Metro. Grp. Prop. & Cas. Ins. Co. v. Hack
Metro. Grp. Prop. & Cas. Ins. Co. v. Hack
Opinion of the Court
Plaintiff Metropolitan Group Property and Casualty Insurance Company ("Metropolitan") advances this action for declaratory judgment against defendant William Hack ("Hack"). (Doc. 1). Hack brings a counterclaim of bad faith pursuant to 42 PA. CONS. STAT. § 8371. (Doc. 14). Metropolitan moves to dismiss Hack's counterclaim for failure to state a claim pursuant to Federal Rule of Civil Procedure 12(b)(6) (" Rule 12"). For the reasons that follow, the court will grant the motion in part and deny it in part.
I. Factual Background & Procedural History
Hack resides in Neelyton, Pennsylvania with his sister. (Doc. 1 ¶ 2, 14; Doc. 14 ¶ 2, 14). Metropolitan issued a personal automobile insurance policy to Hack's sister that covers Hack. (Doc. 1 ¶ 8; Doc. 1-2 at 2; Doc. 14 ¶ 8). Shortly after midnight on December 21, 2014, a motor vehicle struck his sister's home directly below Hack's second floor bedroom. (Doc. 1 ¶¶ 9-10, 17-18; Doc. 14 ¶¶ 9-10, 17-18, 49). Hack was asleep at the time of the accident. (Doc. 1 ¶ 17; Doc. 14 ¶ 17). During two recorded statements, Hack told insurance investigators for Metropolitan and the driver's insurance company that the force of the impact threw him out of bed causing him to hit and break a desk. (Doc. 1 ¶ 17-18; Doc. 14 ¶¶ 17-18, 23; see also Doc. 1-4; Doc. 1-5). Hack did not report any injuries the night of the accident. (Doc. 1 ¶ 17-18; Doc. 14 ¶ 17-18).
Following the accident, Hack experienced pain in his right arm and shoulder, and numbness in his fingertips. (Doc. 1 ¶¶ 17-18; Doc. 14 ¶¶ 17-18). After a few months of self-treating with Ibuprofen, Hack obtained professional treatment at his family's insistence. (Doc. 1 ¶¶ 17-18; Doc. 14 ¶¶ 17-18, 51). Hack saw an orthopedic surgeon who diagnosed him with C5 and C6 disc injuries and a pinched nerve. (Doc. 1 ¶¶ 17-18; Doc. 14 ¶¶ 17-18). Hack underwent physical therapy for his injuries at the Fulton County Medical Center. (Doc. 1 ¶ 17; Doc. 14 ¶ 17).
Hack filed an insurance claim with Metropolitan for services rendered to treat his injuries arising from the motor vehicle accident. (Doc. 14 ¶¶ 16, 21-23, 52). As requested, Hack provided Metropolitan with medical bills and authorizations, photographs of the vehicle and home involved, a copy of the police accident report, a diagram, and a recorded statement. (Doc. 14 ¶¶ 43, 53, 56, 58, 59). Metropolitan retained an accident reconstruction expert in furtherance of its investigation into Hack's claim. (Doc. 1 ¶ 26; Doc. 1-8). The expert's report indicates that the accident likely did not cause Hack's injuries. (Doc. 1 ¶ 28; see Doc. 1-8).
Metropolitan filed a complaint on June 30, 2016 seeking declaratory judgment and punitive damages for common law fraud. (Doc. 1). In its complaint, Metropolitan alleges that Hack made a fraudulent insurance claim and misrepresented the cause and extent of his injuries. (Id. ¶¶ 30-35). The court dismissed Metropolitan's fraud claim pursuant to the gist of the action doctrine. (Doc. 12).
*443Hack filed an answer on May 22, 2017 and asserted a counterclaim against Metropolitan for bad faith under 42 PA. CONS. STAT. § 8371. (Doc. 14 ¶¶ 71-78). He alleges that Metropolitan violated Section 8371 when it acted in bad faith toward Hack as follows:
(a) By unilaterally denying William Hack's medical claims without sufficient foundation to do so;
(b) By failing to utilize the ability to have William Hack to [sic] submit to a medical exam to determine the causal relationship of his injuries to the December 21, 2014, motor vehicle incident, as authorized by 75 Pa.C.S.A. § 1796 ;
(c) By failing to communicate with William Hack's medical providers to determine the causal relationship of his injuries to the December 21, 2014, motor vehicle incident;
(d) By failing to have William Hack's medical file referred to a Peer Review Organization for a determination of the reasonableness or necessity of treatment as authorized by 75 Pa.C.S.A § 1797(b) ;
(e) By purposefully withholding from William Hack transcribed recorded statements until it was on the verge of filing suit;
(f) By refusing to pay benefits under the policy when it knew, or should have known, it has no reasonable basis for doing so;
(g) By failing to investigate Plaintiff's claim in good faith;
(h) In being motivated by such improper purposes such as self-interest and ill-will;
(i) By conducting itself in such a manner so as to breach a known duty of good faith and fair dealing;
(j) By not attempting, in good faith, to effectuate prompt, fair, and equitable coverage of claims, once the [sic] its responsibility under its policy of insurance had become reasonably clear, in violation of 40 P.S. § 1171.5(10)(vi) ;
(k) By failing to affirm or deny coverage of its claims within a reasonable time after proof of loss was communicated and supplied to a representative of Metropolitan, in violation of 40 P.S. § 1171.5(10)(v) ;
(l) By failing to promptly provide a reasonable explanation of the basis of a denial of coverage in relation to the facts or applicable law for the denial of the claim, in violation of 40 P.S. § 1171.5(10)(xvi)[1 ];
(m) By instituting litigation alleging William Hack was fraudulently seeking to make claims for medical expenses;
(n) By misrepresenting to William Hack and his counsel the company's true position on the claim, in violation of 40 P.S. § 1171.5(10)(i) ;
(o) By failing to state its position on William Hack's claim prior to filing a lawsuit against its insured in order to deny coverage owed to William Hack;
(p) By failing to state its position on William Hack's claim for more than one year after the claim was initiated;
(q) By failing to state its position on William Hack's claim for more than six months after receiving a recorded *444statement from William Hack; and
(r) By refusing to pay claims without conducting a reasonable investigation based upon all available information, in violation of [ 40 P.S. § 1171.5(1)(iv) ].
(Doc. 14 ¶ 77). Metropolitan filed a motion to dismiss Hack's bad faith claim. (Doc. 18). Metropolitan's motion is fully briefed and ripe for disposition.
II. Legal Standard
Rule 12(b)(6) of the Federal Rules of Civil Procedure provides for the dismissal of complaints that fail to state a claim upon which relief may be granted. FED. R. CIV. P. 12(b)(6). When ruling on a motion to dismiss under Rule 12(b)(6), the court must "accept all factual allegations as true, construe the complaint in the light most favorable to the plaintiff, and determine whether, under any reasonable reading of the complaint, the plaintiff may be entitled to relief." Phillips v. Cty. of Allegheny,
Federal notice and pleading rules require the complaint to provide "the defendant fair notice of what the ... claim is and the grounds upon which it rests." Phillips,
III. Discussion
Hack asserts a bad faith counterclaim against Metropolitan under Section 8371. Metropolitan seeks dismissal of that counterclaim, arguing that Section 1797 of the Pennsylvania Motor Vehicle Financial Responsibility Law ("MVFRL"), 75 PA. CONS. STAT. § 1701 et seq. , preempts a Section 8371 claim when an insurer denies its insured first party medical benefits. We begin with a review of Sections 8371 and 1797.
A. Statutory Framework
The Pennsylvania legislature enacted Section 8371 to protect insureds from bad faith denials of coverage. The Brickman Group, Ltd. v. CGU Ins. Co.,
Pennsylvania's bad faith statute provides a private cause of action against insurance companies for bad faith denials of insurance coverage. 42 PA. CONS. STAT. § 8371. A successful Section 8371 bad faith claim permits an award of interest on the amount of the insurance claim, punitive damages, and costs and attorneys' fees. Id."[A]ny frivolous or unfounded refusal to pay proceeds of a policy" constitutes bad faith. Wolfe v. Allstate Property & Cas. Ins. Co.,
The MVFRL contains a similar provision permitting the award of exemplary damages when an insurer acts wantonly in denying first party benefits. 75 PA. CONS. STAT. § 1797(b)(4). The MVFRL mandates that automobile insurers provide medical benefits coverage "for reasonable and necessary medical treatment and rehabilitative services" arising out of the maintenance or use of a motor vehicle. Hickey v. Allstate Property and Cas. Ins. Co.,
The Third Circuit evaluated the potential conflict between Section 8371 and Section 1797 in Gemini Physical Therapy & Rehabilitation, Inc. v. State Farm Mutual Automobile Insurance Co.,
*446The Barnum court determined that the two statutes were "irreconcilable." Barnum,
Several district courts within the Third Circuit have interpreted Barnum and Gemini as affixing blanket preemption to all claims for first party benefits under the MVFRL.
This prevailing consensus emanates from the reasoning in Schwartz v. State Farm Insurance Co., No. 96-160,
We agree with the ratio decidendi of Schwartz and the expanding number of cases adopting it. The sine qua non that triggers Section 1797 is a dispute over the reasonableness or necessity of medical treatment. Hickey,
B. Application to Hack's Bad Faith Counterclaim
The pertinent inquiry sub judice is whether the misconduct alleged by Hack in support of his bad faith counterclaim falls outside the scope of Section 1797. See Urena,
Courts routinely hold that allegations of failure to pay first party benefits, investigate claims, act in a reasonable time and in good faith, fairly evaluate coverage, explain decisions, and effectuate a prompt and fair resolution of the claim are merely challenges to the reasonableness and necessity of the medical treatment. See Urena,
A number of Hack's allegations are not preempted by Section 1797. Subparagraph 77(d) asserts that Metropolitan failed to properly invoke the PRO process and does not appertain to the reasonableness or necessity of Hack's medical treatment. See
Hack's allegations in subparagraphs 77(j), (k), and (l) outline general claims of Metropolitan's failures in: (1) effectuating prompt settlement of claims in which Metropolitan's liability under the policy has become reasonably clear; (2) affirming or denying coverage within a reasonable time; and (3) explaining the basis for a denial of benefits. (Doc. 14 ¶ 77(j), (k), (l) ). Such claims are typically categorized as challenges to the denial of benefits. See Urena,
IV. Conclusion
The court will grant in part and deny in part Metropolitan's motion. (Doc. 18). Subparagraphs 77(a), (f), (g), (o), (p), (q), and (r) will be dismissed as preempted by Section 1797. Subparagraphs 77(b), (c), (d), (e), (h), (i), (m), and (n) fall outside the scope of Section 1797 and are cognizable under Section 8371. Subparagraphs 77(j), (k), and (l) will be dismissed to the extent they challenge a denial of benefits, but survive to the extent they relate to determinations of causation or contract interpretation. An appropriate order shall issue.
Section 1171.5(10)(xvi) does not exist. The language Hack quotes falls under Section 1171.5(10)(xiv). The court will address Section 1171.5(10)(xiv) when evaluating paragraph 77(1)'s sufficiency to state a claim upon which relief can be granted.
An insurer, insured, or medical provider may request reconsideration following a PRO's initial determination.
After the Third Circuit's decision, the Pennsylvania Supreme Court later reversed the superior court's decision in Barnum. The reversal was limited to the issue of whether an insured must request reconsideration under Section 1797(b)(2) before seeking judicial review under Section 1797(b)(4). The substantive rationale undergirding Gemini's holding thus remains sound and controls disposition of the matter sub judice.
The court notes with interest that district courts in this circuit have not applied a blanket preemption interpretation of Gemini and Barnum since 2006. See Cronin v. State Farm Mut. Auto. Ins. Co., No. 06-1081,
An insurer need not utilize the PRO process to enjoy the protections of Section 1797, however. Hickey,
Hack asserts that Metropolitan denied his claim for first party medical benefits. (See, e.g., Doc. 14 ¶¶ 74-75). It is unclear whether Metropolitan formally denied Hack's claim prior to commencing this litigation. (See Doc. 14 ¶¶ 60-66). Nevertheless, the complaint clearly sets forth the basis for Metropolitan's nonpayment of Hack's insurance claim. (See Doc. 1 ¶ 40).
Reference
- Full Case Name
- METROPOLITAN GROUP PROPERTY AND CASUALTY INSURANCE COMPANY v. William HACK
- Cited By
- 6 cases
- Status
- Published