Parkway Ins. Co. v. NJ Neck & Back

748 A.2d 1221, 330 N.J. Super. 172
CourtNew Jersey Superior Court Appellate Division
DecidedOctober 14, 1998
StatusPublished
Cited by13 cases

This text of 748 A.2d 1221 (Parkway Ins. Co. v. NJ Neck & Back) is published on Counsel Stack Legal Research, covering New Jersey Superior Court Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Parkway Ins. Co. v. NJ Neck & Back, 748 A.2d 1221, 330 N.J. Super. 172 (N.J. Ct. App. 1998).

Opinion

748 A.2d 1221 (1998)
330 N.J. Super. 172

PARKWAY INSURANCE COMPANY, Plaintiff,
v.
NEW JERSEY NECK & BACK as Assignee of Clemente Mendoza; Clemente Mendoza, New Jersey Neck & Back as Assignee of Aida Acosta; Aida Acosta; Accident Therapy Center as Assignee of Ramon Peralta; Ramon Peralta; Accident Therapy Center as Assignee of Prisilla Illa; Prisilla Illa; Injury Treatment Center as Assignee of Claribel Azcona; Clari bel Azcona; Junction Diagnostics as Assignee of Claribel Azcona; Injury Treatment Center as Assignee of Marabel Azcona; Marabel Azcona and Junction Diagnostics as Assignee of Marabel Azcona, Defendants, and American Arbitration Association, Defendant in Interest.

Superior Court of New Jersey, Law Division, Morris County.

Decided October 1, 1998.
Revised October 14, 1998.

*1223 Robert Francis Gold, Morristown, for plaintiff (Gold & Albanese, attorneys; Mr. Gold and Daniel S. Hunczak, Belmar, on the brief).

Patrick J. Mangan, Edison, for defendant Injury Treatment Center (Howard Z. Buckner, attorney; Mr. Buckner, on the brief).

Anthony B. Vignuolo, North Brunswick, for defendant New Jersey, Neck & Back (Borrus, Goldin, Foley, Vignuolo, Hyman, Stahl and Clarkin, attorneys; Mr. Vignuolo, on the brief).

VILLANUEVA, J.A.D. (retired and temporarily assigned on recall).

Plaintiff, Parkway Insurance Company ("Parkway"), filed an Order to Show Cause and Verified Petition in the Superior Court of New Jersey seeking the following relief:

a. A declaration that the medical provider assignees had no standing to have filed for arbitration through the American Arbitration Association ("AAA"), hence precluding coverage under the Parkway insurance policy for the claims submitted by said defendants;

b. A declaration that the plaintiff is not obligated to pay any medical bills submitted by the defendants as assignees;

c. A dismissal of all arbitration hearings pending with the AAA filed by defendant assignees for personal injury protection ("PIP") benefits through Parkway.

Counsel for Injury Treatment Center ("I.T.C.") and New Jersey Neck & Back Center (improperly pled as New Jersey Neck & Back) ("NJNBC") filed opposition to the Order to Show Cause and moved to dissolve preliminary restraints which this court had issued. On the return date, the court reserved decision.

At issue is whether the prohibition against assignment of medical expense benefits contained in Parkway's automobile insurance policies is enforceable against the medical provider assignees in this case without the written consent of Parkway.

Parkway, as well as numerous other insurance companies, is a member of the Insurance Services Office, Inc. ("ISO"). ISO is an underwriting company that submits forms of insurance—as well as endorsements consistent with legislative enactments—on behalf of the insurance industry and its members to the Commissioner of Banking and Insurance of New Jersey ("Commissioner")[1] for approval. On December 7, 1995, the Commissioner approved ISO PAP94, wherein Part F— General Provisions, Transfer of Your Interest *1224 in this Policy provides in pertinent part:

"Your rights and duties under this policy may not be assigned without our written consent."

The Commissioner also approved the endorsement language under Section IV Part F—General Provisions, Part D— Payment of Benefits that

1. We may, at our option, pay any medical expense benefits or essential service benefits to the:

a. "Insured", or

b. Person or organization providing products or services for such benefits.

I.

In an effort to review and investigate claims of insureds, Parkway, as a general policy, attempts to contact its insured—as well as tortfeasors—to obtain statements. It additionally attempts to contact and obtain records from treating medical providers regarding an insured's injuries and treatments. Further, Parkway conducts investigations into prior accidents, subsequent accidents, PIP eligibility checks, as well as conducting peer reviews and independent medical examinations. Parkway finds these investigative procedures are necessary due to the failure of its insureds, as well as medical care providers, to provide basic information regarding the causation of the accidents and due to the difficulty in verifying treatment from the providers' records. As is evidenced in Parkway's submissions, it has gone to great expense in its attempt to verify claims and thereafter make payments for medical services which were reasonable and necessary.

In 1996 Parkway was billed $28,630 by NJNBC; in 1997 Parkway was billed $60,340; in 1998 Parkway was billed $27,960. Hence, the total amount that NJNBC has billed Parkway is $116,930. Parkway has made payments to NJNBC of $13,207, leaving an alleged balance of $103,722. The only patients designated in its opposing papers are Aida Acosta and Clemente Mendoza. The only patients designated by I.T.C. are Claribel Azcona and Marabel Azcona.

Since 1996 Parkway has attempted unsuccessfully to obtain all the necessary documents from the medical providers, insureds and other claimants, and Parkway has been unable to obtain examinations under oath of some claimants. This court finds its unnecessary to recite, ad nauseam, all the other facts contained in Parkway's supporting papers.

The record is replete with examples of lack of cooperation by the aforementioned insureds, passengers and medical providers. Defendants lack of cooperation in this case alone has cost Parkway $17,510.85 for legal, medical and investigative services. One of the continuing problems Parkway has encountered is that most of the claimants have received treatment from multiple medical providers. For example, Parkway received records from only three of Aida Acosta's nine medical providers and from only one of five of Claribel Azcona's medical providers. Clemente Mendoza and seven of his nine medical providers have been uncooperative in Parkway's attempts to verify not only Mendoza's injuries, but also the reasonableness and necessity of his treatment by these nine medical providers. Parkway has received only two sets of medical records with regard to Prisilla Illa's five medical providers. These actions clearly violate N.J.S.A. 39:6A-13. This lack of cooperation shows one reason why a prohibition against assignment without Parkway's consent, in the language approved by the Commissioner, is included in all of Parkway's automobile insurance policies.

Parkway contends that both insureds and medical providers make little or no effort to cooperate with Parkway in its attempts to verify the reasonableness or necessity of treatment. Moreover, it is usually only after the providers seek payment and file AAA arbitrations that they *1225 supply the requisite medical records, regardless of prior requests for same. Another quandary with assignments arises when a claimant fails to appear for requested examinations under oath and independent medical examinations and when medical providers fail to provide requested records. An insurer cannot adequately defend its interest if an investigation has been thwarted by the same individuals who have the burden of establishing the reasonableness and necessity for the treatment provided—the patients and their medical providers.

II.

It was because of this lack of cooperation and fraud that the Legislature, commencing in 1977, began to limit eligibility for PIP benefits.

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Bluebook (online)
748 A.2d 1221, 330 N.J. Super. 172, Counsel Stack Legal Research, https://law.counselstack.com/opinion/parkway-ins-co-v-nj-neck-back-njsuperctappdiv-1998.