Pierce v. State Farm Insurance

27 Pa. D. & C.4th 464, 1994 Pa. Dist. & Cnty. Dec. LEXIS 45
CourtPennsylvania Court of Common Pleas, Lackawanna County
DecidedOctober 20, 1994
Docketno. 93 Civil 4799
StatusPublished

This text of 27 Pa. D. & C.4th 464 (Pierce v. State Farm Insurance) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Lackawanna County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Pierce v. State Farm Insurance, 27 Pa. D. & C.4th 464, 1994 Pa. Dist. & Cnty. Dec. LEXIS 45 (Pa. Super. Ct. 1994).

Opinion

COTTONE, J.,

Before the court are preliminary objections to both counts of the plaintiff’s complaint filed pursuant to Pa.R.C.P. 1028, Title 42 of Pennsylvania Consolidated Statutes by defendant, State Farm Insurance Company. The plaintiff opposes the objections. The parties have briefed their respective [465]*465positions and oral argument was held on August 4, 1994.

The plaintiff was involved in an auto accident on June 17, 1992, wherein she suffered various injuries. At the time of the accident she was insured by the defendant, State Farm. Following the accident, the plaintiff sought medical care from Allied Services Rehabilitation Hospital and G.R.R Associates.

On February 5, 1993, the defendant contracted with a peer review organization, to challenge the Allied medical services. On March 29, 1993, the PRO, I-PRO of State College, issued its determination that services performed after November 20, 1992, were not medically necessary. Allied then requested a reconsideration of this determination, and the reconsideration echoed the original findings. The plaintiff did not request a reconsideration.

On March 17, 1993. the defendant contracted with Omni-Medicorp, another PRO, to challenge the G.R.P. services. On April 30, 1993, Omni-Medicorp issued its determination that the G.R.P. treatment could not be addressed because the services provided did not conform to professional standards. Based on this, State Farm refhsed to pay the G.R.P. bill. The plaintiff did not request a reconsideration of this determination.

As a result of the defendant’s refusal to pay the bills of Allied and G.R.P., the plaintiff has filed the instant action. In Count I of her complaint she seeks payment of the medical expenses and in Count II seeks damages for bad faith under Title 42 of Pennsylvania Consolidated Statutes based on the defendant’s alleged improper use of the peer review process. The defendant’s preliminary objections to this complaint are threefold.

The defendant’s first preliminary obj ection is to Count I of the complaint, in the form of a demurrer, asserting that the plaintiff has failed to state a claim on which [466]*466relief may'be granted. According to the defendant, the plaintiff has failed to request reconsideration of both PRO decisions and, as a result, did not exhaust her statutory remedies before proceeding to a court of law. The defendant contends that the reconsideration of an adverse PRO determination is a prerequisite to court action.

The defendant’s second preliminary objection to Count I is based on subject matter jurisdiction. The defendant relies on the grounds stated immediately above and maintains that, as a result of the plaintiff’s failure to seek a reconsideration prior to filing suit, this court lacks subject matter jurisdiction to hear the plaintiff’s action. As both of these preliminary obj ections are premised on the same theory, we will discuss them together.

This court’s standard of review in passing upon a preliminary objection in the form of a demurrer is well-settled:

“All material facts set forth in the complaint as well as all [reasonable] inferences ... therefrom are admitted as true ... [t]he question presented by the demurrer is whether, on the facts averred, the law says with certainty that no recovery is possible.... Where doubt exists as to whether a demurrer should be sustained, this doubt should be resolved in favor of overruling it.” See Muhammad v. Strassburger, 526 Pa. 541, 547, 587 A.2d 1346, 1349 (1991), (citations omitted), cert. denied, 112 S.Ct. 196, 116 L.Ed.2d 156 (1991).

The PRO process is set out in section 1797(b) of the Motor Vehicle Financial Responsibility Law, 75 Pa.C.S. §1701 et seq. (Purdon 1994). Section 1797(b) provides that insurers can contract with a PRO in order to determine whether a claim for medical benefits should be paid or denied. The initial determination of the PRO may be reconsidered if requested by an insurer, medical services provider or the insured within 30 days of that determination.

[467]*467The defendant argues that, because section 1797(b) provides for a reconsideration process, this step must be taken by the plaintiff prior to the institution of a lawsuit. However, based on the recent Pennsylvania Supreme Court decision of Terminato v. Pennsylvania National Insurance Co., 538 Pa. 60, 645 A.2d 1287 (1994), we disagree.

Terminato involved a factual situation nearly identical to the instant case. There, the plaintiff did not seek reconsideration of an adverse PRO decision prior to filing a suit in court. The defendant argued that, because the plaintiff failed to request a reconsideration, she had not exhausted her administrative/statutory remedies. Justice Zappala, writing the opinion of the court, held that an insured is not required to request reconsideration of a PRO decision before proceeding to court.

He explained that the doctrine of the exhaustion of administrative remedies has no application to the PRO procedure. A PRO is not an administrative agency, a court of record or a tribunal authorized to resolve disputes arising out of insurance polices. A PRO is not entitled to the judicial deference afforded to administrative agencies because it is not a neutral body. Only an insurer participates in the PRO process, forming a contractual relationship lacking detachment and neutrality. The insurer pays for the PRO’S services and the PRO has a strong financial incentive, lest business be sent elsewhere. At the same time, the PRO is not concerned with the insured’s thoughts on the matter because they will not affect its future business. Therefore, a PRO does not have the characteristics of an independent body for which the legislature intended judicial deference.

The Terminato decision goes on to state that section 1797(b) does not empower a PRO to serve as a forum to resolve disputes between the insured and the insurer. [468]*468The PRO process is a mechanism through which an insurer may seek professional assessment of medical care in order to determine how to act on a claim. Section 1797(b) is a cost containment provision, not an alternative dispute resolution procedure. Justice Zappala, therefore, held that the legislature did not intend to impose reconsideration of the PRO determination as a precondition to the judicial resolution of a private contractual dispute.

We agree with the reasoning of Terminato. An insured does not need to seek reconsideration of an adverse PRO decision prior to proceeding to court. As such, the plaintiff has, indeed, stated a claim upon which relief may be granted, and we do have subject matter jurisdiction to hear her claim for medical benefits. Thus, the defendant’s first two preliminary objections, to Count I, are denied.

The third and final preliminary objection refers to Count II of plaintiff’s complaint and involves whether a claim for bad faith under Section 8371 of the Judicial Code, 42 Pa.C.S. §101 et seq. (Purdon 1994), can be raised in a complaint together with a claim for medical benefits under the MVFRL, 75 Pa.C.S. § 1797(b).

The defendant asserts that the MVFRL and 42 Pa.C.S. §8371 conflict, and it is improper to join the claims.

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Related

Barnum v. State Farm Mutual Automobile Insurance
635 A.2d 155 (Superior Court of Pennsylvania, 1993)
Terminato v. Pennsylvania National Insurance
645 A.2d 1287 (Supreme Court of Pennsylvania, 1994)
Muhammad v. Strassburger, McKenna, Messer, Shilobod & Gutnick
587 A.2d 1346 (Supreme Court of Pennsylvania, 1991)

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Bluebook (online)
27 Pa. D. & C.4th 464, 1994 Pa. Dist. & Cnty. Dec. LEXIS 45, Counsel Stack Legal Research, https://law.counselstack.com/opinion/pierce-v-state-farm-insurance-pactcompllackaw-1994.