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No Need to Act VI:
Excess Medical Bills in PA Automobile Cases

Written by Marc Simon, Esquire.

Introducing excess medical bills into evidence at trial is one of the most overlooked and ignored technical skills in litigating Pennsylvania automobile cases. However, since parties cannot provide juries with dollar figures for pain and suffering recoveries, the introduction of excess medical bills becomes critical in giving juries a frame of reference or starting point from which they can calculate pain and suffering damages.

Most practitioners simply produce a PIP payout log and exhaustion letter to defense counsel and come to an agreement with defense counsel that the excess unpaid medical bills are admissible under the ACT VI payment scheduled at between sixty and seventy percent of the full bill. However, Pennsylvania case law permits plaintiffs to introduce full, non-reduced excess medical bills into evidence at trial.

In Pennsylvania, pursuant to under Sections 1722 and 1719 of the Motor Vehicle Financial Responsibility Law (MVFRL), plaintiffs are permitted to present evidence of all excess/outstanding medical bills not paid or payable by a private health insurance and/or HMO. Where a Plaintiff exhausts all first party benefits under their PIP coverage, submits excess medical bills to any private health insurance, and has those bills rejected, those bills become “unpaid and not payable” under the MVFRL. Thus, all bills rejected by such providers are admissible pursuant to

The right of the Plaintiff to recover excess and/or outstanding medical bills is further governed by 75 Pa.C.S.A. §1797 (ACT VI), which sets forth the proper reimbursable amounts permitted for medical treatment arising out of a motor vehicle accident at 110% of what Medicare would pay a provider for the same service. This is generally the method by which most practitioners come to an agreement regarding the recoverable medical bills at trial. However, at least one Superior Court case can be cited for the proposition that when there is no objection to the admissibility of medical bills in a jury trial, the full amount of medical bills, not the “Act VI number”, may be introduced.

The case of Pittsburgh Neurosurgery Associates, Inc. v. Danner, 733 A.2d 1279 (Pa.Super. 1999) arose when the appellee was injured in an automobile accident and sought treatment at appellant’s facility. After appellee’s first-party benefits were exhausted, Pittsburgh Neurosurgery filed suit to recover fair market value ($16,579.00) of its unpaid bill. Danner filed a motion for summary judgment seeking a reduction, arguing that the cost containment provisions of §1797 applied to those medical charges and that it was only entitled to $5,523.25. Pittsburgh Neurosurgery filed a cross-motion for summary judgment arguing §1797 was inapplicable because Danner had already exhausted his first party benefits. The trial court granted Danner’s motion, entering judgment in favor of Pittsburgh Neurosurgery in the reduced amount of $5,523.

On appeal, Pittsburgh Neurosurgery argued that the trial court's interpretation of §1797 was inconsistent with the legislature's goal of containing insurance costs; because if an injured party can place into evidence medical bills “not paid or payable” by health insurance, then the injured party is entitled to place the full amount of unpaid medical bill before the jury and if he wins on liability, he can avoid full repayment of the same because cost containment provisions apply. This scenario, it argued, would result in the injured party receiving a windfall resulting from his full recovery of unpaid medical bills and a corresponding limited obligation of repayment to the provider if §1797(a) is applicable.

The Superior Court agreed that the cost containment provisions shouldn’t put a party in a better position than he or she was in had the accident not occurred, and by allowing a party to introduce the full amount of the provider's medical bills absent the cost containment provisions and yet allow the medical provider to recover a cost contained amount would permit a windfall recovery. However, the Court held that in the context of an automobile accident jury trial, an injured party may introduce unpaid medical bills into evidence and the amount introduced may not be subject to cost containment; but then any jury award could be molded by the trial court to reflect cost containment, thus avoiding the problem of double recoveries. Thus, the court reasoned, by limiting the amount of damages an injured party can receive after a jury verdict in his or her favor, the verdict will be lower and insurance costs will be reduced, in accordance with the legislature's objective in drafting §1797.

Therefore, although the MVFRL limits a Plaintiff’s right to recover excess medical bills, Pennsylvania case law permits Plaintiffs to introduce at trial, full, non-reduced amount of excess medical bills incurred from a motor vehicle accident.

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