Slaby v. Nationwide Insurance

39 Pa. D. & C.4th 98, 1997 Pa. Dist. & Cnty. Dec. LEXIS 6
CourtPennsylvania Court of Common Pleas, Northumberland County
DecidedAugust 13, 1997
Docketno. CV-96-348
StatusPublished
Cited by1 cases

This text of 39 Pa. D. & C.4th 98 (Slaby v. Nationwide Insurance) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Northumberland County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Slaby v. Nationwide Insurance, 39 Pa. D. & C.4th 98, 1997 Pa. Dist. & Cnty. Dec. LEXIS 6 (Pa. Super. Ct. 1997).

Opinion

FEUD ALE, P.J.,

The factual essence of this case is an insurance bad faith claim by plaintiff against defendant. On June 26, 1993, plaintiff was involved in a motor vehicle accident when Helen Henderson allegedly failed to stop at a stop sign and collided with plaintiff’s vehicle. Both plaintiff and Ms. Henderson were insured by defendant Nationwide. After the accident, plaintiff received medical treatment and sent the bills directly to defendant for payment under the first party provisions of her policy. In early 1994, defendant sought a peer review organization review of the reasonableness and necessity of plaintiff’s continued treatment. Plaintiff alleges that the PRO reports indicated that plaintiff’s treatment was medically necessary and that defendant still refused to pay. Defendant, [100]*100apparently, has a different interpretation of the PRO reports.

Defendant filed the instant preliminary objections to plaintiff’s amended complaint. In reviewing preliminary objections, all facts that are well-pleaded, material, and relevant are considered as true. Additionally, the court may draw any reasonable inferences from those facts. In order to sustain a demurrer, it is essential that the face of the complaint indicates that its claims may not be sustained and that the law will not permit a recovery. If there is any doubt, the demurrer should be overruled. Mellon Bank N.A. v. Fabinyi, 437 Pa. Super. 559, 650 A.2d 895 (1994).

Through its preliminary objections, defendant argues that plaintiff is solely limited to the remedies provided in Pennsylvania’s Motor Vehicle Financial Responsibility Law, specifically, 75 Pa.C.S. §1797. Section 1797 of the MVFRL provides a mechanism to review the medical necessity of claims submitted to an insurer and applies, in certain instances, when an insured seeks first party benefits from their insurer. As we understand the process, when a dispute occurs over the medical necessity of an insured’s treatment, the insurer has two options. The insurer can either refuse to pay the claim outright or submit the claim to a PRO for review. If an insurer simply refuses to submit the claim to a PRO, an unsatisfied insured can proceed directly to court for redress. If the insurer submits a claim to the PRO, an unsatisfied insured can request reconsideration of the PRO determination or appeal to the court. 75 Pa.C.S. §1797; Terminato v. Pennsylvania National Insurance Co., 538 Pa. 60, 645 A.2d 1287 (1994); M.S. Hershey Medical Center v. State Farm Insurance, 21 D.&C.4th 62, 68 (Franklin County 1992) (although section 1797 does not expressly authorize an appeal to the court [101]*101from a PRO determination, such an interpretation has been adopted based on due process grounds). Although only persuasive authority, it appears that the issue addressed in Hershey has not been specifically addressed by a higher court. However, Hershey’s holding still continues to be implied in this area of the law. See Terminato, supra.

Under the MVFRL, if the court determines that an insurer refused to pay for treatment that was medically necessary, the insurer must pay the amount of the claim “plus interest at 12 percent, as well as the costs of the challenges and all attorney fees.” 75 Pa.C.S. §1797(b)(6). If the insurer chose not to submit the claim to a PRO and in so doing its behavior is deemed to be “wanton,” the insured shall be subject to payment of treble damages. 75 Pa.C.S. § 1797(b)(4).

Plaintiff argues in the alternative that she is entitled to seek damages under the MVFRL and/or the more expansive damages provided in 42 Pa.C.S. §8371. Under section 8371, if a court determines that an insurer acted in bad faith, the court may:

“(1) Award interest on the amount of the claim from the date the claim was made by the insured in an amount equal to the prime rate of interest plus 3 percent.
“(2) Award punitive damages against the insurer.
“(3) Assess court costs and attorney fees against the insurer.”

Defendant argues that section 1797 specifically and exclusively provides a remedy if plaintiff can substantiate her allegations. Defendant contends that section 1797 is the exception to a more general statutory remedy provided by section 8371. The legislature has provided the following guidance when a general and a specific statute both appear to be applicable to the same matter:

[102]*102“Whenever a general provision in a statute shall be in conflict with a specific provision in the same or another statute, the two shall be construed, if possible, so that effect may be given to both. If the conflict between the two provisions is irreconcilable, the specific provisions shall prevail and shall be construed as an exception to the general provision, unless the general provision shall be enacted later and it shall be the manifest intention of the General Assembly that such general provision shall prevail.” 1 Pa.C.S. §1933.

In this case, however, we do not share defendant’s view and we are able to reconcile the MVFRL and 42 Pa.C.S. §8371. In reviewing case law concerning the co-application of these statutes, it appears that no higher court has addressed the specific issue presented before us. That particular issue is whether an insurer who is alleged to have misused the PRO process can be made to pay damages provided by section 8371. We find that public policy requires that the insurer can be held liable for damages under section 8371, including punitive damages, if they abuse the very process that was enacted to shield them.

Although it has no precedential value, Barnum v. State Farm Mutual Auto Insurance Co., 430 Pa. Super. 488, 635 A.2d 155 (1993), reversed and remanded without opinion, 539 Pa. 673,652 A.2d 1319 (1995), comes closest to addressing how the MVFRL and 42 Pa.C.S. §8371 are to be applied when both, arguably, appear to apply. In Bamum, Leroy Barnum was injured in an accident and submitted medical bills to be paid under his first party coverage with State Farm. State Farm questioned the necessity of Bamum’s medical bills and submitted them to a PRO. The PRO determined that some of Barnum’s medical treatment was unnecessary and State Farm refused to pay. Barnum then initiated [103]*103a civil action to recover damages allowed under section 8371.

State Farm filed preliminary objections in the nature of a demurrer and argued that (1) Bamum failed to exhaust his statutory remedies because his did not request reconsideration of the PRO review and (2) that section 8371 was not applicable for a claim which arose under the MVFRL. In addressing the first issue, the Supreme Court, in Terminato v. Pennsylvania National Insurance Co., supra, held that the doctrine of exhaustion of administrative remedies does not apply to the PRO procedure. Shortly thereafter, in accord with Terminato, Bamum was reversed and remanded without opinion. In so doing, the Supreme Court provided no guidance concerning the Superior Court’s determination of the co-application of the MVFRL and section 8371, and the issue remains as to whether the Supreme Court would sustain or overrale the Superior Court’s determination.

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Bluebook (online)
39 Pa. D. & C.4th 98, 1997 Pa. Dist. & Cnty. Dec. LEXIS 6, Counsel Stack Legal Research, https://law.counselstack.com/opinion/slaby-v-nationwide-insurance-pactcomplnorthu-1997.