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Medical Arbitration Case Law

Case Law

Internal Appeal Requirement Prior To Arbitration

03-2-9454 N.J. Mfrs. Ins. Group v. North Jersey Surgery Ctr., N.J. Super. App. Div. (per curiam) (6 pp.) After being involved in an automobile accident, plaintiff’s insured received medical treatment from defendant on various dates. Defendant obtained an assignment of the insured’s claim for PIP benefits. After a dispute arose regarding those benefits, defendant filed a demand for arbitration, seeking payment from plaintiff for the treatment rendered. The arbitrator found that the only valid appeal related to one date and that the other dates of service were invalid in light of plaintiff’s internal appeals process, which required specification of the issues accompanied by supporting documentation at least 21 days prior to initiating arbitration. Defendant filed an appeal with plaintiff for the denied dates of service. After plaintiff denied coverage, defendant renewed its demand for arbitration. The second dispute resolution professional found that the demand with respect to the disputed dates of service was barred by the doctrine of collateral estoppel. Plaintiff filed an order to show cause with a verified complaint seeking to confirm the second DRP’s award, which was granted. On appeal, defendant argued that the trial judge failed to utilize the statutory criteria for vacating an arbitration award, N.J.S.A. 2A:23A-13, and that its claims were not barred by collateral estoppel. Noting that the New Jersey Alternative Procedure for Dispute Resolution Act imposed strict limitations on the appeal of an arbitration award, and discerning no applicable exception to the statutory prohibition of appellate review set forth in N.J.S.A. 2A:23A-18(b), the panel affirmed. [Filed May 19, 2015].

PIP Statute of Limitations Runs Two Years From Receipt of the Formal PIP Application

In New Jersey Manufacturers Ins. v. Holger Trucking Corp., 417 N.J. Super. 393 (App. Div. 2011), the Appellate Division ruled that the phrase “filing of the claim” means the receipt, by the insurer, of the formal PIP application/claim form, even where the insurer had previously opened a file, assigned it a claim number, received medical bills and treatment plans and had had approved a treatment plan.

PIP discovery narrowed as to medical providers

Selective Ins. Co. v. Hudson East Pain Management, 416 N.J. Super. 418(App. Div. 2010), Parrillo. 210 N.J. 597 (2012), Welfing.  On July 18, 2012, a unanimous New Jersey Supreme Court narrowly read the cooperation clauses of automobile insurance policies, and a discovery provision of New Jersey’s personal injury protection (PIP) statute, ruling that health insurers cannot rely upon such cooperation clauses or the PIP discovery statute to demand information on ownership, billing practices and referral methods of medical providers who have been assigned PIP benefits by their insureds.

Physician Assistants are Precluded from performing needle EMG studies

Selective v. Rothman, 414 N.J. Super. 331 (App. Div. 2010), Yannotti.208 N.J. 580(2012), per curiam. The Supreme Court affirmed the Appellate Division’s decision that physician assistants are precluded from performing needle EMG studies because they may not insert a needle into a muscle. In short, a licensed physician must perform EMG testing.

Insurer to pay Counsel fees

IFA Ins. Co v. Millburn Surgical Center, (unreported -2011 WL 1376677, N.3. Super A.D., April 13,2011 (NO. A-5352-09T1)). A medical provider who successfully defends against an insurance carrier’s suit over PIP benefits can collect attorney’s fees and costs without having to prove bad faith, a state appeals court ruled. The Appellate Division, in IFA Insurance Co. v. Millburn Surgical Center, A-5352-09 found an Essex County judge erred in declining to award fees where a carrier failed in its challenge to the amount of an arbitrator’s award to a medical provider.