In a workers’ compensation case, an injured worker saw two different medical providers who were in the same medical practice. The Commonwealth Court ruled that even so, a separate utilization review must be performed for each provider as to the reasonableness and necessity of care rendered to the patient. This means that an insurance company can no longer write on the utilization review request “and all other providers under the same license and specialty,” and expect to use one utilization review to cut  off care for all providers in the same practice or having the same specialty. (Bucks County Community College v. WCAB, Nemes, Jr., February 12, 2007.)

The Pennsylvania Supreme Court affirmed a lower unit ruling that the Fair Share Act is unconstitutional. The Fair Share Act could only allow for a portion of a verdict to be paid by any one defendant if that defendant was found to be 60% or more liable for the verdict. Prior to that, and now because of the veto of Governor Rendell to a similar bill, any defendant may be liable to pay for the entire verdict irrespective of its percentage of the verdict. This is good news for patients who may have a case against multiple defendants in a motor vehicle accident, where one of the defendants was uninsured and another defendant had insurance.

A Common Pleas Court in Monroe County has ruled that attorneys’ fees cannot be awarded once a provider’s bills for care related to a motor vehicle accident have been submitted to peer review under Section 1797 of the Motor Vehicle Financial Responsibility Law (MVFRL), and that Section 1716 of the MVFRL, the section dealing with the award of attorneys’ fees for unreasonable behavior on the part of the insurance carrier, does not apply. It is only when bills have not been submitted to peer review that attorneys’ fees can be awarded by a Court in a successful challenge to the peer review. The Court further ruled that only interest (12% per annum) can be awarded in a successful challenge to the peer review under Section 1797, and not attorneys’ fees. (Todd L. Roth vs. Erie Insurance Co., et al, Monroe County Court of Common Pleas, No. 9943 Civil 2005.)

One would think that if an insurance company paid for medical bills that it would also be willing to pay an uninsured motorist claim. Not so in the case of Pantellis v. Erie Insurance Company. The plaintiff in that case was a woman who was injured when a stolen van sideswiped her car. As a result of the accident, the plaintiff submitted her medical bills which were paid by Erie Insurance. She also submitted an uninsured motorist claim to Erie which Erie disputed by stating her injuries were not related to the accident with the uninsured van. This assertion was made by Erie even though they had already paid her medical bills relating to the same accident.

Unfortunately, the Pennsylvania Superior Court sided with Erie. The Court reasoned that just because an insurance company pays medical bills does not mean it is on the hook for paying an uninsured motorist claim. The Court reasoned that the statute regarding payment of first party benefits, i.e. medical bills, has a different standard under which an insurance company must meet its obligations to pay a claimant than it does to pay for under the uninsured motorist statute. Payment of medical bills, according to the Court, can be “triggered by something as simple as submission of a bill by a medical provider.” Payment of an uninsured motorist claim, however, requires “the wrongful conduct of a third party.” The Court is wrong for a number of reasons. First, an insurance carrier can deny payment of a medical bill if it does not think the care is related to the injury by having an independent medical exam conducted. Secondly, the insurance carrier can also submit the medical provider’s bill to peer review for denial. Submission of a bill, therefore, does not necessarily “trigger” payment of the bill by the carrier.