Solomon v. United States Health Care Systems of Pennsylvania Inc.

62 Pa. D. & C.4th 104, 2001 Pa. Dist. & Cnty. Dec. LEXIS 315
CourtPennsylvania Court of Common Pleas, Philadelphia County
DecidedJune 19, 2001
Docketno. 1288
StatusPublished

This text of 62 Pa. D. & C.4th 104 (Solomon v. United States Health Care Systems of Pennsylvania Inc.) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Philadelphia County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Solomon v. United States Health Care Systems of Pennsylvania Inc., 62 Pa. D. & C.4th 104, 2001 Pa. Dist. & Cnty. Dec. LEXIS 315 (Pa. Super. Ct. 2001).

Opinion

LEVIN, S.J.,

INTRODUCTION

This case involves the payment of insurance claims by health care providers to licensed insurance carriers. Plaintiffs Mark Solomon M.D., and Regional Neurosurgical Associates PC. (RNA), are health care providers. They claim that United Health Care Systems of Pennsylvania Inc., and Aetna Inc., defendants, have failed to timely pay insurance claims, or to pay interest thereon. Plaintiffs make two specific claims: first, plaintiffs claim that defendants’ failure to pay claims within 45 days, or to pay interest thereon, is a violation of the Pennsylvania 1998 Quality Health Care Accountability and Protection Act, 40 Pa.C.S. §991.2101 et seq.; and second, plaintiffs claim that defendants’ failure to pay claims for reimbursement within 30 days, or to pay interest to plaintiffs on claims not paid within 30 days, is a breach of the parties’ contract.

This case is presently before this court on defendants’ preliminary objections, defendants’ motion for summary judgment and plaintiffs’ cross-motion for summary judgment. Earlier in this case, on November 30, 1999, this court sustained defendants’ preliminary objections to five of six counts in plaintiffs’ first amended complaint, thereby dismissing with prejudice all of plaintiffs’ claims except plaintiffs’ claim for breach of contract (Count I). (See order dated 11/30/99.) Thereafter, plaintiffs filed a second amended complaint on October 11,2000, in which they added a new count (Count VII), which claims that defendants have violated the Pennsylvania Health Care [106]*106Act. Hence, the claims presently pending before this court are defendants’ preliminary objections to plaintiffs’ new Count VII (violation of the Health Care Act), defendants’ motion for summary judgment to plaintiffs’ Count I (breach of contract), and plaintiffs’ cross-motion for summary judgment.

DEFENDANTS’ PRELIMINARY OBJECTIONS TO PLAINTIFFS’ FIRST AMENDED COMPLAINT

Following is a discussion of the reasons this court sustained defendants’ preliminary objections to five counts contained in plaintiffs’ first amended complaint. The five counts to which this court sustained preliminary objections are as follows: breach of the implied covenant of good faith and fair dealing, unjust enrichment, fraud, conversion, and negligent misrepresentation. This court found that all of these counts, except for the count for breach of the implied covenants of good faith and fair dealing, were fundamentally flawed because they are contract counts that merely sound in tort law.

In Pennsylvania, the basis of a legal action dictates which claims may be brought. An action based on an agreement between the parties is in fact a contract action, and therefore it cannot be enforced by tort principles. The “important difference between contract and tort actions is that the latter lie from the breach of duties imposed as a matter of social policy while the former lie for the breach of duties imposed by mutual consensus.” Redevelopment Authority of Cambria County v. International Insurance Co., 454 Pa. Super. 374, 392, 685 A.2d 581, 590 (1996). A contract action may not be converted into a tort action simply by alleging that the conduct in [107]*107question was done wantonly. In order for there to lie an agreement-based tort action, the wrong ascribed to the defendant must be the “gist of the action,” with the contract being “collateral.” Id.

The instant action is both in its essence and upon its face one for breach of contract. Here, there is a clearly written agreement governing the conduct between the parties. Thus, the duties of the parties here were imposed by mutual consensus. A tort action cannot lie here because the contract is central, not collateral, to the action. Therefore, plaintiffs’ claims sounding in tort were properly dismissed by this court as inconsistent with plaintiffs’ breach of contract claim. Id.1

DEFENDANTS’ PRELIMINARY OBJECTIONS TO PLAINTIFFS’ SECOND AMENDED COMPLAINT

Defendants limit their preliminary objections to plaintiffs’ second amended complaint to plaintiffs’ newly pleaded Count VII. Defendants claim that Count VII lacks legal sufficiency, and should be dismissed by this court.

In Count VII of the second amended complaint, plaintiffs seek to enforce the defendants’ alleged statutory obligations of the Pennsylvania 1998 Quality Health Care Accountability and Protection Act, 40 Pa.C.S. §991.2101 et seq. Section 2166(a) of the Health Care Act requires that defendants promptly pay “clean claims” (as that term is defined in the statute) “within 45 days of receipt of the [108]*108clean claim.” 40 Pa.C.S. §991.2166(a). When defendants fail to pay clean claims within 45 days of receipt they are required to pay “interest at 10 percentum per annum . . . beginning the day after the required payment date and ending on the date the claim is paid” in addition to the amounts owed for the clean claims. 40 Pa.C.S. §991.2166(b). Count VII of plaintiffs’ second amended class action complaint alleges that defendants’ failure to pay within 45 days, or pay interest thereon, constitutes a violation of the Health Care Act.2

Defendants, on the other hand, argue that the Health Care Act confers “no private statutory cause of action.” (See defendants’ preliminary objections to plaintiffs’ second amended class action complaint at p. 1.) Plaintiffs respond to defendants’ argument in three ways. First, they argue that the Health Care Act provides an explicit private right to seek redress in this court; second, they argue that there is an implicit private right of action in the Health Care Act; and third, plaintiffs argue that the permissive language of the governing regulations confers a private right of action.

This court’s standard of review on preliminary objections is well established. Preliminary objections may be sustained only if it is clear from all the facts pleaded that [109]*109the pleader will be unable to prove facts legally sufficient to establish his or her right to relief. Hazleton Area School District v. Bosak, 671 A.2d 277, 281 (Pa. Commw. 1996). The court must consider as true all the well-pleaded material facts set forth in the complaint and all reasonable inferences that may be drawn from those facts. Bower v. Bower, 531 Pa. 54, 56, 611 A.2d 181, 182 (1992). Where (as here) the grant of preliminary objections will result in the denial of a claim, or dismissal of a suit, preliminary objections should be sustained only in cases that are clear and free from doubt. Legman v. Scranton School District, 432 Pa. 342, 345, 247 A.2d 566, 569 (1968). Finally, the preliminary objector has the burden of supporting its objections to the court’s jurisdiction. Schmitt v. Seaspray-Sharkline Inc., 366 Pa. Super. 528, 531, 531 A.2d 801, 803 (1987).

This court finds that no private right of action is conferred by section 991.2166(a) of the Health Care Act, 40 Pa.C.S. §991.2166(a).

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Bluebook (online)
62 Pa. D. & C.4th 104, 2001 Pa. Dist. & Cnty. Dec. LEXIS 315, Counsel Stack Legal Research, https://law.counselstack.com/opinion/solomon-v-united-states-health-care-systems-of-pennsylvania-inc-pactcomplphilad-2001.