Justia Insurance Law Opinion Summaries

From 2010 to 2012, Appellant Freedom Medical Supply, Inc. (“Freedom”), provided electrical muscle stimulators (“EMSs”) and portable whirlpools to automobile accident victims covered by Appellee State Farm Fire and Casualty Company and/or State Farm Mutual Automobile Insurance Company (collectively, “State Farm”). Notably, although Freedom purchased these items for relatively little cost, it applied significant markups. As found by the United States District Court for the Eastern District of Pennsylvania herein, Freedom purchased the EMSs for approximately $20 to $30 each, yet charged approximately $1,525 to $1,600 each, and purchased the whirlpools for approximately $40 each, yet charged approximately $525 each. Because neither the EMSs nor portable whirlpools have a federally-determined Medicare fee, Freedom sought reimbursement from State Farm for 80% of the foregoing charges. State Farm denied Freedom's claims, and the district court ultimately agreed with State Farm when Freedom filed suit. Freedom appealed to the United States Court of Appeals for the Third Circuit, which, noting that no Pennsylvania court or agency has addressed the question, sought to certify to the Pennsylvania Supreme Court. The question presented was: "[m]ay an insurer use methods not specifically identified in [the Motor Vehicle Financial Responsibility Law (MVFRL)] to calculate the 'usual and customary' charge for devices and services not listed on the Medicare Fee Schedule for purposes of determining the amount to be paid to providers of those devices and services?" In answer to the question submitted, the Supreme Court held that Section 69.43(c) of the MVFRL permitted, but did not require, that reimbursements be calculated predicated on the provider’s bill for services or the data collected by the carrier. View "Freedom Medical Supply v. State Farm" on Justia Law

This appeal centered on the availability of attorneys’ fee awards against insurance companies that have invoked the peer-review provisions of the Motor Vehicle Financial Responsibility Law (MVFRL). In 2004, Angela LaSelva sustained injuries in a motor vehicle accident. She was treated by a licensed chiropractor, David Novatnak, D.C., who practiced with appellee Doctor’s Choice Physical Medicine and Rehabilitation Center, P.C. (“Provider”). Provider submitted invoices for the services directly to LaSelva’s first-party benefits insurance carrier, Appellant Travelers Personal Insurance Company (“Insurer”), as required per the Motor Vehicle Financial Responsibility Law. Insurer later requested peer review through IMX Medical Management Services (“IMX”), a peer review organization (“PRO”). IMX, in turn, enlisted Mark Cavallo, D.C., to conduct the peer review. Dr. Cavallo issued a report deeming certain of the treatments provided by Dr. Novatnak to have been unnecessary. Based on this report, Insurer denied reimbursement for the treatment aspects deemed as excessive. Provider opposed this withholding and commenced a civil action against Insurer. Among other things, the complaint alleged that all treatments undertaken through Provider were reasonable and necessary and that the review conducted by IMX did not comport with the mandates of Section 1797 of the MVFRL. Furthermore, Provider asserted that IMX failed to comply with requirements of the Pennsylvania Code directing PROs to apply national or regional norms in their determinations or, where such norms do not exist, to establish written criteria to be used in conducting reviews. As relevant here, the complaint included a specific demand for attorneys’ fees. After a bench trial, the common pleas court entered a verdict in the Provider’s favor, encompassing an award of attorneys’ fees of approximately $39,000. On appeal, the Superior Court reversed the decision to strike the fee award. The Supreme Court reversed the Superior Court: "the Superior Court’s cryptic pronouncement of 'absurdity' [regarding fee-shifting] that lacks foundation. . . . This Court remains cognizant of the shortcomings of the peer-review regime. We have no reasonable means, however, of assessing the degree to which these may be offset by the benefits of cost containment and potentially lower insurance premiums available to the public at large. Rather, the Legislature is invested with the implements to conduct investigations, hearings, and open deliberations to address such salient policy matters. In such landscape, we decline to deviate from conventional statutory interpretation to advance directed policy aims." View "Doctor's Choice v. Traveler's Personal Ins." on Justia Law