Milton S. Hershey Medical Center v. State Farm Insurance

21 Pa. D. & C.4th 62, 1992 Pa. Dist. & Cnty. Dec. LEXIS 4
CourtPennsylvania Court of Common Pleas, Franklin County
DecidedDecember 8, 1992
Docketno. 1992-298
StatusPublished
Cited by1 cases

This text of 21 Pa. D. & C.4th 62 (Milton S. Hershey Medical Center 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
Milton S. Hershey Medical Center v. State Farm Insurance, 21 Pa. D. & C.4th 62, 1992 Pa. Dist. & Cnty. Dec. LEXIS 4 (Pa. Super. Ct. 1992).

Opinion

WALKER, J.,

FINDINGS OF FACT

Plaintiff, Linda S. Hershey, was injured in an automobile accident on November 8, 1990. Plaintiffs, Dr. F. Todd Wetzel and The Milton S. Hershey Medical [63]*63Center treated and provided services to Ms. Hershey. Dr. Wetzel and Hershey Medical Center submitted bills to Ms. Hershey’s insurance carrier, defendant State Farm Insurance Company.

Pursuant to 75 Pa.C.S. §1797, defendant State Farm submitted the bills to a peer review organization to determine the necessity of treatment provided to Ms. Hershey. State Farm refused to pay certain medical expenses, asserting that the PRO deemed them unnecessary. In addition, State Farm refused to pay Ms. Hershey’s wage loss benefits, which are presently accruing.

Plaintiffs requested a peer review reconsideration in accordance with 75 Pa.C.S. § 1797(b)(2). Based upon the PRO’S reconsideration report, State Farm again refused to pay the medical bills.

Plaintiffs filed this suit to recover the cost of medical treatment and services, as well as wage loss benefits, that the defendant refused to pay. This opinion addresses the following preliminary objections raised by the defendant:

(A) The court lacks subject matter jurisdication.

(B) The complaint lacks conformity to rule of law.

(C) The insured lacks standing.

(D) Punitive damages under 42 Pa.C.S. §8371 are not available in the instant case.

DISCUSSION

The court will address each preliminary objection individually.

A. Subject Matter Jurisdiction

Defendant asserts this court lacks subject matter jurisdiction because the defendant complied with the requirements of 75 Pa.C.S. §1797. Section 1797 provides [64]*64specific procedures to follow in reviewing the necessity of an insured’s medical expenses. Defendant argues that compliance with these procedures renders a decision to deny payment of medical expenses final and unappealable. This court does not agree.

Section 1797 sets forth the following procedures for determining the necessity of medical care provided to an injured person:

“(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 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 the 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.” 75 Pa.C.S. § 1797(b)(1), (2).

Under the amended legislation, it is clear that an insured or a health care provider may appeal to the court an insurer’s denial of medical benefits if the bills [65]*65were not submitted to a PRO. 75 Pa.C.S. § 1797(b)(4). What is not clear, however, is whether an appeal to the court can be taken when the insurer denies medical benefits based upon a PRO’S determination that they were medically unnecessary.

In the instant case, defendant refused to pay the medical bills because a PRO, initially and upon reconsideration, deemed certain treatment provided to be medically unnecessary. This court finds that the legislature did not intend for a PRO’S determination to substitute for the judgment of the trial court.

If the court accepted defendant’s interpretation, questions regarding the constitutionality of the legislation would also be raised. In Lehman v. State Farm Insurance Co., 140 P.LJ. 78, 82 (1992), the court addressed this issue and concluded

“that the legislature did not intend for the court to treat a PRO determination in the same fashion as a common law or statutory arbitration award or as an adjudication of an independent agency.”

The Lehman court reasoned that the “PRO is not a neutral body.” Id. The insurance company chooses one of the PROs to review a claim and initially pays them. The financial relationship between the insurance company and the PRO creates a strong incentive for the PRO to ignore the concerns of the insured party. Moreover, there is no requirement that the health care provider or the insured be given notice of the PRO determination or the opportunity to submit evidence to the PRO. See Id.

This court views the PROs as merely hired guns for the insurance companies. The medical professionals comprising the PROs submit their opinions as to the necessity of the treatment provided without examining the insured party or hearing evidence submitted by the [66]*66health care providers or the insured. The court agrees with the rationale in Lehman. The legislature could not have intended for the PRO’S determination of the medical necessity of treatment to displace the right to proceed in a court of law. Accordingly, the court denies defendant’s preliminary objection asserting lack of subject matter jurisdiction.

B. Motion To Strike Complaint for Lack of Conformity to Law

Defendant asserts that plaintiffs’ cause of action is not contemplated by 75 Pa.C.S. §1797 and should be stricken for its lack of conformity to law. See Pa.R.C.P § 1028(a)(2). For the reasons set forth regarding subject matter jurisdiction, this court finds that plaintiffs’ cause of action is contemplated by 75 Pa.C.S. §1797 and denies the preliminary objection.

C. Insured’s Standing

Defendant asserts that plaintiff Linda Hershey, the insured, lacks standing to sue her insurance company for refusal to pay the health care providers for services rendered. The amended legislation states that health care providers

“May not bill the insured directly but must bill the insurer for a determination of the amount payable. The provider shall not bill or otherwise attempt to collect from the insured the difference between the provider’s full charge and the amount paid by the insurer.” 75 Pa.C.S. § 1797(a).

Defendants argue that because Linda Hershey has no liability or financial responsibility to pay the medical expenses in question, she has no standing to seek payment from her insurance company. This court disagrees.

[67]*67The “law of standing is generally articulated in terms of whether a would-be litigant has a ‘substantial interest’ in the controverted matter, and whether he has been ‘aggrieved’ or ‘adversely affected’ by the action in question.” Commonwealth Game Commission v. Department of Environmental Resources, 521 Pa.

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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)
21 Pa. D. & C.4th 62, 1992 Pa. Dist. & Cnty. Dec. LEXIS 4, Counsel Stack Legal Research, https://law.counselstack.com/opinion/milton-s-hershey-medical-center-v-state-farm-insurance-pactcomplfrankl-1992.