providers subject to this section may not bill the insured directly but must bill the insurer for a determination of the amount payable. The provider shall [199]*199not bill or otherwise attempt to collect from the insured the difference between the provider’s full charge and the amount paid by the insurer.’

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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)
39 Pa. D. & C.4th 193, 1997 Pa. Dist. & Cnty. Dec. LEXIS 7, Counsel Stack Legal Research, https://law.counselstack.com/opinion/evans-v-state-farm-insurance-pactcomplelk-1997.