This article originally ran in The Legal Intelligencer on January 28, 2014.
The state Superior Court has revoked the class certification issued to medical providers who have received overdue medical benefit payments from Progressive Insurance Co. excluding interest.
On Jan. 24, the court ruled 2-1 in Glick v. Progressive Northern Insurance to vacate a Philadelphia judge's order granting class status to Dr. Richard S. Glick and others who are awaiting interest payments from medical benefit claims arising from auto accidents.
In the court's memorandum, Judge John T. Bender wrote that the invoice forms Glick submitted to Progressive indicating that he had performed medical services for patients and charged for treatment did not constitute reasonable proof that the benefits were owed.
"Receipt of the HCFA-1500 form is merely indicative of treatment and provides prima facie evidence that such treatment was medically justified. It does not establish coverage for such treatment. Whether an insured is entitled to coverage in the form of medical benefits raises additional questions unanswered by mere submission of the form, including causation for example," Bender said. "Thus, we conclude that the HCFA-1500 form is relevant, but not necessarily sufficient evidence of the amount of the benefits."
In a separate dissenting statement, Judge Jack A. Panella said that he disagreed with the court's decision. Panella offered no reasoning beyond noting that he would have affirmed the trial court's order granting class certification.
According to Bender, Glick filed suit against Progressive, alleging that Progressive allows bills submitted to it to become overdue, subsequently remits payment of the principal, but fails to include payment of 12 percent interest required by Pennsylvania's Motor Vehicle Financial Responsibility Law (MVFRL).
The trial court granted class certification Oct. 1, 2003, Bender said. The class consisted of medical providers who had not received payment in full—that is, payment including interest—from Progressive in relation to payment of medical benefits stemming from motor vehicle accidents.
Bender said that construction of the phrase "reasonable proof of the amount of benefits," as it appears in the MVFRL, was the focus of both parties' arguments.
Submission of a HCFA-1500 form, Glick reasoned, directly states the amount of benefits due an injured person. According to Bender, Progressive argued on appeal that the form fails to address issues such as causation, coverage and medical necessity, thereby not constituting reasonable proof that an amount is owed.
Glick argued that the invoice provides precisely the proof that is required under the statute, according to Bender, with each form listing the patient, the insured, the medical provider, the diagnosis, the treatment administered, and the amount charged for the treatment.
The trial court concluded that the HCFA-1500 invoice did constitute reasonable proof and that if Progressive wished to challenge the amount listed on a bill, it could do so by consulting peer review. The court additionally ruled that Progressive had to pay the accrued interest on the received invoices.
Bender said that the trial court made a twofold error in its ruling.
"First, it equated receipt of the form with reasonable proof of the amount of the benefits. There is no support for this in the statutory language," Bender said.
Glick acknowledged that it was his common practice to submit medical records and insurance claims forms in addition to the invoices; thus, Bender concluded, the submission of the invoice alone was not enough to be considered reasonable proof.
The second error was that the trial court misconstrued the peer review process defined in Section 1797(b) of the MVFRL, Bender said.
The statute states that peer review evaluations shall be for the purpose of confirming that medical treatment, products, services or accommodations conform to the professional standards of performance and are medically necessary.
According to Bender, the statute "does not permit an insurer to investigate or challenge a bill on other grounds, such as whether a patient lacks coverage under a Progressive policy, whether a patient's injuries resulted from a motor vehicle accident, or whether a patient may be entitled to coverage under a different insurer's policy."
Bender remanded the case to the lower court, and noted that Glick could pursue his claims on an individual basis.
Progressive was represented by Robert Feltoon of Conrad O'Brien. Feltoon said he was pleased that the class certification that stood for roughly 12 years has been revoked.
Feltoon added, "At oral argument in July, Judge Bender was quite vocal and asked a lot of very difficult questions. Notwithstanding those difficult questions, I was pleased to see he authored the opinion in my favor."
Steven A. Schwartz of Chimicles & Tikellis in Haverford, Pa., represented Glick and did not return a call seeking comment.
Reprinted with permission from the January 28, 2014 issue of The Legal Intelligencer. © 2014 ALM Media Properties, LLC. Further duplication without permission is prohibited. All rights reserved.