FINDINGS OF FACTS AND CONCLUSIONS OF LAW. This is a claim arising out of an accident that occurred on October 3, 2000. Claimant submitted the following documents:
FINDINGS OF FACTS AND CONCLUSIONS OF LAW. This matter concerns a dispute regarding the recovery of medical expense benefits under personal injury protection coverage arising out of an automobile accident that occurred on August 22, 2002. It was submitted to me on the initiative of claimant by way of Demand for Arbitration received by AAA on March 28, 2003. More specifically, this dispute involving medical expense benefits concerns interpretation of the insurance contract and whether the treatment performed was reasonable, necessary, and compatible with the protocols provided for under AICRA. FINDINGS OF FACT: Claimant submitted: Demand for Arbitation received by AAA on March 28, 2003; and Letter dated June 14, 2003. Respondent submitted a letter dated July 9, 2003. On August 22, 2002, DJ was injured in an automobile accident. As a result of his injuries, DJ went to claimant for treatment. On September 30, 2002, claimant treated DJ. More specifically, DJ underwent an MRI of the cervical spine and an MRI of the lumbar spine. On September 30, 2002, claimant submitted the bills for this testing to respondent for payment. Respondent paid the bill for the MRI of the cervical spine subject to a PPO reduction but did not pay for the MRI of the lumbar spine. As a result, claimant filed this Demand for Arbitration. The issue presented is two-fold: (1) whether or not the PPO reduction was proper; and (2) whether or not the MRI of the lumbar spine was medically necessary. Regarding the first issue, claimant argues that the PPO reduction was improper. In support of its argument, claimant relies upon its argument detailed in its June 14, 2003 submission. In summary, claimant argues that the PPO reduction was improper because the PPO contract operates outside the statutory and administrative scheme; respondent is not a direct party to the contract between claimant and CHN and no contract exists between respondent and claimant; and claimant was not notified that respondent had entered into an agreement with CHN to pay claimant. Respondent, on the other hand, argues that its PPO reduction was proper. In support of its argument, respondent relies upon its argument contained in its submission. In summary, respondent argues that AICRA does not preclude a voluntary PPO agreement between private parties. Regarding the second issue, claimant argues that the MRI of the lumbar spine was medically necessary. In support of its argument, claimant relies upon its argument detailed in its June 14, 2003 submission. In short, th...
FINDINGS OF FACTS AND CONCLUSIONS OF LAW. The within matter arises from an automobile accident which occurred on May 15, 2000. Based upon the date of the accident, I find that the provisions of the 1998 New Jersey “Automobile Insurance Cost Reduction Act” do apply to the within claim. At issue are the bills of Allcare Medical and Rehabilitation Group. The insured, A.J., treated with this provider under the care of a Xx. Xxxx, who had been previously with Old Hook Medical Group, PA, a separate entity with a separate Tax ID Number. He later became the medical director of Allcare Medical and Rehabilitation Group. Allcare and CHN/PPO Network began negotioations to enter into a contract so Allcare Medical and Rehabilitation Group could join the CHN/PPO Network, but they were never finalized. However, CHN began to take PPO reductions in the bills of Allcare Medical and Rehabilitation Group. It seems from the proofs presented that Old Hook Medical Group had been a CHN Member. Xxxxxxxx argues that based on the proofs presented; certifications, contracts, billing information and correspondence, that it is clear that no contract existed between CHN and Allcare Medical and Rehabilitation Group and that the reductions were taken in error. The outstanding balance claimed is $445.00 No opposition has been submitted to this Demand. Telephone calls were placed at the time of hearing to representatives of Respondent with no reply. As of the date of this award, nothing has been presented to contest the claim. I make no findings as to the validity of any CHN/PPO agreement. I do find that based on the evidence provided, that it is uncontroverted that Allcare Medical and Rehabilitation Group was not a signatory to a contract with CHN and that Respondent was not entitled to any CHN/ PPO reduction. Xx. Xxxx did sign a PPO agreement on behalf of Old Hook, a separate employer and entity and this would in no way bind Allcare. Based upon the uncontroverted evidence presented, I award the entire amount claimed, $445.00. I also award interest as claimed in the amount of $62.72. Claimant has submitted a Certification of Services seeking counsel fees ($1875.00) and costs ($325.00) in this matter. I note that no discovery was engaged in, oral hearing was requested by Xxxxxxxx, and that no complex or novel legal issues were involved in the handling of this matter. Based upon a review of the file, I find that a counsel fee in the amount of $750.00 would be consonant with both the amount of the award and with Rule
FINDINGS OF FACTS AND CONCLUSIONS OF LAW. 14. AIMCO is a corporation formed under the laws of the State of Maryland. AIMCO does business in at least forty-seven (47) states and the District of Columbia.
FINDINGS OF FACTS AND CONCLUSIONS OF LAW. The issue in dispute in this matter is the reduction taken by respondent for a "PPO" . While I have decided this issue a number of times, I have found that a PPO contract is valid and binding on the provider if the terms of the agreement have been properly adhered to and if the provider has been made aware that the insurance carrier is a member of the network applying the reduction. In the matter at hand, respondent has supplied an agreement between CHN and East Bergen Imaging, LLC, D/B/A 401 Medical Imaging that was signed in the spring of 1999 by both parties. The exact effective date is illegible. Section 5 of that agreement (p21) is entitled Time for payment. 5/1 provides that "except where coordination of benefits applies or when a claim is subject to audit, payor or its paying agent shall use all reasonable efforts to make all payments due to participating provider within forty five
