MARCH 2006 BAD FAITH CASES BAD FAITH CLAIM PERMITTED WHERE PEER REVIEW PHYSICIAN ALLEGEDLY ENGAGED TO CHALLENGE CAUSATION BETWEEN AUTO ACCIDENT AND INJURY (Cumberland)
The Court of Common Pleas of Cumberland County was faced with the issue of whether plaintiff stated a bad faith claim by alleging that the carrier contracted with a PRO physician to manufacture grounds to avoid paying medical expense benefits. That court found that a claim had been stated, and overruled the motion to dismiss.
The insured alleged that the peer review doctor was engaged to negate the causal connection between an automobile accident and the plaintiff’s injuries. The Pennsylvania trial judge rejected the idea that a PRO doctor could use the peer review functions of making a determination of medical necessity or whether there was an accommodation to professional standards to get to causation.
Thus, “whether treatment is medically necessary for a specified injury is an entirely different issue form whether that injury is causally related to the accident and therefore covered under the applicable policy of insurance.”
Date of decision: March 24, 2006
Krol-Knight v. Peerless Insurance, Court of Common Pleas of Cumberland County, No. 2005-3844 Civil Term (C.C.P. Cumb. March 24, 2006) (Guido, J.)