Doctor's Choice Physical Medicine & Rehabilitation Center, P.C. v. Travelers Personal Insurance
92 A.3d 813
Pa. Super. Ct.2014Background
- Doctor’s Choice sued Travelers for unpaid medical charges under MVFRL, with LaSelva treated after a 2004 motor vehicle accident.
- Travelers refused payment after IMX peer review directed by Dr. Cavallo deemed some treatments unnecessary.
- Trial court ruled Cavallo’s review invalid, found the treatments reasonable and necessary, and awarded Doctor’s Choice unpaid expenses plus 12% interest, costs, and attorney’s fees.
- Herd-based post-trial ruling removed the attorney fees portion from the verdict after Travelers’ post-trial motions in 2013.
- Doctor’s Choice sought reinstatement of attorney fees; court ultimately vacated judgment and remanded for recovery of appropriate fees under 1797(b)(4).
- This appeal centers on whether attorney fees arise when the peer review is invalid but the treatment is found reasonable and necessary.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether 'challenged before a PRO' requires a valid peer review. | Doctor’s Choice: completed, compliant peer review required. | Travelers: Herd precludes fees when a peer review is pursued, regardless of validity. | Completed peer review required; invalid review cannot support fees. |
| Whether insurer is liable for attorney fees when the PRO review is invalid but treatment is found reasonable and necessary. | Doctor’s Choice: fees appropriate under 1797(b)(4)/(b)(6). | Travelers: Herd bars fees if a PRO was engaged, even if invalid. | Fees may be awarded where there is a valid challenge before a PRO; invalid review does not bar fees if no valid PRO decision exists. |
| How Herd, Levine, and related authorities apply to the 'challenged before a PRO' language. | Levine supports treating non-peer-review IMEs differently; must be a peer review. | Travelers: Herd controls and negates fees when a PRO is involved. | Levine controls; a true peer review must exist; Herd distinguished; fees may be reinstated. |
Key Cases Cited
- Herd Chiropractic Clinic, P.C. v. State Farm Mut. Auto. Ins. Co., 64 A.3d 1058 (Pa. 2013) (interprets 'challenged before a PRO' to require a completed peer review)
- Levine v. Travelers Property Cas. Ins. Co., 69 A.3d 671 (Pa. Super. 2013) (IME is not peer review; defines 'challenged before a PRO' not satisfied by non-peer-review reviews)
- Terminato v. Pa. Nat’l Ins. Co., 645 A.2d 1287 (Pa. 1994) (procedural framework for appeals from PRO determinations)
- Commonwealth v. Webbs Super Gro Prods., Inc., 2 A.3d 591 (Pa. Super. 2010) (statutory interpretation principles guiding construction of PRO provisions)
- In Re B.A.M., 806 A.2d 893 (Pa. Super. 2002) (reaffirms that statutory interpretation seeks plain meaning; avoid absurd results)
- Levine v. Travelers Property Cas. Ins. Co., 69 A.3d 671 (Pa. Super. 2013) (IME not peer review; distinguishes types of PRO determinations)