Pennsylvania Dental Ass'n v. Medical Service Ass'n

32 Pa. D. & C.3d 380, 1982 Pa. Dist. & Cnty. Dec. LEXIS 52
CourtPennsylvania Court of Common Pleas, Cumberland County
DecidedOctober 12, 1982
Docketno. 1 Equity 1977
StatusPublished

This text of 32 Pa. D. & C.3d 380 (Pennsylvania Dental Ass'n v. Medical Service Ass'n) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Cumberland County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pennsylvania Dental Ass'n v. Medical Service Ass'n, 32 Pa. D. & C.3d 380, 1982 Pa. Dist. & Cnty. Dec. LEXIS 52 (Pa. Super. Ct. 1982).

Opinion

SHEELY, J.,

On January 18, 1977, the above named plaintiffs filed a complaint in equity against the above named defendant.1 The complaint broadly attacked the operation of defendant’s insurance plan. The essential allegations are paraphrased as follows:

[382]*382(1) Pennsylvania Blue Shield [hereinafter PBS], in violation of the Act of November 15, 1972, P.L. 1063, as amended, 40 Pa.C.S. §6324(b), imposes illegal restrictions on health service doctors as to their methods of diagnosis and treatment. Defendant conducts a dental review program in which it investigates health care diagnosis and that treatment proposed by the doctor as well as that treatment actually given. Before defendant will pay for dental services, it requires the doctor to submit a statement of the services he intends to render and the cost thereof. Defendant also requires that pre-treatment and post-treatment radiographs (x-ray pictures) be submitted before payment is made. The taking of pre-and post-treatment radiographs results in unnecessary radiation exposure to defendant’s subscribers. In some instances, for example, those involving only teeth with gingival (“gum”) problems, this requirement leads to radiation exposure which is wholly unnecessary in the first instance. In some instances defendant refused to pay for the proposed treatment. In so doing, it substitutes its judgment for that of the doctor and thus imposes illegal restrictions on the doctor’s methods of diagnosis and treatment.

(2) Defendant, by conducting its dental review program in the above-stated manner, constantly violates § 6324(b) by interfering in the type of services to be rendered and the method of rendering them. This results in a doctor-patient relationship which is not “identical with the relation that ordinarily exists in the community between a health service doctor and his patient “as is provided for in 40 Pa.C.S. § 6324(b).

(3) Defendant, by changing the plan for dental treatment agreed to by a dentist and patient, creates in the patient’s mind a doubt as to both the compe[383]*383tency and honesty of the dentist and causes the patient to “change” dentists, thus interfering with “the choice or selection by a patient of his ‘dentist’ after that choice has been made by an adult of sound mind.”

(4) Defendant violates the provisions of its “participating agreement” with health service doctors who provide diagnosis and treatment to defendant’s subscribers in that the “participating agreement” provides that “preauthorization” for a procedure is limited to a determination of the eligibility of its subscriber, the coverage for services proposed, and defendant’s allowance for such services. (See “Participating Doctor’s agreement with PBS,” attached to original complaint of January 18, 1977 as Exhibit A). In practice, defendant is affecting diagnosis and treatment methods by its use of the “preauthorization” procedure.

(5) The Act of November 15, 1972, P.L. 1063, as amended, 40 Pa.C.S. §6303, establishes categories of low-income and over-income persons. Guidelines for specifically differentiating the services to which low-income persons are entitled from those to which persons of over-income are entitled are provided in the Act of November 15, 1972, P.L. 1063, as amended, 40 Pa.C.S. §6325(c). Defendant violates these guidelines in its “Prevailing Fee Program”2 which makes no distinction between low-income and over-income subscribers. In order for doctors to become “participating doctors” with PBS, [384]*384(a status which permits the doctors to receive payment directly from PBS rather than having the payment sent to the individual subscriber) they must agree to be bound by the “Prevailing Fee Program” which denies plaintiffs’ permission to charge over-income persons for that portion of plaintiffs’ fees which are not paid by defendants. This results in losses of income to plaintiffs.

On February 8, 1977, PBS filed preliminary objections to the complaint and a date was set for argument. It was soon thereafter brought to the attention of the court that there was then pending before the Pennsylvania Insurance Department a proceeding concerning a number of amendments to the PBS dental service agreement, wherein the Pennsylvania Dental Association [hereinafter PDA] and certain individual dentists, including all of plaintiffs in this case, had intervened. They there raised a number of the same objections to the operation of the PBS dental program as were raised in their complaint. Accordingly, the court stayed proceedings in this action pending a determination of the similar issues then before the Pennsylvania Insurance Department.

PBS’s amended rules for its dental service agreement, filed under No. 5-H-1970, were approved by the Insurance Commissioner in an adjudication issued on July 19, 1977. In that adjudication, the issues raised by plaintiffs in their complaint were disposed of. On August 8, 1977, plaintiffs filed an appeal from the adjudication of the Insurance Commissioner. In view of these pending proceedings in the Commonwealth Court dealing with issues raised in the instant case, the court, in an order of August 16, 1977, again stayed the proceedings in this case pending a decision by the Commonwealth [385]*385Court. Plaintiffs, on September 15, 1977, filed an application for extraordinary relief in the Supreme Court of Pennsylvania, seeking to compel this court to proceed in this action. The application was denied by the Supreme Court by order dated October 12, 1977.

On March 5, 1979, the Commonwealth Court, in a unanimous decision, affirmed the Insurance Commissioner’s approval of the amendments to the PBS dental plan. Pennsylvania Dental Association, et al. v. Commonwealth of Pennsylvania, Insurance Department, 41 Pa. Commw. 47, 398 A.2d 729 (1979). (Plaintiffs’ petition for allowance of appeal was denied by the Pennsylvania Supreme Court on June 4, 1979 (No. 437 Allocatur Docket)). This court then heard arguments upon defendant’s preliminary objections to the complaint, which had been stayed since June of 1977. In an opinion and order issued on May 9, 1980, this court sustained defendant’s preliminary objections to the original complaint, and granted plaintiffs leave to file an amended complaint. Pennsylvania Dental Association v. Medical Service Association of Pennsylvania, 30 Cumb. L.J. 147 (1980).

Plaintiffs filed their amended complaint on May 29, 1980. Their amended complaint retained substantial portions of their original complaint and added a number of paragraphs pertaining to plaintiffs’ ability to represent the interests of an entire class. Plaintiffs also added serveral paragraphs alleging that PBS’s use of “profiles” (mathematically calculated scales), to determine the fee PBS will pay to dentists for services violates the above-mentioned sections of the Regulatory Act of November 15, 1972, 40 Pa.C.S. §6301 et seq.

PBS filed preliminary objections to the amended complaint. On January 5, 1981, this court denied [386]*386PBS’s preliminary objections to the amended complaint, holding that plaintiffs had pled sufficient questions of fact to defeat a demurrer. This court, at pages 2 and 3 of its January 5, 1981 opinion, specifically noted that plaintiffs, after the decisions of the Insurance Commissioner and the Commonwealth Court, were no longer averring that the written policies of PBS’s dental program were illegal.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

In Re HOTEL TELEPHONE CHARGES
500 F.2d 86 (Ninth Circuit, 1974)
Ablin, Inc. v. Bell Tel. Co. of Pa.
435 A.2d 208 (Superior Court of Pennsylvania, 1981)
ABC Sewer Cleaning Co. v. Bell of Pennsylvania
438 A.2d 616 (Superior Court of Pennsylvania, 1981)
Bell v. Beneficial Consumer Discount Co.
360 A.2d 681 (Superior Court of Pennsylvania, 1976)
Samuels v. SMOCK
422 A.2d 902 (Commonwealth Court of Pennsylvania, 1980)
Klemow v. Time Incorporated
352 A.2d 12 (Supreme Court of Pennsylvania, 1976)
Bell v. Beneficial Consumer Discount Co.
348 A.2d 734 (Supreme Court of Pennsylvania, 1975)
Metropolitan Hospital ex rel. Themselves v. Commonwealth
343 A.2d 695 (Commonwealth Court of Pennsylvania, 1975)
Pennsylvania Dental Ass'n v. Commonwealth
398 A.2d 729 (Commonwealth Court of Pennsylvania, 1979)
Adamson v. Commonwealth
410 A.2d 392 (Commonwealth Court of Pennsylvania, 1980)
Berley v. Dreyfus & Co.
43 F.R.D. 397 (S.D. New York, 1967)
Philadelphia Electric Co. v. Anaconda American Brass Co.
43 F.R.D. 452 (E.D. Pennsylvania, 1968)
Minnesota v. United States Steel Corp.
44 F.R.D. 559 (D. Minnesota, 1968)
Boshes v. General Motors Corp.
59 F.R.D. 589 (N.D. Illinois, 1973)
Ralston v. Volkswagenwerk, A. G.
61 F.R.D. 427 (W.D. Missouri, 1973)
Hedges Enterprises, Inc. v. Continental Group, Inc.
81 F.R.D. 461 (E.D. Pennsylvania, 1979)

Cite This Page — Counsel Stack

Bluebook (online)
32 Pa. D. & C.3d 380, 1982 Pa. Dist. & Cnty. Dec. LEXIS 52, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pennsylvania-dental-assn-v-medical-service-assn-pactcomplcumber-1982.