Sharp v. Travelers Personal Security Insurance
Opinion of the Court
— The insured and insurer have both filed de novo discovery appeals in this first-party medical expense benefits case in which the insured has asserted causes of action for breach of contract and violations of the Unfair Trade Practices and Consumer Protection Law (“UTPCPL”), 73 P.S. § 201-1 et seq. The parties’ cross-appeals concern the discovery of the insurer’s loss reserves for the insured’s claims, its underinsured motorist (UIM) claim file for the insured, the insurer’s claims practices manuals, the personnel files for certain adjusters of the insurer, a compilation of other peer reviews requested by the insurer, other lawsuits and insurance department complaints pertaining to medical expense benefits claims against the insurer under insurance policies with coverage limits of $100,000.00 or more, records of payments made to the health care professionals who conducted any peer reviews in this matter, and materials generated by the insurer after the insured’s medical expense benefits claim was initially closed by the insurer.
Since the insured has not asserted an independent claim for bad faith liability against the insurer, its reserves information is protected from discovery as opinion work product and the personnel files of its claims representatives are not discoverable under the heightened standard of relevance applicable to such requests. Nor is the insurer’s closed UIM claim file for the insured relevant to any issues raised in this case. The insurer’s 2009-2010 claims practices manuals and training materials concerning the handling
I. FACTUAL BACKGROUND
On February 13, 2009, plaintiff, Rowland Sharp (“Sharp”), was involved in a motor vehicle accident
On April 2, 2009, Sharp’s original counsel notified Travelers’ claims representative of his representation of Sharp. (Id. at ¶ 38). Sharp contends that on the following day, Travelers retained Professional Dynamics Inc. to conduct a peer review of the chiropractic treatment of Dr. Pavelski.
Travelers did not inform Sharp or his counsel of Dr. Schensul’s three peer review reports which found that Sharp’s chiropractic treatment was reasonable and necessary and that further chiropractic treatment was indicated. (Id. at ¶¶ 53-54). Instead, on July 28, 2009, Travelers notified Sharp that the chiropractic records and bills of Dr. Pavelski and Dr. Evans were being forwarded to a PRO to determine if that treatment was reasonable and necessary, and Travelers thereafter forwarded those bills to Jess P. Armine, D.C., for his review. (Id. at ¶¶ 46-47). On September 10, 2009, Dr. Armine authored a report in which he opined that any chiropractic care provided after April 15, 2009, was not reasonable and necessary. (Id. at ¶¶ 47,49). On September 15, 2009, Travelers mailed a copy of Dr. Armine’s report to Dr. Pavelski, Dr. Evans and Sharp’s original counsel, and advised them that Travelers would not pay for any chiropractic care provided after April 15, 2009. (Id. at ¶¶ 49,51,56).
Less than one month later, Travelers retained MES Solutions on October 10, 2009, in an effort to schedule a medical examination of sharp.
By letter dated January 8, 2010, Travelers informed Sharp that his medical examination would be conducted by another physician, and that the examination would be unilaterally scheduled by Travelers unless Sharp notified Travelers by January 13, 2010, of “any days during the week that would not be convenient” for him. (Id. at ¶ 72). On January 27, 2010, Travelers’ unit manager demanded that Sharp furnish Travelers with prospective dates and times for a medical examination, and indicated that Travelers would discontinue payment of his first party benefits if Sharp did not provide convenient dates and times by February 1, 2010. (Id. at ¶ 73). On March 8, 2010, Travelers forwarded a letter to Sharp stating that it would not pay any medical bills incurred after January 15, 2010, due to Sharp’s “noncompliance” in scheduling
After Sharp retained his current counsel in 2012, (Docket entry no. 1 at ¶ 54), he commenced this action against Travelers on November 1, 2012, asserting causes of action for breach of contract, violations of the MVFRL and the Uniform Trade Practices and Consumer Protection Law (UTPCPL), 73 P.S. § 201-1 et seq., and “Vicarious Liability.” (Id. at ¶¶ 99-132). Sharp maintains
Sharp’s complaint contains a litany of allegations of misconduct by Travelers in connection with its handling and consideration of Sharp’s claims for medical expense benefits. (Id. at ¶ 95(a)-(xx)). Included among those allegations is Sharp’s assertion that Travelers breached its implied duty of “good faith and fair dealing” under the insurance policy. (Id. at^ 95(v), 96,102-104, 111). Sharp demands payment of his unpaid medical and chiropractic bills, as well as 12% interest on those benefits, and recovery of counsel fees and expenses pursuant to Sections 1716 and 1798 of the MVFRL, 75 Pa.C.S.A. §§ 1716, 1798. (Id. at ¶¶ 87, 95, 117-121). Sharp does not assert a claim for first party bad faith liability under 42 Pa.C.S.A. § 8371, presumably due to the fact that his present counsel was not retained, and this action was not filed, within two years of
Sharp served 101 interrogatories and 75 requests for production of documents upon Travelers, which asserted twenty-five objections to the interrogatories and forty-nine objections to the requests for production. (Docket entry no. 33 at p. 2). Sharp presented a discovery motion to the special discovery master on September 23, 2013, (Docket entiy nos. 22-24), and on November 7, 2013, the discovery master issued an order addressing Travelers’ objections, only eight of which are relevant to these appeals. (Docket entry no. 25). The discovery master sustained Travelers’ objection to Sharp’s request for Travelers’ “reserve information” pertaining to Sharp’s first-party benefits claim and underinsured motorist (UIM) claim. (Id. at p.l). The master overruled Travelers’ objections to the following seven items of discovery: (1) Travelers’ file concerning Sharp’s UIM claim; (2) Travelers’ “claims and policy manuals” and “educational and training materials” regarding the handling of first-party benefits claims “insofar as they were in place at the time of the adjustment” of Sharp’s claim; (3) the “personnel files of each adjuster” who handled Sharp’s first-party benefits claim, “with the appropriate redaction of personal, private and protected information;” (4) “information regarding any and all Pennsylvania
On November 15, 2013, Sharp and Travelers both filed de novo appeals of the special discovery master’s ruling.
II. DISCUSSION
Under Pa.R.C.P. 4003.1, “discovery is liberally allowed with respect to any matter, not privileged, which is relevant to the cause being tried.” Berg v. Nationwide Mutual Insurance Company. Inc., 44 A.3d 1164, 1178 n. 8 (Pa. Super. 2012), app. denied, 65 A.3d 412 (Pa. 2013). Information is relevant “if it logically tends to establish a material fact in the case, tends to make a fact at issue more or less probable or supports a reasonable inference or presumption regarding a material fact.” Kelin v. Aronchick, 2014 WL 46648, at * 9 (Pa. Super. 2014); Smith v. Morrison, 42 A.3d 131, 137 (Pa. Super. 2012), app. denied, 57 A.3d 71 (Pa. 2012).
The relevancy standard applicable to discovery is necessarily broader than the standard used at trial for the admission of evidence. Com. v. TAP Pharmaceutical Products, Inc., 904 A.2d 986, 994 (Pa. Cmwlth. 2006); George v. Schirra, 814 A.2d 202, 205 (Pa. Super. 2002). The party objecting to discovery generally bears the burden of establishing that the requested information is not relevant or discoverable. Koken v. One Beacon Insurance Company, 911 A.2d 1021, 1025 (Pa. Cmwlth. 2006); Yadouga v. Cruciani, 66 Pa. D. & C. 4th 164, 168 (Lacka. Co. 2004). Any doubts regarding relevancy are to be resolved in favor of discovery. Ario v. Deloitte & Touche, LLP, 934 A.2d 1290, 1293 (Pa. Cmwlth. 2007).
(B) RELEVANT THEORIES OF LIABILITY
In addition to demanding the payment of medical and chiropractic expenses under the policy’s first-party
Section 1798(b) similarly provides that “[i]n the event an insurer is found to have acted with no reasonable foundation in refusing to pay the benefits...when due, the insurer shall pay, in addition to the benefits owed and the interest thereon, a reasonable attorney fee based upon actual time expended.” 75 Pa.C.S.A. § 1798(b). For example, an insurer’s “decision to rely upon the reports of
In Count III of the complaint, Sharp also advances a private cause of action under the UTPCPL for alleged “unfair or deceptive business practices” by Travelers. See Lesoon v. Metropolitan Life Insurance Company, 898 A.2d 620, 627 (Pa. Super. 2006) (“This court has repeatedly observed that the UTPCPL is governed by a six-year statute of limitations”), app. denied, 590 Pa.
The UTPCPL is designed “to protect the public from unfair or deceptive business practices,” Dearmitt v. New York Life Ins. Co., 73 A.3d 578, 591 (Pa. Super. 2013), and Section 9.2 of the act provides a private cause of action for any person who “suffers any ascertainable loss of money or property” as a result of an “unlawful” method, act or practice under the Act. 73 P.S. § 201-9.9.2(a). Section 2(4)
Successful claimants may “recover actual damages” under the UTPCPL, Dearmitt, 73 A.3d at 593, and “the court may, in its discretion, award up to three times the actual damages sustained,” together with “costs and reasonable attorney fees.” 73 P.S. § 201-9.2(a). Pursuant to their authority to fashion an appropriate damages multiplier, trial courts possess the discretion under the UTPCPL to award double damages rather than treble damages. Bennett, 40 A.3d at 156. In deciding whether to award double or treble damages, the court “should focus on the presence of intentional or reckless, wrongful conduct, as to which an award of treble damages would be consistent with, and in furtherance of, the remedial purposes of the UTPCPL.” Schwartz v. Rockey, 593 Pa. 536, 557, 932 A.2d 885, 898 (2007); Pasqualini v. Altieri Enterprises, Inc., 2010 WL 28655, at * 5 (M.D. Pa. 2010).
Based upon the foregoing, the relevant issues in this case are: (1) whether Travelers breached its express or implied duties under the insurance contract by failing to pay Sharp’s medical and chiropractic expenses; (2) whether Travelers “acted in an unreasonable manner in refusing to pay” those benefits by acting “clearly contrary to the terms of the policy,” or “acted with no reasonable foundation in refusing to pay” the benefits; and (3) whether Travelers committed “malfeasance” in the performance of its contractual obligations, and if so, whether it engaged in “intentional or reckless, wrongful conduct” in the process, thereby warranting an award of treble damages. However, since Sharp has not asserted a timely claim for bad faith
(C) RESERVE INFORMATION FOR MEDICAL EXPENSE BENEFITS AND UIM CLAIMS
Sharp’s discovery appeal concerns his interrogatory nos. 29 and 30 and requests for production of documents nos. 7,66 and 67 seeking information pertaining to Travelers’ insurance reserves for Sharp’s medical expense benefits and UIM claims. Pennsylvania law requires insurance companies to set aside reserves upon notice of potential claims under their policies, see 40 P.S. §§71, 71.1, 73, 92, 112, 115, 151, 156, in order to “ensure that insurance companies are able to pay once liability is established or
Reserves represent “the insurer’s own estimate of the amount which the insurer could be required to pay on a given claim,” and “the criteria used to set them vary widely depending upon the company and the type of insurance.” Mirarchi v. Seneca Specialty Insurance Company, 2011 WL 2982401, at * 2 (E.D. Pa. 2011). Some courts have noted a “tenuous link between reserves and actual liability given that numerous considerations factor into complying with this statutory directive.” Fidelity & Deposit Co., 168 F.R.D. at 525 (citing Rhone-Poulenc Rorer, Inc. v. Home Indemnity Co., 139 F.R.D. 609, 613 (E.D. Pa. 1991)). In the only appellate precedent addressing the discoverability of insurance reserve information, the Superior Court of Pennsylvania concluded that “[ijnsurance reserves, by their very nature, ‘are prepared in anticipation of litigation, and consequently, are protected from discovery as opinion work product.’” PECO Energy Co. v. Insurance Co. of North America, 852 A.2d 1230, 1234 (Pa. Super. 2004) (quoting Rhone-Poulenc Rorer, 139 F.R.D. at 614). Characterizing insurance reserves information as non-discoverable work product under
Several trial courts, including this court, have reasoned that insurance reserves are discoverable in bad faith litigation against insurers, where liability for the underlying claim has already been established, since such information may be relevant to the issue of whether the insurer acted in bad faith in failing to settle or pay the original claim. See Consugar v. Nationwide Insurance Co. of America, 2011 WL 2360208, at * 5 (M.D. Pa. 2011) (“Since plaintiff here claims that defendant acted in bad faith, a comparison between the reserve value of the claim and defendant’s actions in processing plaintiff’s claim could shed light on defendant’s potential liability”); North River Ins. Co., 872 F.Supp. at 1412 (finding reserve information “relevant to the question of whether or not [the insurer] acted in bad faith during the pre-trial settlement negotiations”); McAndrew v. Donegal Mutual Ins. Co., 56 Pa. D. & C. 4th 1, 18 (Lacka. Co. 2002); Fretz v. Mutual Benefit Ins. Co., 37 Pa. D. & C. 4th 173, 180 (Alleg. Co. 1998). Other courts have concluded that insurance reserves are not discoverable in bad faith actions against insurers. See Safeguard Lighting System v. American Specialty Ins.
Sharp contends that Travelers’ loss reserve for his “first
Since Sharp has not presented a first party bad faith claim against Travelers based upon its handling of Sharp’s medical expense benefits and UIM claims, Travelers’ loss reserves information for those claims remains protected from discovery as opinion work product. See PECO Energy Company, 852 A.2d at 1234-1235. Sharp argues that his assertion of breaches of the implied duties of good faith and fair dealing transforms his breach of contract
Because Sharp has not filed a separate claim for bad faith liability in this case, Travelers’ reserve information is not relevant or discoverable. As a result, Travelers’ objections to that discovery will be sustained, and Sharp’s de novo discovery appeal will be denied.
(D) TRAVELERS’ UIM CLAIM FILE
In its discovery appeal, Travelers first challenges the discovery master’s order requiring it to produce its file
“Evidence is relevant if it tends to prove or disprove a material fact.” Schuenemann V. Dreemz, LLC, 34 A.3d 94, 101 (Pa. Super. 2011). The record submitted by the parties does not suggest that information or material contained in the UIM file could conceivably indicate that Travelers conducted peer reviews of Sharp’s medical and chiropractic bills in an intentional and concerted effort to negatively impact his UIM claim. Compare Robertson v. Allstate Insurance Company, 1999 WL 179754, at * 6 (E.D. Pa. 1999) (“Allstate admits that the first party claim file had been reviewed by the UIM negotiator”). Although discovery should be liberally allowed, “fishing expeditions” are not to be countenanced under the guise of discovery. See Koken, 911 A.2d at 1025 (stating that while “[discovery is liberally allowed,” “[discovery requests must also be reasonable” and “a court can prohibit the discoveiy of matters which...would amount
(E) TRAVELERS’ CLAIMS/POLICY MANUALS AND EDUCATIONAL/TRAINING MATERIALS
Travelers has also appealed the discovery master’s order compelling production of its “claims and policy manuals” and “educational and training materials” that relate to the handling of first party benefits claims, and which were in effect during the time period that Sharp’s medical and chiropractic bills were considered and denied. Travelers argues that training and policy manuals have only been deemed discoverable in bad faith actions, and that those materials “will not shed light on the factual issue of whether Travelers improperly withheld payment or whether Travelers engaged in deceptive trade practices.” (Docket entry no. 35 at pp. 7-8). Once again, Sharp posits that these documents are discoverable because “[Sharp] has clearly asserted a common law bad faith claim within his complaint.” (Docket entry no. 36 at p. 6).
It is beyond cavil that an insurer’s claims practice manual setting forth its procedures and guidelines for handling claims is relevant evidence in a bad faith action against an insurer. See Grossi, 79 A.3d at 1149; Zappile v. Amex Assurance Co., 928 A.2d 251, 258 (Pa. Super. 2007), app.
Travelers’ policy manuals and training materials should reflect its guidelines and philosophy for reviewing claims for medical expense benefits, including the use of peer reviews and medial examinations. See, e.g., Bonenberger, 791 A.2d at 381-382 (insurer’s claims manual “called for ‘aggressive use of [medical examinations],’ attempts at catching claimants ‘off guard’ and assigning cases to defense counsel who fully follow the adjuster’s orders and who refrain from exercising independent judgment”). Those materials should indicate whether Travelers has formulated a policy of submitting peer review requests to “biased” PROs for the purpose of fabricating a basis upon which to deny payment of medical or chiropractic bills. See Perkins, 589 F.Supp.2d at 567. Conversely, if Travelers’ claims handling manual discourages the use of serial peer reviews, particularly after obtaining a PRO report concluding that the treatment reviewed was reasonable and necessary, it could arguably demonstrate that any alleged malfeasance by Travelers’ adjusters in that regard was “intentional or reckless,” thereby justifying an award of treble damages. See Schwartz, supra. In either event,
Consequently, Travelers will be directed to produce its “claims and policy manuals” and “educational and training materials” regarding the consideration and disposition of medical expense benefits claims, to the extent that those policies were in effect in 2009-2010. Travelers’ claims manuals could contain confidential or proprietary information withrespectto itshandlingoffirstparty benefits claims. For that reason, Sharp will be required to execute a confidentially agreement barring Sharp, his counsel, their representatives and expert witnesses from divulging, without further leave of court, any information contained in the manuals and materials produced by Travelers. See Platt v. Fireman’s Fund Insurance Company, 2011 WL 5598359, at * 2 (E.D. Pa. 2011); Jones, supra.
(F) CLAIMS REPRESENTATIVES’ PERSONNEL FILES
In cases where insureds have sought production of the personnel files of claims representatives who handled the insureds’ claims, the courts have uniformly applied “a heightened standard of relevance” to those discovery requests. See Allied World Assurance Company v. Lincoln General Insurance Co., 280 F.R.D. 197, 204 (M.D. Pa. 2012); Santer v. Teachers Insurance and Annuity Association, 2008 WL 755774, at * 9 (E.D. Pa. 2008); Carlucci v. Maryland Casualty Company, 2000 WL 298925, at * 1 (E.D. Pa. 2000); Kaufman v. Nationwide Mutual Insurance Company, 1997 WL 703175, at * 1
Sharp has not presented a timely bad faith claim against Travelers, nor has he identified a “sufficient nexus” between that purported bad faith claim and the personnel files that he seeks to review. Sharp may depose Travelers’ claims representatives to discover information regarding their training and performance evaluations, as well as any company practices relating to peer reviews, medical examinations and processing of medical expense benefits claims. See Arvonio v. PNC Wealth Management, 2013 WL 6776299, at * 3 (Lacka. Co. 2013) (under Pa. R.C.P. 4012(a)(3), the court may direct that discovery shall be
(G) OTHER LITIGATION AND ADMINISTRATIVE COMPLAINTS INVOLVING MEDICAL EXPENSE BENEFITS CLAIMS
In its fourth appeal issue, Travelers contests the discovery ruling requiring it to disclose, in response to Sharp’s interrogatory nos. 83, 84, 85 and 94, information relating to lawsuits and Insurance Department complaints filed against Travelers in Pennsylvania between February 13, 2004, and February 13, 2009, relative to first-party medical expense benefits claims where the policies at issue furnished coverage in the amount of $100,000.00 or more. Travelers submits that Sharp’s reliance upon Soldi, supra, is misplaced, and that “[tjhere is no reasonable correlation between lawsuits filed against Travelers for failure to disburse benefits under its insurance policies and the issue of whether Travelers engaged in unfair trade practices which induced Sharp to procure the policy.” (Docket entry no. 32 at pp. 9-10). Sharp responds that “[information from other claims, suits and complaints may demonstrate a pattern and practice of illusory coverage under $ 100,000 first party benefits policies.” (Docket entry no. 36 at p. 12).
The only state appellate authority addressing the discoverability of “similar claims evidence” allowed such discovery, provided that it was restricted to the same type of claims at issue in the pending litigation. See PECO Energy Company, 852 A.2d at 1235 (holding, in action brought against insurers on claims arising out of environmental damage at gas plants and waste storage areas, that “[ojther insureds’ claims information” was discoverable, but that “the requests must not be unduly burdensome and should be limited to environmental claims.”). More recent federal rulings have likewise determined that “other litigation” evidence could lead to the discovery of
In opposing Sharp’s discovery requests, Travelers claims that the discovery sought is irrelevant, but does not assert that the requested information in unavailable or that it would be unduly burdensome or expensive to produce it. (Docket entry no. 32 at pp. 9-10). Sharp’s interrogatories are narrowly framed and restricted to lawsuits or administrative complaints within a five year period which involve medical expense benefits claims where the first party benefits coverage is $100,000.00 or more. That information is arguably relevant to Sharp’s assertion that Travelers engaged in deceptive practices and committed malfeasance by intentionally and arbitrarily targeting medical expense benefits claims for peer reviews, medical examinations and other challenges whenever their
Thus, Travelers’ objections to Sharp’s interrogatories nos. 83,84, 85 and 94 will be overruled, and Travelers will be required to produce information pertaining to lawsuits and administrative complaints filed against it between February 13,2004, and February 13,2009, with respect to medical expense benefits claims involving policies with first-party benefits coverage of $100,000.00 or more. In order to protect the privacy and confidentiality interests of non-party insureds who filed any such administrative complaints with the Pennsylvania Insurance Department, Travelers may redact those insureds’ names and other identifying information when responding to Sharp’s discovery requests. See PECO Energy Co, supra.
(H) PENNSYLVANIA PEER REVIEWS BY TRAVELERS
Travelers has also appealed the discovery master’s order directing them to provide an itemization of all “utilization reviews and/or peer reviews” that it performed between February 13, 2004, and February 14, 2009, in cases where the first party medical expense benefits coverage was $100,000 or more.
Every PRO, which has been approved by the Insurance Commissioner to provide peer review services in Pennsylvania, must file an annual report with the Commissioner identifying the number of peer reviews performed, the results of the PRO’S initial determination,
By reviewing the annual reports that were filed by the approved PROs from 2004 through 2009, Sharp will be able to determine the number of peer reviews that Travelers performed in that five year period. If Travelers identifies the number of peer reviews which were conducted at its request in situations where the medical expense coverage was $100,000.00 or more, Sharp will be able to ascertain whether an inordinance percentage of peer reviews were initiated by Travelers in cases involving higher first party benefits coverage limits. The result would be probative evidence of Sharp’s unfair trade practices claim that Travelers improperly targeted insureds with substantial medical expense coverage for peer reviews in an effort to avoid its contractual obligation to honor their claims for medical expense benefits.
No argument has been made by Travelers that the requested peer review information does not exist or that it would be unreasonably expensive or oppressive to provide it. Travelers contends that the peer review information sought by Sharp is irrelevant inasmuch as Sharp has not asserted a bad faith claim. However, for the reasons stated above, this peer review data is germane to Sharp’s UTPCPL claim. Accordingly, Travelers’ objections will be overruled and it will be ordered to furnish that peer review information, subject to Sharp’s execution of an appropriate confidentially agreement protecting Travelers’ proprietary and confidential information.
(I) TRAVELERS’ PAYMENTS TO PEER REVIEWERS
An insurer may potentially be held liable for actionable malfeasance under the UTPCPL if it knowingly submits “medical bills to a biased PRO knowing that it would receive a determination as to the reasonableness and necessity of treatment which would allow it to deny” payment for those bills. Perkins, 589 F.Supp.2d at 567. In the case at hand, Travelers initiated Dr. Armine’s peer review of Sharp’s chiropractic bills within less than four weeks of the date that it had secured the peer review of Dr. Schensul opining that the same chiropractic treatment was reasonable and necessary and that ongoing treatment was indicated. In determining whether Sharp’s chiropractic
Impeachment of an expert witness by demonstrating partiality is always permissible. Polett v. Public Communication, Inc., 83 A.3d 205, 224 (Pa. Super. 2013). Long standing case law recognizes that expert witnesses may always be interrogated regarding the level of compensation that they have received in a matter so as to demonstrate the expert witnesses’ bias or partiality, and that it is reversible error for a trial court to prohibit such cross-examination. See Grutski v. Kline, 352 Pa. 401, 405-406, 43 A.2d 142, 144 (1945); J. S. v. Whetzel, 860 A.2d 1112, 1120 (Pa. Super. 2004); Coward v. Owens-Corning Fiberglass Corp., 729 A.2d 614, 625 (Pa. Super. 1999); Smith v. Celotex Corp., 387 Pa. Super. 340, 350, 564 A.2d 209, 213-214 (1989); Mohn v. Hahnemann Medical College and Hospital of Philadelphia, 357 Pa. Super. 173, 178-179, 515 A.2d 920, 923 (1986), app. discontinued, 515 Pa. 582, 527 A.2d 542 (1987). In fact, we have previously required medical experts to answer discovery requests seeking information regarding fees that they received for forensic services that they provided for the party who retained them and for one particular side of litigation. See Yadouga, 66 Pa. D. & C. 4th at 179.
Documents indicating payments that Travelers made to the peer reviewers of Sharp’s treatment and bills are relevant to the show potential partiality or bias of those experts. Those records may also shed light on Sharp’s
(J) INFORMATION CREATED AFTER PLAINTIFF ’ S FIRST-PARTY BENEFITS FILE WAS CLOSED
Last, Travelers appeals the discovery master’s decision granting Sharp’s motion to compel documents in his first party benefits file that were created after his “claim was formally closed” by Travelers. Travelers contends that the actions alleged in the complaint “took place well prior to the closing of Sharp’s first party benefits file,” such that “Sharp’s request for information generated for his claims file after it was closed is temporally flawed and not relevant to this action because such information has no bearing on the issues alleged in the complaint.” (Docket entry no. 32 at p. 12). Sharp counters that “[tjhere is no basis to withhold documents based merely on the date produced.” (Docket entry no. 36 at p. 18). He further argues that “the fact that Travelers ‘reopened’ the claim at some point and then ‘reclosed’ the claim again supports [Sharp’s] claim that information cannot be withheld simply based upon when Travelers arbitrarily ‘closed’ its file” (Id.).
Travelers’ objection appears to be a hybrid relevancy
Once an insurer identifies a reasonable foundation for denying a claim, it is not relieved of its duty of good faith and fair dealing, [citation omitted]. In other words, if evidence arises that discredits the insurer’s reasonable basis, the insurer’s duty of good faith and fair dealing requires it to reconsider its position and act accordingly, all the while remaining “committed to engage in good faith with its insured.”
Condio v. Erie Insurance Exchange, 899 A.2d 1136, 1145 (Pa. Super. 2006) (quoting Bonenberger, 791 A.2d at 381), app. denied, 590 Pa. 668, 912 A.2d 838 (2006). Accord 14 Couch on Insurance § 207:6 (3d ed.) (“However, the insurer does have a duty to timely make payment once it
As the party objecting to discovery on the basis of work product protection, Travelers bears the burden of establishing that the information sought by Sharp is immune from discovery. Yadouga, 66 Pa. D. & C. 4th at 168; McAndrew, 56 Pa. D. & C. 4th at 7-8. Pennsylvania’s version of the work product doctrine is contained in Pennsylvania Rule of Civil Procedure 4003.3, which shields from discovery an attorney’s mental impressions, conclusions or opinions “prepared in anticipation of litigation” and pertaining to the merit of a claim or defense or respecting strategy or tactics. McAndrew, 56 Pa. D. & C. 4th at 9 (quoting Pa. R.C.P. 4003.3). The final sentence of Rule 4003.3 extends work product protection to non-attorneys as well, and provides that “[wjith respect to the representative of a party other than the party’s attorney, discovery shall not include disclosure of his or her mental impressions, conclusions or opinions respecting the value or merit of a claim or defense or respecting strategy or tactics.” Pa.R.C.P. 4003.3.
Prior to the adoption of Rule 4003.3, former Pa.R.C.P. 4001(d) expressly prohibited the discovery of any materials prepared by a party’s attorney or representative in anticipation of litigation or for trial. See Pa.R.C.P. 4003.3, Explanatory Comment (1978). Former Rule
“The language of Pa.R.C.P. 4003.3 does not contain a temporal limitation for when material may be deemed ‘prepared in anticipation of litigation.’” Church of the Forgotten Souls v. NGM Insurance Company, 2011 WL 5244490, at * 3 (Lacka. Co. 2011). “Anticipation of litigation” means in “expectation of or looking forward” to litigation and includes situations where no lawsuit has yet been filed. Brogan v. Rosenn, Jenkins & Greenwald, 2013 WL 6437919, at * 3 (Lacka. Co. 2013) (quoting In re Hennine Estate, 4 Pa. D. & C. 4th, 462, 465 (Alleg.
A determination must be made as to whether the records and information being withheld by Travelers qualifies as protected work product. Travelers will be directed to submit its alleged work product materials to the special discovery master for an in camera review. See Barrick v. Holy Spirit Hospital of the Sisters of Christian Charity, 32 A.3d 800, 812 (Pa. Super. 2011) (“We acknowledge that an in camera review may be necessary in order to determine precisely what aspects of the correspondence fall within the parameters of the attorney work-product doctrine”), app. denied, 616 Pa. 589, 52 A.3d 221 (2012). Travelers will also be required to furnish the discovery master with “a” privilege log identifying by page all records which are being produced, together with the bases for the privileges asserted.” McAndrew, 56 Pa. D. & C. 4th at 7. Following his review of those documents, the discovery master will issue an order identifying those materials which must be produced by Travelers and what records and information are shielded from discovery by the work product doctrine. An appropriate order follows.
ORDER
And now, this 7th day of March, 2014, upon
1. Plaintiff’s de novo appeal of the special discovery master’s order of November 7, 2013, is denied, and defendant’s objections to plaintiffs interrogatories nos. 29 and 30 and requests for production of documents nos. 7, 66 and 67 are sustained;
2. Defendant’s de novo appeal of the special discoveiy master’s order of November 7,2013, is granted in part and denied in part;
3. Defendant’s de novo appeal is granted and defendant’s objections are sustained as to plaintiff’s interrogatories nos. 11, 17, 53, 54 and 63 and requests for production of documents nos. 1,2,3,4,6, 7, 8, 9, 10, 16, 32,46 and 74;
4. Defendant’s de novo appeal is denied and defendant’s objections are overruled as to plaintiff’s interrogatories nos. 39,40,41,42,43,44,45,47,64,83, 84,85,94,99,100 and 101 and requests for production of documents nos. 19, 20,21,22,23,24,30,31,32,33,42,43,44,45, 50,51, 52, 53, 54, 55, 56, 57, 58,63, 64, 68, 69 and 70;
5. Plaintiff shall execute a confidentiality agreement with respect to any proprietary information or trade secrets
6. Within thirty (30) days of plaintiff’s execution of a confidentiality agreement prohibiting him from divulging or disseminating, without further leave of court, any documents or information referenced in paragraph (5) above, except to plaintiff’s counsel, expert witnesses and consultants, and any discovery deponents, defendant shall provide the requested discovery identified in paragraph (4) above; and
7. Within the next thirty (30) days, defendant shall submit the materials identified in its privilege log for first party log notes nos. 60, 61-96, 98, 99 and 110 and its claims file Bates nos. 545, 649, 746, 757, 773, 747-756, and 758-771 for an in camera review by the special discovery Master and a determination as to whether those documents and information are protected from discovery by the work product doctrine.
. Under Section 1797(b)(1) of the Motor Vehicle Financial Responsibility Law (“MVFRL”), an insurer may contract with a peer review organization (“PRO”) “for the purpose of evaluating treatment, health care services, products or accommodations provided to any injured person” and “confirming that such treatment, products, services or accommodations conform to the professional standards of performance and are medically necessary.” 75 Pa.C.S.A. § 1797(b)(1). “The peer review process is a mechanism through which an insurer may seek a professional assessment of the reasonableness and necessity of medical treatment in order to independently determine whether a claim whould be paid or denied.” Terminato v. Pennsylvania Nat. Ins.Co., 538 Pa. 60, 71, 645 A.2d 1287, 1292 (1994). If the PRO determines “that a provider has provided unnecessary medical treatment...or that future provision of such treatment...will be unnecessary,...the provider may not collect payment for the medically unnecessary treatment...” 75 Pa.C.S.A. § 1797(b)(7). Conversely, if the PRO concludes that the treatment provided was medically necessary, “the insurer must pay to the provider the outstanding amount plus interest at 12% per year on any amount withheld by the insurer pending PRO review.” 75 Pa.C.S.A. § 1797(b)(5).
. Unlike a peer review under 75 Pa.C.S.A. § 1797 which is designed “to determine whether medical care and bills are reasonable
. Section 1796(a) of the MVFRL states that “[w]henever the mental or physical condition of a person is material to any claim for medical...benefits, a court of competent jurisdiction may order the person to submit to a mental or physical examination by a physician,” provided, however, that “[t]he order may only be made upon motion for good cause shown.” 75 Pa.C.S.A. § 1796(a). Under the “good cause shown” standard, a motion under Section 1796 “will not be granted solely because there is a controversy or a desire to know,” and “[t]he good cause requirement will prevent harassment, untoward intrusion and unwarranted examination when the proof presented does not meet the standard universally applied when good cause is implicated.” State Farm Ins. Companies v. Swantner, 406 Pa. Super. 235, 245, 248, 594 A.2d 316, 321, 322 (1991) (en banc), app. denied, 530 Pa. 633,606 A.2d 903 (1992). However, “[i]f the insurance policy between the insurer and insured requires the insured to ‘submit to a physical examination by a physician of [the insurer’s] choice,’ the first-party benefits insurer does not have to establish ‘good cause’ under Section 1796 as a condition precedent to compelling the insured to undergo a medical examination.” Olsofsky v. Progressive Insurance Company, 52 Pa. D. & C. 4th 449, 478 n. 2 (Lacka. Co. 2001) (citing Fleming v. CNA Insurance Companies, 409 Pa. Super. 285, 288-289, 597 A.2d 1206, 1207-1208 (1991)). The record submitted for review does not indicate whether Travelers’ policy imposed a duty upon Sharp to submit to a medical examination by a physician chosen by Travelers, without the necessity of first demonstrating “good cause” for that examination.
. Under Lacka. Co. R.C.P. 4000.1, all discovery motions must initially be presented to and decided by the court-appointed discovery master whose ruling “may be appealed de novo” to the court of common pleas within ten days of the master’s decision. Fratzola v. Klepadlo, 26 Pa. D. & C. 5th 533, 537-538 (Lacka. Co. 2012).
. Sharp also charges Travelers with breach of the implied covenant of “good faith and fair dealing” under the insurance contract. (Docket entry no. 1 at ¶¶95^), 96, 102-103, 111). Under Pennsylvania law, a “claim for breach of the implied covenant of good faith and fair dealing is subsumed in a breach of contract claim,” LSI Title Agency, Inc. v. Evaluation Services. Inc., 951 A.2d 384, 392 (Pa. Super. 2008), app. denied, 599 Pa. 694, 960 A.2d 841 (2008), and for that reason, this Commonwealth does not recognize an independent cause of action for breach of the implied duty of good faith and fair dealing. See Stewart v. Swepi, LP, 918 F.Supp.2d 333, 343-344 (M.D. Pa. 2013); Zaloga v. Provident Life & Accident Ins. Co., 671 F.Supp.2d 623,631 (M.D. Pa. 2009); Healey v. Wells Fargo. N.A., 2012 WL 994564, at * 20 (Lacka. Co. 2012). Therefore, Sharp’s allegations regarding the implied covenant of good faith and fair dealing are only germane to his breach of contract claim.
. Travelers filed a demurrer to Sharp’s UTPCPL claim on the basis that Sharp merely “alleges failure to pay and properly administer [Sharp’s] claim for first-party medical benefits, which constitutes nonfeasance, and the UTPCPL does not apply to alleged failures by insurers to pay benefits, regardless of the fanciful language used to bolster the allegations of the complaint.” (Docket entry no. 4 at ¶ 12). On March 20,2013, the parties executed a stipulation pursuant to which Travelers agreed to withdraw that preliminary objection without prejudice to its “right to file a motion for summary judgment with regard to [Sharp’s] Unfair Trade Practices and consumer protection law claims.” (Docket entry no. 9 at ¶ 5).
. In discussing insurer bad faith under Section 8371, the Supreme Court of Pennsylvania “has stated the bad faith insurance statute is concerned with the duty of good faith and fair dealing.” Ash, 593 Pa. at 532, 932 A.2d at 883. Although, “it is not necessary that the refusal to pay be fraudulent” in order to constitute bad faith, Grossi, 79 A.3d at 1148-1149, “mere negligence or bad judgment is not bad faith.” Berg, 44 A.2d at 1172. Rather, the insured must show “that the insurer breached a known duty (i.e., the duty of good faith and fair dealing) through a motive of self-interest or ill will.” Grossi, 79 A.3d at 1149; Berg, supra. The “motive of self-interest of ill will” level of culpability “is not a third element required for a finding of bad faith, but is probative of the second element identified in Terletsky, i.e., ‘the insurer knew or recklessly disregarded its lack of a reasonable basis in denying the claim.”’ Nordi v. Keystone Health Plan West, Inc., 989 A.2d 376, 385 (Pa. Super. 2010) (quoting Greene v. United Services Auto. Ass’n, 936 A.2d 1178, 1190 (Pa. Super. 2007)). The insurer’s bad faith must be established “by clear and convincing evidence.” Johnson v. Progressive Insurance Company, 987 A.2d 781, 784 (Pa. Super. 2009); Rutkowski v. Allstate Insurance Company, 69 Pa. D. & C. 4th 10, 36(Lacka. Co. 2004).
. The discovery master apparently confused this civil action with a workers’ compensation proceeding when he ordered Travelers to produce records pertaining to its “utilization reviews” involving first party medical expense benefits claims. Under Section 306(f.l) (6) of the workers’ compensation act, 77-P.S. § 531(6), and pursuant to 34 Pa. Code §§ 127.401-127.479, an employer or insurer may retain a utilization review organization to conduct a utilization review and to determine the reasonableness or necessity of health care treatment
Case-law data current through December 31, 2025. Source: CourtListener bulk data.