Sunday, December 30, 2012

First Party Benefits Decision Out of Dauphin County

In his recent December 13, 2012 opinion in the case of Doctor’s Choice Physical Medicine & Rehabilitation Center, P.C. (LaSelva), v. Travelers Personal Ins. Co., No. 2008-Civil-16214 (C.P. Dauphin Co. Dec. 13, 2012 Clark, J.), Judge Lawrence F. Clark, Jr., of the Dauphin County Court of Common Pleas entered judgment in favor of a medical provider Plaintiff after a non-jury trial in a first party medical benefits dispute.  The Court awarded to the medical provider the unpaid medical expenses plus statutory interest at 12% per annum, attorney’s fees, and costs of suit.

[On a motion for reconsideration, the trial court removed the award of attorney's fees.  The removal of the attorney's fees from the award became the focal point as this case proceeded up the appellate ladder all the way to the Pennsylvania Supreme Court.  Type "Doctor's Choice" into the Search Box on to view posts on the Superior Court and Supreme Court decisions.].

By way of background, the Plaintiff medical provider sued the carrier after that carrier’s refusal to pay for certain chiropractic treatment bills allegedly resulting from accident-related injuries suffered by the injured party, Angela LaSelva.  The carrier refused to pay based upon a decision made in a peer review process that treatments provided after a certain date were not medically reasonable or necessary.

In his Opinion, Judge Clark reviewed the applicable first party law under 75 Pa. C.S.A. §1797 pertaining to the peer review process. The Plaintiff in this matter alleged that the peer review report relied upon by the carrier was illegal and defective as to the determination made that the treatment was not reasonable or necessary after the date stated. At the bench trial, the Court heard from the treating chiropractor who testified as to the reasonableness and necessity of the treatment. The peer review expert also testified for the defense as well.

According to the Court’s Opinion, after reviewing all of the testimony and exhibits, the Court concluded that the Plaintiff medical provider established by the clear preponderance of the evidence that the questioned treatments were indeed reasonable and necessary for the Plaintiff’s ongoing pain.

This Opinion provides a nice overview of the peer review process and the standard of review of the court in these types of cases.

Anyone desiring to review this Opinion in Doctor's Choice v. Travelers may click this LINK.

I send thanks to Attorney Paul Oven of the Moosic, PA law firm of Dougherty, Leventhal & Price for bringing this case to my attention.

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