Justia Pennsylvania Supreme Court 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

The Pennsylvania Supreme Court granted review to consider an issue of first impression regarding whether an insured forfeits insurance coverage by settling a tort claim without the consent of its insurer, when the insurer defends the insured subject to a reservation of rights, asserting that the claims may not be covered by the policy. In 1994, a class action lawsuit was filed against Appellant-Insureds Babcock & Wilcox Company (B&W) and Atlantic Richfield Company (ARCO) (collectively, Insureds) brought by plaintiffs claiming to have suffered bodily injury and property damage caused by emissions from nuclear facilities owned by Insureds. Over time, the class action grew to include over 500 named plaintiffs, who lived near the nuclear facilities. Insureds denied that the facilities released any emissions or that the harm suffered by plaintiffs resulted from the facilities. While the underlying tort action was pending in federal court, disputes arose between Insureds and their insurers, Appellees American Nuclear Insurers and Mutual Atomic Energy Liability Underwriters (collectively ANI or Insurer). At the outset of the litigation, Insurer acknowledged that it would defend Insureds but contested whether the policy covered aspects of the claims, and thus defended subject to a reservation of rights. While staying various claims for future determination, including the breach of the duty to cooperate claim, the court decided issues regarding the trigger of coverage and held that B&W and ARCO were entitled to separate counsel. During the course of the litigation, Insurer refused consent to any settlement offers presented to it due to its conclusion that the case had a strong likelihood of a defense verdict given the lack of medical and scientific support for plaintiffs’ claims and decisions by the federal trial court regarding procedural and evidentiary issues in the pending retrial, which Insurer viewed as highly favorable to Insureds’ ultimate outcome. After presenting the settlement offers to Insurer and being denied consent, Insureds ARCO and B&W, respectively in 2008 and 2009, settled with the class action plaintiffs for a total of $80 million, which was substantially less than the $320 million of potential coverage. Insureds then sought reimbursement of the settlement amount from Insurer. The Supreme Court found that after an extensive trial where the jury was presented with voluminous evidence relating to the strength of the underlying action and the settlement offer, the jury determined that the settlement was “fair and reasonable from the perspective of a reasonably prudent person in the same position of [Insureds] and in light of the totality of the circumstances,” a standard which the Court adopted as the proper standard to apply in a reservation of rights case where an insured settles following the insurers’ refusal to consent to settlement. The Court concluded that the Superior Court erred by requiring an insured to demonstrate bad faith when the insured accepts a settlement offer in a reservation of rights case. Accordingly, the Superior Court's decision was reversed and the trial court's judgment reinstated. View "Babcock & Wilcox Co. v. American Nuclear Insurers & Mutual Atomic Energy Liability Underwriters" on Justia Law

Penn Treaty Network America Insurance Company (“PTNA”) and its subsidiary, American Network Insurance Company (“ANIC”) (collectively, the “Companies”), were Pennsylvania life insurers specializing in long-term care insurance, covering skilled-nursing, nursing home, and assisted living and home health care for individuals with chronic illnesses or disabilities. In January 2009, the Commonwealth Court ordered the rehabilitation of the Companies, upon application of then-Insurance Commissioner Joel Ario, who cited the consent of both entities as the sole grounds for the orders of rehabilitation. Nine months after entry of the rehabilitation order, however, Commissioner Ario filed petitions to covert the Companies’ rehabilitations into liquidations. The Commonwealth Court, per a single-judge proceeding, conducted hearings spanning thirty days of testimony and encompassing the submission of thousands of pages of exhibits and documentary evidence. In May 2012, the Commonwealth Court entered an order denying the petitions to liquidate and directed the Commissioner to develop a plan of rehabilitation within ninety days. The Commonwealth Court concluded the Rehabilitator’s evidence did not show that a rehabilitation was tried and failed. "Rather, it showed that a rehabilitation plan was abandoned in its nascency. In short, the Rehabilitator did not prove that continued rehabilitation substantially increases the risk to policyholders, creditors and the public or is futile." A critical facet of the Commonwealth Court’s opinion concerned the degree of deference owing to a statutory rehabilitator on consideration of a conversion petition. The Commissioner challenged the Commonwealth Court’s decision in such regard, namely, that the court’s no-deference determination was, in fact, inconsistent with the case which it had referenced as being supportive. The Supreme Court affirmed: "In all events, deference does not require the courts to accede to a misuse of the process. In light of the above, and the former Commissioner’s accession at the outset of the rehabilitation proceedings that liquidations would be harmful to policyholders, as well as the Commonwealth Court’s supported finding that there is no present harm in moving forward in rehabilitation, we decline to impede that court’s review of the rehabilitation plan which it directed should be filed, and which has now been submitted. The judicial review, however, should proceed subject to a more deferential overlay relative to the new acting Commissioner." View "In Re: Penn Treaty Network" on Justia Law

In 2009, George Lawrence, while employed by Schneider National Inc., suffered a work-related injury when he slipped and fell in a parking lot leased by Domtar Paper Company, and allegedly owned and maintained by Commercial Net Lease Realty Services, Inc., Commercial Net Lease Realty Trust, Commercial Net Lease Realty, Inc., National Retail Properties, Inc., and National Retail Properties Trust. As a result of this injury, Schneider's workers' compensation carrier, Liberty Mutual Insurance Company, paid Lawrence $33,929.23 in workers' compensation benefits. The issue this case presented for the Supreme Court's review centered on whether section 319 of the Pennsylvania Workers' Compensation Act (WCA) conferred on employers or their workers' compensation insurers a right to pursue a subrogation claim directly against a third-party tortfeasor when the injured employee took no action against the tortfeasor. Based on established precedent, the Superior Court held that Section 319 did not permit employers/insurers to commence an action directly against the third-party tortfeasor, and affirmed the trial court's grant of preliminary objections in favor of the tortfeasors. Agreeing with that reasoning, the Supreme Court affirmed. View "Liberty Mutual Ins. Co. v. Domtar Paper Co." on Justia Law

In this matter, Appellants John and Kathy St. John challenged the Superior Court’s decision to affirm a declaratory judgment order finding Pennsylvania National Mutual Casualty Insurance Company (“Penn National”) liable for a judgment against its insured LPH Plumbing and Heating under a commercial general liability (CGL) insurance policy in effect from July 1, 2003 to July 1, 2004. The Supreme Court granted review to determine whether, under the facts of this case and the policy language at issue, Penn National was instead liable for the judgment against its insured under a separate policy of CGL insurance as well as a companion umbrella policy in effect from July 1, 2005 to July 1, 2006. Furthermore, the Court also considered whether the multiple trigger theory of liability insurance coverage (adopted by the Supreme Court in "J.H. France Refractories Co. v. Allstate Ins. Co.," 626 A.2d 502 (Pa. 1993)), within the context of asbestos bodily injury claims applied in this case, where property damage was continuous and progressive, to trigger coverage under all policies in effect from exposure to the harmful condition to manifestation of the injury. After review, the Supreme Court affirmed all aspects of the lower court’s decision finding that coverage was triggered under the policy in effect from July 1, 2003 to July 1, 2004, when property damage became reasonably apparent, and declining to apply the multiple trigger theory of liability insurance coverage. View "PA Natl Mut Casualty v. St. John" on Justia Law

In 2007, Jared Wolfe was injured when his vehicle was hit from behind by an automobile driven by Karl Zierle. Wolfe attributed blame to Zierle and demanded $25,000 from Zierle’s insurer carrier, Appellant Allstate Property and Casualty Insurance Company, equating to half the liability limits under the applicable policy. Allstate counteroffered $1,200, which Wolfe refused. Wolfe then instituted a personal injury action against Zierle seeking compensatory damages grounded in negligence. Allstate assumed Zierle’s defense while maintaining its additional right, under the policy, to effectuate a settlement. The Pennsylvania Supreme Court accepted certification from a federal appeals court to clarify whether, under Pennsylvania law, an insured may assign the right to recover damages from his insurance company deriving from the insurer’s bad faith toward the insured. The Court concluded that the entitlement to assert damages under Pennsylvania law may be assigned by an insured to an injured plaintiff and judgment creditor such as Wolfe. Having answered the certified question, the Court returned the matter to the federal court. View "Allstate Prop & Casualty Ins Co. v. Wolfe" on Justia Law

In an interlocutory appeal, the issues before the Supreme Court were: (1) whether a negligence claim brought against an insurer by its insureds for alleged statements made by the insurer’s adjuster and an engineer the insurer had retained (that mold the insureds discovered while performing home renovations was harmless and that they should continue their renovations) was barred by the “gist of the action” doctrine on the grounds that the true gist or gravamen of the action was an alleged breach of the insurance contract (their homeowners’ policy); and (2) whether the provisions of Pa.R.C.P. 1042.1 and 1042.3 required the insureds to obtain a certificate of merit in order for them to proceed with their negligence suit against the professional engineer employed by the insurer to evaluate the mold. After careful review, the Supreme Court held that the insureds’ negligence claim was not barred by the gist of the action doctrine, as the claim was based on an alleged breach of a social duty imposed by the law of torts, and not a breach of a duty created by the underlying contract of insurance. Furthermore, the Court concluded that the insureds were not required to obtain a certificate of merit in order to proceed with their negligence suit against the professional engineer, since they were not patients or clients of the engineering company which employed him. Consequently, the Court reversed the Superior Court and remanded for further proceedings. View "Bruno v. Erie Insurance" on Justia Law

In 2007, neighbors reported a fire that had erupted at the home of the Terrence and Judith Tincher in Downingtown. The residence was the central unit of a two-story triplex purchased by the Tinchers in 2005. The fire was eventually extinguished and no one was harmed. Investigators concluded that a lightning strike near the home caused a small puncture in the corrugated stainless steel tubing (“CSST”) transporting natural gas to a fireplace located on the first floor of the residence. The CSST installed in the Tinchers’ home was manufactured and sold by Omega Flex as part of a gas transportations system marketed as the TracPipe System. The melting of the CSST caused by the lightning strike ignited the natural gas and fueled the fire estimated to have burned for over an hour. The fire caused significant damage to the Tinchers’ home and belongings. After the fire, the Tinchers reported the incident to their insurer, United Services Automobile Association (“USAA”). USAA compensated the Tinchers for their loss up to the limit of their policy and received an assignment of liability claims. The Tinchers suffered an additional out-of-pocket loss because a portion of their claimed loss exceeded the limits of the USAA policy. In January 2008, the Tinchers filed a complaint against Omega Flex; USAA prosecuted the claims in the name of the Tinchers to obtain reimbursement of the insurance proceeds payout, but the Tinchers retained an interest in the litigation to recover the losses exceeding their insurance coverage. The Tinchers asserted claims premised upon theories of strict liability, negligence, and breach of warranty, alleging that Omega Flex was liable for damages to their home caused by the placement on the market and sale of the TracPipe System. Omega Flex, Inc., appealed the Superior Court's decision to affirm the judgment on the verdict entered in favor of the Tinchers. After review, the Supreme Court reversed in part, and remanded the case with instructions: (1) "Azzarello v. Black Brothers Company," (391 A.2d 1020 (Pa. 1978)) was overruled; (2) a plaintiff pursuing a cause upon a theory of strict liability in tort must prove that the product is in a “defective condition”; (3) whether a product is in a defective condition is a question of fact ordinarily submitted for determination to the finder of fact; (4) to the extent relevant here, the Court declined to adopt the Restatement (Third) of Torts: Products Liability despite acknowledging that "certain principles contained in that Restatement has certainly informed [its] consideration of the proper approach to strict liability in Pennsylvania in the post-Azzarello paradigm." View "Tincher v. Omega Flex, Inc." on Justia Law

Appellant, a six-year-old boy diagnosed with an autism-spectrum disorder, was receiving applied behavior analysis (“ABA”), a type of autism-related service, in his home. ABA was covered by his family’s insurance policy with Appellee Independence Blue Cross. Appellant’s family requested that Blue Cross cover similar ABA services to be provided at Appellant’s elementary school in 2009. The insurer denied the request, pointing to a place-of-service exclusion in the policy which specified that no services would be covered if the care was provided at certain types of locations, including schools. This decision was unsuccessfully appealed internally. The dispute was then submitted to an independent external review agency appointed by the Pennsylvania Department of Insurance. In December 2009, that agency upheld the denial based on the policy’s place-of-service exclusion. Meanwhile, the General Assembly passed Act 62 of 2008, which, inter alia, required that health insurance policies provide coverage for the treatment of autism spectrum disorders. In 2010, Appellant filed suit seeking declaratory and injunctive relief in the form of a ruling that the policy’s place-of-service exclusion is null and void under Act 62, as well as an order directing the insurer to cover Appellant’s medically necessary treatments. Blue Cross filed responsive pleadings and Appellant requested judgment on the pleadings. The court ultimately rejected the argument that the policy’s place-of-service exclusion was a general exclusion as contemplated by Section 764h(c). Thus, it held that, under Section 764h(a), Blue Cross was required to provide coverage for school-based ABA services during the relevant time period. The common pleas court ordered the insurer to “take action consistent with this decision.” On appeal, the Superior Court, sua sponte, questioned whether the common pleas court should have entertained the appeal under Act 62. The Pennsylvania Supreme Court allowed review to consider whether individuals diagnosed with autism spectrum disorders have the right to judicial review of a denial of insurance coverage, considering the language of Act 62. "Here, we are faced with a situation in which a litigant sought a declaration of his rights under a legislative enactment, a task over which the common pleas court could have exercised jurisdiction, pursuant to the Declaratory Judgments Act, in response to the correct form of pleading. Furthermore, the complaint’s asserted basis for jurisdiction was deficient only because of the confusion created by an apparent drafting mistake by our General Assembly. Neither the court nor the defendant Insurer realized that anything was amiss in this regard and, if they had, Appellant could presumably have made any necessary formal corrections. Under these circumstances, we conclude that the common pleas court was permitted to reach the substantive claim forwarded in Appellant’s pleadings. It follows that the intermediate court should not have reversed the order of that court by sua sponte pointing to the language of Section 764h(k)(2) as a bar to Appellant’s ability to seek relief in a judicial forum, without first evaluating whether the common pleas court’s assessment of the substantive question could be justified on some other basis." View "Burke v. Independence Blue Cross" on Justia Law