Riverside Chiropractic Group v. Mercury Ins. Co.

961 A.2d 21, 404 N.J. Super. 228, 2008 N.J. Super. LEXIS 267
CourtNew Jersey Superior Court Appellate Division
DecidedDecember 17, 2008
DocketDOCKET NO. A-3034-07T2
StatusPublished
Cited by38 cases

This text of 961 A.2d 21 (Riverside Chiropractic Group v. Mercury Ins. Co.) 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
Riverside Chiropractic Group v. Mercury Ins. Co., 961 A.2d 21, 404 N.J. Super. 228, 2008 N.J. Super. LEXIS 267 (N.J. Ct. App. 2008).

Opinion

961 A.2d 21 (2008)
404 N.J. Super. 228

RIVERSIDE CHIROPRACTIC GROUP, a/s/o Megan Machado, Plaintiff-Appellant,
v.
MERCURY INSURANCE COMPANY, Defendant-Respondent.

DOCKET NO. A-3034-07T2.

Superior Court of New Jersey, Appellate Division.

Argued November 13, 2008.
Decided December 17, 2008.

*23 Joseph A. Massood, Wayne, argued the cause for appellant (Mr. Massood, attorney; Brian O'Reilly, on the brief).

Michael R. Speer, Roseland, argued the cause for respondent (Marshall, Dennehey, Warner, Coleman & Goggin, attorneys; Anthony F. Andrisano, Jr., on the brief).

Before Judges STERN, LYONS and WAUGH.

The opinion of the court was delivered by

LYONS, J.A.D.

Plaintiff, Riverside Chiropractic Group, appeals from a judgment affirming an arbitration award entered pursuant to the Alternative Procedure for Dispute Resolution Act, N.J.S.A. 2A:23A-1 to -19 (APDRA), regarding personal injury protection (PIP) costs incurred by one of its patients. Because we find that the APDRA, N.J.S.A. 2A:23A-18(b), bars appeal to this court, we dismiss. The following factual and procedural history is relevant to our consideration of the issues advanced on appeal.

On March 1, 2006, plaintiff's patient, who was twenty-two years old at the time, was injured in an automobile accident. On March 5, 2006, the patient sought treatment from plaintiff for her resulting injuries. The patient, who was insured pursuant to her mother's policy, assigned plaintiff all of her rights under the insurance contract on that date. The patient thereafter began a course of treatment for her injuries that lasted several months.

On May 10, 2006, plaintiff sent a pre-certification request to defendant[1] for payment for the treatments it had provided to the patient. Plaintiff made its request pursuant to defendant's decision point review plan,[2] which defendant implemented in accordance with N.J.A.C. 11:3-4.7(c)(4) which requires decisions regarding payment pre-certification to be based upon medical necessity and treatment. The request contained the patient's medical evaluation and history, as well as information on her range of motion, a diagnostic assessment, and a plan of treatment.

Two days later, on May 12, 2006, defendant responded by letter and informed plaintiff that Dr. Louis Cuccaro, D.C. had *24 reviewed the request and approved certain medical services but denied others on behalf of defendant. Specifically, Dr. Cuccaro determined that plaintiff's "[s]ervices exceed the usual and customary care required for the diagnosis." The response letter also informed plaintiff that a more detailed explanation of the denial would be provided upon request and plaintiff could seek reconsideration of the determination. Defendant also included information regarding plaintiff's right to appeal to the National Arbitration Forum.

Plaintiff continued to treat the patient and made more pre-certification requests. Defendant denied each of these requests in the same manner and plaintiff sought reconsideration from defendant on these denials. Defendant upheld all of its decisions.

On October 10, 2006, plaintiff filed a demand for arbitration. At that time, plaintiff had not obtained a copy of the applicable insurance contract, and assumed that the contract mandated arbitration for PIP disputes. However, defendant provided a copy of the contract post-oral argument, supplementing the record on appeal. The policy states, in pertinent part, that "[a] PIP dispute, as defined in N.J.A.C. 11:3-5, may be submitted to dispute resolution by: a) an injured party, b) the Insured, c) a provider who is an assignee of PIP benefits of the company." (Emphasis added).

Plaintiff filed a PIP claim in the amount of $4,465.01 with the National Arbitration Forum, arguing that defendant's denial of the pre-certification requests violated N.J.A.C. 11:3-4.7(c)(4). The National Arbitration Forum assigned a Dispute Resolution Professional (DRP) to hear the matter.

In response to plaintiff's demand for arbitration, Dr. Cuccaro drafted a letter documenting his reasons for denying pre-certification in more detail. This letter was dated February 2, 2007.

The DRP heard oral arguments on July 24, 2007. At that time, plaintiff argued that Dr. Cuccaro's February 2, 2007, letter was in fact an impermissible retrospective denial of payment, prohibited by N.J.A.C. 11:3-4.7(g). The DRP rejected this argument.

The DRP issued a written opinion awarding defendant the cost of medical supplies used for treating the patient in the amount of $300. He also awarded $500 for attorney's fees and $225 in costs pursuant to N.J.S.A. 39:6A-5.2(g), but held that defendant's reasons for the pre-certification denials were "sufficient" and denied plaintiff the remaining $3,540.01 requested.

On November 26, 2007, plaintiff filed a verified complaint and an order to show cause seeking to vacate the DRP's decision in the Law Division, pursuant to N.J.S.A 2A:23A-13(a). The trial court affirmed the arbitration award and this appeal ensued.

Plaintiff presents the following arguments for our consideration:

POINT ONE:
The procedural bar of N.J.S.A. 2C:23A-18(b) [sic] is unconstitutional as applied to plaintiff because a knowing and voluntary waiver of the right to an appeal is not valid in a contract of adhesion. (Not Raised Below).
POINT TWO:
N.J.A.C. 11:3-4.7(c)(4) clearly requires that denials of precertification requests be based upon medical necessity and defendant's February 2, 2007 peer review was an impermissible and incorrect retrospective denial prohibited by N.J.A.C. 11:3-4.7(g) which requires that the award be vacated. (Raised Below).
*25 A. Defendant's retrospective denial is prohibited by the Code and contrary to public policy.
B. This court should exercise appellate jurisdiction to provide needed supervisory authority.

We first turn to plaintiff's claim that the APDRA, N.J.S.A. 2A:23A-18(b), is unconstitutional as applied.[3] We begin by noting that "the burden [is] upon a challenger of a statute on constitutional grounds [and] is indeed onerous." Williams v. State, 375 N.J.Super. 485, 506, 868 A.2d 1034 (App.Div.2005), aff'd, In re P.L. 2001, Chapter 362, 186 N.J. 368, 895 A.2d 1128 (2006). Moreover, our Supreme Court has stated "every possible presumption favors the validity of an act of the Legislature." State v. Trump Hotels and Casino Resorts, Inc., 160 N.J. 505, 526, 734 A.2d 1160 (1999) (quoting New Jersey Sports & Exposition Auth. v. McCrane, 61 N.J. 1, 8, 292 A.2d 545 (1972)). We, therefore, "exercise `extreme self restraint' before using `the judicial power to invalidate a legislative act[,]' and we will not declare a legislative act void `unless its repugnancy to the Constitution is clear beyond a reasonable doubt.'" LaManna v. Proformance Ins., 184 N.J. 214, 223, 876 A.2d 785 (2005) (quoting Trump Hotels & Casino, supra, 160 N.J. at 526, 734 A.2d 1160). Moreover, "a constitutional issue should not be decided `unless its resolution is imperative to the disposition of litigation.'" Gac v. Gac, 186 N.J. 535, 547, 897 A.2d 1018 (2006) (quoting Randolph Town Ctr., L.P. v. County of Morris, 186 N.J. 78, 80, 891

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

Related

Milagros Cintron v. Brink's Incorporated
New Jersey Superior Court App Division, 2026
Panat Taranat v. Rokt US Corp.
New Jersey Superior Court App Division, 2026
Cavalry Spv I LLC, Etc. v. Sakari T. Miakoda
New Jersey Superior Court App Division, 2025
Timothy Tisder v. Citibank N.A.
New Jersey Superior Court App Division, 2025
Julien J. Coppi v. Family Adventures North Jersey, LLC
New Jersey Superior Court App Division, 2025
Michael Savage v. Trinity Solar, Inc.
New Jersey Superior Court App Division, 2025
Michael T. Mack v. Wells Fargo Bank, N.A.
New Jersey Superior Court App Division, 2025
Adrian Evans and Kenneth Hicks v. City of Paterson, Etc.
New Jersey Superior Court App Division, 2025
David J. Singer, Etc. v. Maureen E. Vella
New Jersey Superior Court App Division, 2024
Georgia M. McGinty v. Jia Wen Zheng
New Jersey Superior Court App Division, 2024
Citizens United Reciprocal Exchange v. Hackensack Umc A/S/O A.R.
New Jersey Superior Court App Division, 2024

Cite This Page — Counsel Stack

Bluebook (online)
961 A.2d 21, 404 N.J. Super. 228, 2008 N.J. Super. LEXIS 267, Counsel Stack Legal Research, https://law.counselstack.com/opinion/riverside-chiropractic-group-v-mercury-ins-co-njsuperctappdiv-2008.