Summary
accusing the Armour Pharmacy Court of creating "an administrative proceeding for putative providers" that "cannot be found in the language of the [Act]"
Summary of this case from Elite Care, RX, LLC v. Premier Comp Sols.Opinion
1144 WDA 2020 J-E02002-22
05-23-2023
ELITE CARE, RX, LLC v. PREMIER COMP SOLUTIONS, LLC; LAUNDRY OWNERS' MUTUAL LIABILITY INSURANCE ASSOCIATION; UPMC BENEFIT MANAGEMENT SERVICES, INC. D/B/A UPMC WORK PARTNERS; LACKAWANNA CASUALTY COMPANY; AND BRICK STREET MUTUAL INSURANCE COMPANY APPEAL OF: PREMIER COMP SOLUTIONS, LLC, LAUNDRY OWNERS' MUTUAL LIABILITY INSURANCE ASSOCIATION, LACKAWANNA CASUALTY COMPANY AND BRICK STREET MUTUAL INSURANCE COMPANY
Appeal from the Order Entered June 5, 2020 In the Court of Common Pleas of Allegheny County Civil Division at No(s): GD-19-005312
BEFORE: PANELLA, P.J., OLSON, J., DUBOW, J., KUNSELMAN, J., NICHOLS, J., MURRAY, J., McLAUGHLIN, J., McCAFFERY, J., and SULLIVAN, J.
OPINION
KUNSELMAN, J.
I. Introduction
Premier Comp Solutions, LLC; Laundry Owners' Mutual Liability Insurance Association; Lackawanna Casualty Company; and Brick Street Mutual Insurance Company (hereafter "Insurers") appeal from the order overruling their preliminary objections to Elite Care, Rx, LLC's complaint. The trial court rejected Insures' challenge to its subject-matter jurisdiction. We affirm.
Since the filing of this appeal, Laundry Owners' Mutual Liability Insurance Association settled with Elite Care and discontinued its appeal in this matter.
II. Factual & Procedural Background
When reviewing an order overruling preliminary objections challenging subject-matter jurisdiction, our "standard of review is de novo, and the scope of review is plenary." Mazur v. Trinity Area Sch. Dist., 961 A.2d 96, 101 (Pa. 2008). We reverse "only when, based on the facts pleaded, it is clear and free from doubt that the complainant will be unable to prove facts legally sufficient to establish a right to relief." Id. Also, this Court "must accept as true all well-pleaded, material, and relevant facts alleged in the complaint and every inference that is fairly deducible from those facts." Id. Therefore, we turn to Elite Care's complaint to glean the relevant facts of this case.
According to Elite Care, Insurers offer workers' compensation insurance to employers to cover the costs of treatment and medication under the Workers' Compensation Act for employees who suffer work-related injuries. Complaint at ¶8. The employees may choose to fill their prescriptions to treat these injuries through Patient Direct Rx, a home-delivery pharmacy. Id. at ¶12. After Patient Direct Rx fills the prescriptions, certain licensed health care providers ("Providers") purchase the claims arising from these prescriptions (i.e., the right to bill and collect from the insurance carrier) from Patient Rx for fair-market value. Id. at ¶14. The Providers are then legally entitled to collect payment for the prescriptions from the insurance carrier and bear the risk of collection. Elite Care (a separate entity) serves as billing agent for the Providers and ensures their accounts receivable are properly paid. Id. at ¶16.
Elite Care avers that it has implemented this practice of collecting on behalf of healthcare providers throughout the country, without issue or objection by other insurers. Id. at ¶18. Even within Pennsylvania, all insurance companies (other than Insurers) reimburse Elite Care the price of employees' prescriptions without objection. Id. at ¶19. As such, Elite Care claims that Insurers are intentionally and wrongfully refusing to pay for prescriptions that the covered employees have received and for which payment is due. Id. at ¶21. Elite Care contends that, when this lawsuit began, Insurers owed $548,035.28 in prescription fees for 110 different employees and that figure continues to accrue as more bills are being improperly denied. Id. at ¶ 38.
After negotiations stalled, Insurers indicated that Elite Care's "exclusive remedy" was through an Application for Fee Review in the Pennsylvania Bureau of Workers' Compensation ("Bureau"). Id. at ¶ 29. Hence, Elite Care filed an Application for Fee Review before the Bureau's Medical Fee Review Section. When the Medical Fee Review Section began ruling in favor of Elite Care, Insurers appealed those rulings "to a [Fee Review] Hearing Officerand argued that the Fee Review [Section] lacked jurisdiction over this issue of whether Elite Care was an agent of these providers." Id. at ¶ 32. The Hearing Officer issued opinions and orders holding that the Fee Review Section lacked subject-matter jurisdiction and advised "that Elite Care may wish to pursue other remedies, which may be available outside of the fee-review process." Id. at ¶ 33.
The Medical Fee Review Section is an administrative body that may decide only the "amount and timeliness of the payment made by an insurer." 34 Pa. Code. § 127.251. It has no authority to make legal conclusions. See Crozer Chester Medical Center v. Bureau of Workers' Compensation, Health Care Services Review Division, 22 A.3d 189, 196-97 (Pa. 2011).
The Fee Review Hearing Office conducts evidentiary hearings on the validity of a fee-review determination. The hearing includes an examination of "all relevant evidence" and the testimony is "recorded and a full record kept of the proceeding." 34 Pa. Code § 127.259(b), (d). The Hearing Office issues a "fee review adjudication" that "will include all relevant findings and conclusions and state the rationale." 34 Pa. Code § 127.260(a). These procedures ensure that the Bureau's adjudication comports with the requirements of Administrative Agency Law, 2 Pa. C.S.A. § 504, for a valid adjudication. By contrast, the Medical Fee Review Section performs an administrative function. Its review is limited to the timeliness of an employer's payment and the correct amount owed to the provider. 34 Pa. Code § 127.252. Thus, according to the Commonwealth Court, it would violate due process if the Medical Fee Review Section were to make such a determination. See Amour Pharmacy v. Bureau of Workers' Comp. Fee Rev. Hearing Office, 206 A.3d 660, 670 (Pa. Cmwlth. 2019) (en banc). As such, either a Hearing Officer or a Workers' Compensation Judge must make legal determinations on behalf of the Bureau, rather than the Fee Review Section.
Based on the administrative adjudication that the Medical Fee Review Section lacked subject-matter jurisdiction, Elite Care filed the instant civil action. Elite Care's complaint included counts of declaratory judgment, fraud, civil conspiracy, and unjust enrichment.
In response, Insurers filed various preliminary objections, one of which alleged the trial court lacked subject-matter jurisdiction over the legal issues raised in the complaint. Following oral argument, the trial court overruled Insurers' preliminary objections. Regarding subject-matter jurisdiction, the court determined this case was not a workers' compensation matter, but rather a claim for damages based on allegations of conspiracy and fraud. The trial court refused to certify its order for an immediate appeal, and Insurers filed a timely Petition for Permission to Appeal.
UPMC Benefit Management Services Inc. filed preliminary objections but did not object to the trial court's subject-matter jurisdiction. That company did not participate in this appeal.
See Pennsylvania Rule of Appellate Procedure 1311(a)(1).
On October 30, 2020, this Court granted review of the following issue:
Because the issues raised by the complaint . . . have, as their ultimate basis, injuries compensable under the act, must they be decided by a workers' compensation judge or a fee-review Hearing Officer and not by the court of common pleas?
Insurers' Brief at 7 (capitalization removed). A three-judge panel of this Court unanimously affirmed the trial court's decision. Upon petition of the Insurers, we granted en banc review.
III. Analysis
Insurers attack the trial court's subject-matter jurisdiction based upon the Workers' Compensation Act ("WCA"). They contend that the Bureau has exclusive jurisdiction over this matter, because the prescriptions at issue treat work-related injuries. Insurers argue that all counts of the complaint fall under the Bureau's jurisdiction. See Insurers' Brief at 24-25. We disagree.
See 77 P.S. §§ 1-2708.
Subject-matter jurisdiction is "the power of the court to hear the cases of the class to which the case before the court belongs, that is, to enter into inquiry, whether or not the court may ultimately grant the relief requested." Harley v. HealthSpark Found., 265 A.3d 674, 687 (Pa. Super. 2021), reargument denied (Dec. 1, 2021), appeal denied, 277 A.3d 1105 (Pa. 2022). "Except where exclusive original jurisdiction of an action or proceeding is by statute . . . vested in another court of this Commonwealth, the courts of common pleas shall have unlimited original jurisdiction of all actions and proceedings, including all actions and proceedings heretofore cognizable by law or usage in the courts of common pleas." 42 Pa.C.S.A. § 931(a).
In its complaint, Elite Care raised counts of declaratory judgment, fraud, civil conspiracy, and unjust enrichment. Thus, we must determine whether these matters are actions over which courts of common pleas have subject-matter jurisdiction or whether they lie exclusively within the jurisdiction of the Bureau.
The General Assembly established the Bureau in 1915 by passing the first iteration of the Workers' Compensation Act. Elite Care's three common-law causes of action clearly predate the Bureau's establishment and have been under the subject-matter jurisdiction of the courts of common pleas since time immemorial. Moreover, we find nothing in the current Workers' Compensation Act granting the Bureau jurisdiction over those specific common-law torts or contract matters. The legislative purpose of the WCA was to divest trial courts of jurisdiction over work-related-negligence cases between employers and employees. In place of trial-court jurisdiction, the statute grants the Bureau administrative and appellate authority over the compensation of employees who are injured at work, without regard to fault.
See Pennsylvania Department of Labor & Industry, Pennsylvania Workers' Compensation Act, available at https://www.dli.pa.gov/Individuals/Workers-Compensation/publications/Pages/WC%20Act/WC-Act-Landing-Page.aspx (last visited 11/30/22).
In its administrative scheme, the WCA provides a remedy for employees with unpaid claims to seek recourse before a Worker's Compensation Judge. A claimant can file a petition to establish an insurer's liability to a billing agent, such as a review petition or a penalty petition. See Amour Pharmacy v. Bureau of Workers' Comp. Fee Rev. Hearing Office, 206 A.3d 660, 666 (Pa. Cmwlth. 2019) (en banc). Indeed, the court in Amour Pharmacy stated, "claimants have an incentive to file a petition on behalf of a provider, because when an insurer violates the WCA by failing to make proper payment to a medical provider, the penalty is payable to the claimant." Id. (citing Selective Insurance Co. of Am. v. Bureau of Workers' Comp. Fee Rev. Hearing Office, 86 A.3d 300 (Pa. Cmwlth. 2014)). However, regarding putative providers and billing agents (like Elite Care), the Amour Pharmacy Court found an "absence of a direct statutory remedy" for such entities. Id.
In Armour Pharmacy, an employer challenged the authority of the Fee Review Section to award reimbursement to the pharmacy on the grounds that it was not a "provider" under the WCA. The employer further challenged the jurisdiction of the Hearing Officer to determine whether the pharmacy was a provider. Based on Selective Insurance, supra, the Hearing Office ruled that it lacked jurisdiction over the legal issue of whether the pharmacy was a provider and dismissed the pharmacy's fee-review petitions. The pharmacy petitioned for review of that determination before the Commonwealth Court and argued that its due process rights would be denied if the Bureau did not adjudicate its status as provider under the WCA. The pharmacy asserted that the language of the WCA did not give putative providers a procedure to adjudicate their rights. The Armour Pharmacy Court agreed.
The court also acknowledged that it could not expand the scope of a fee review to create a remedy for those entities, because enlarging the scope of the WCA is a matter "for the legislature assuming there is a need for a provider to have another remedy." Id. Critically, the court also observed that, if a party believes "the other is effecting a fraud, it can pursue that claim in a legal action, such as a declaratory-judgment action." Id. at 667.
Despite those acknowledgements, the Armour Pharmacy Court held that before a claim can go to fee review, a hearing officer must determine the legal issue of who is a "provider" under the WCA. "Whether an entity is a 'provider' has been considered a question of employer liability and, thus beyond the scope of a fee-review proceeding." Id. at 666. The court stated that, when an "employer challenges a fee determination of the Medical Fee Review Section for the stated reason that the medical service was not rendered by a 'provider' within the meaning of the WCA, that threshold question must be decided by the Hearing Office." Id. Significantly, the issue could not be decided by the Medical Fee Review Section.
Thus, although the WCA creates no administrative proceeding for a putative provider to seek redress within the Bureau, the Commonwealth Court manufactured one. That court remanded the matter to the Hearing Office for a determination of whether the billing agent was a provider within the meaning of the WCA. In doing so, the Armour Pharmacy Court created jurisdiction in the Bureau even though the legislature had not.
Respectfully, in our view, the Commonwealth Court lacked the power to graft an extra-statutory scheme onto the WCA for the benefit of the putative provider. The Supreme Court of Pennsylvania has held that, under 1 Pa.C.S.A. § 1923, courts may not add to a statute, because this "expands its application" in a manner that the legislature did not intend. Crown Castle NG E. LLC v. Pennsylvania Pub. Util. Comm'n, 234 A.3d 665, 682 (Pa. 2020). When "the language of a statute is clear and unambiguous, a court may not add matters the legislature saw fit not to include under the guise of construction." Mohamed v. Com., Dep't of Transp., Bureau of Motor Vehicles, 40 A.3d 1186, 1194-95 (Pa. 2012).
Attempting to effectuate due process, the Armour Pharmacy Court legislated from the bench. The court created an administrative proceeding for putative providers by bestowing a jurisdiction upon Bureau Hearing Officers. That proceeding and jurisdiction cannot be found in the language of the WCA. Therefore, we decline to follow Armour Pharmacy, in so far as it stands for the proposition that Elite Care may or should have sought redress within the Bureau.
Simply stated, the Worker's Compensation Act does not provide for an administrative proceeding by or against putative providers or their billing agents in the Bureau. Such entities have no standing there, because the WCA does not confer it upon them. That statute has not divested the original jurisdiction of the courts of common pleas over matters such as the instant lawsuit.
In this case, Elite Care has asserted four causes of action. We begin with its statutory cause of action for declaratory judgment. In the Declaratory Judgment Act, the General Assembly dictates that "Courts of record, within their respective jurisdictions, shall have power to declare rights, status, and other legal relations whether or not further relief is or could be claimed." 42 Pa.C.S.A. § 7532 (emphasis added). This statute makes no mention of the Bureau. By the plain language of Section 7532, the legislature clearly vested jurisdiction over declaratory-judgment actions in the courts of records, i.e., the courts of the common pleas and the Commonwealth Court (when sitting in its original jurisdiction).
The Declaratory Judgment Act further identifies who may file an action for relief:
Any person interested under . . . contract, or other writings constituting a contract, or whose rights, status, or other legal relations are affected by a statute, municipal ordinance, contract, or franchise, may have determined any question of construction or validity arising under the instrument, statute, ordinance, contract, or franchise, and obtain a declaration of rights, status, or other legal relations thereunder.42 Pa.C.S.A. § 7533.
Here, Elite Care is an interested party to its contracts with various Providers. Its rights and legal relations are affected by Insurers' actions in denying those Providers payment for the prescriptions at issue. Elite Care seeks a determination of its rights to be paid on behalf of Providers, under its contracts, as their billing agents. Thus, Elite Care is a person interested in certain contracts with the Providers, and, therefore, it may request declaratory relief under the Declaratory Judgment Act.
And, as noted, the court of common pleas is the court of record for such an action to declare rights, status, and other legal relations whether further relief is or could be claimed. 42 Pa.C.S.A. § 7532.
Additionally, Elite Care has filed claims of fraud, civil conspiracy, and unjust enrichment. Those claims fall within the exclusive, original jurisdiction of the Court of Common Pleas of Allegheny County. Therefore, the trial court correctly ruled that it has subject-matter jurisdiction over the common-law causes of action in this case and the statutory action for declaratory judgment. See 42 Pa.C.S.A. § 7532, supra.
The WCA does not divest trial courts of that jurisdiction over causes of actions where, as here, the parties to a lawsuit are an employer's insurers and a provider's billing agent.
Order affirmed. Case remanded for further proceedings.
Jurisdiction relinquished.
Panella, P.J., Dubow, Murray, McCaffery and Sullivan, JJ. join this Opinion.
Nichols, J., concurs in the result.
CONCURRING OPINION
McLAUGHLIN, J.
I respectfully believe that we do not need to consider whether the Commonwealth Court's decision in Armour Pharmacy v. Bureau of Workers' Compensation Fee Review Hearing Office, 206 A.3d 660, 666 (Pa.Cmwlth. 2019) (en banc), was correct. Rather, we can resolve this appeal under the Supreme Court's recent decision in Franczyk v. The Home Depot, Inc., __ A.3d __, 2023 WL 2992700, at *8 (Pa. Apr. 19, 2023).
In Franczyk, the Court held that whether an injury alleged in a lawsuit is subject to the exclusivity provision of the Workers' Compensation Act ("WCA") turns on whether "the asserted injury . . . is 'intertwined' inextricably with the workplace injury." Id. at *8. The plaintiff in Franczyk worked at a retail store and had been bitten at work by a customer's dog. Id. at *1. She sued her employer and her supervisors, alleging they had "negligently allowed the dog owner and witnesses to leave without obtaining identifying information." She claimed that in so doing, they "denied her the opportunity to file a third-party suit against the dog owner." Id.
The Supreme Court found that the WCA's exclusivity provision immunized the defendants from the employee's suit because her claimed injury was "not truly separable" from the work injury. Id. at *8. In reaching its decision, the Court drew a contrast between its prior decisions in Martin v. Lancaster Battery Co., Inc., 606 A.2d 444 (Pa. 1992), and Kuney v. PMA Insurance Co., 578 A.2d 1285 (Pa. 1990) ("Kuney II").
In Martin, an employee sustained extensive exposure to lead at his work. Martin, 606 A.2d at 448. His employer tested employees on a regular basis for lead content in their blood. Over several years, the employer willfully and intentionally withheld test results from him or gave him altered results. Id. The employer closely monitored lead levels in employees' blood and reported the results to them so that those with elevated levels of lead could transfer to areas of work where they would not be exposed to lead. Id. The plaintiff was then diagnosed with chronic lead toxicity, lead neuropathy, and other ailments. Id. at 446. His condition would have been substantially better if his employer had not engaged in the deception. Id.
The Martin Court concluded that the claim for the aggravation of the lead toxicity was not subject to the exclusivity provision. The Court found that the claimed injury was separable from the work injury:
There is a difference between employers who tolerate workplace conditions that will result in a certain number of injuries or illnesses and those who actively mislead employees already suffering as the victims of workplace hazards. . . . The aggravation of the [physical] injury arises from and is related to the fraudulent misrepresentation of the employer.Id. at 448. As the Supreme Court explained in Franczyk, the lawsuit was permissible in Martin because "the employee was not seeking compensation for the initial exposure but rather for the distinct (and preventable) aggravation of the original injury-an injury unto itself." Franczyk, 2023 WL 2992700, at *7.
In Kuney II, however, the Court did not find the injuries separable. There, the Court framed the issue before it as whether the employer's immunity under the WCA protects its workers' compensation insurer if it allegedly "engaged in fraud and deceit to deprive an injured employee of his workers' compensation benefits." Kuney II, 578 A.2d at 1285. The employee there had sued the employer's insurer for bad faith, claiming he had emotional distress injuries allegedly distinct from his workplace injury. See Franczyk, 2023 WL 2992700, at *8 n.50. The Court pointed out that the WCA provides a remedy of 10% interest for due and unpaid compensation. Id. at 1286. Because the employee's claim boiled down to an allegation that "the insurance company wrongfully delayed his receipt of compensation benefits," the Court concluded that "the employee was limited to the remedies provided within the framework of the" WCA. Id. at 1287, 1288.
The Court in Franczyk also cited this Court's decision in Santiago v. Pennsylvania National Mutual Casualty Insurance Co., 613 A.2d 1235 (Pa.Super. 1992). There, this Court relied on Kuney II to hold that the WCA's exclusivity provision barred an employee's suit for an insurer's bad faith in settlement negotiations, as "completely intertwined with the original injury." Id. at 1243.
The Franczyk Court synthesized these cases and concluded that the employee's "asserted injury" there was likewise "'intertwined' inextricably with the workplace injury." Franczyk, 2023 WL 2992700, at *8. The Court explained that allowing the suit would necessitate a "trial within a trial" of the underlying claim against the dog owner, in effect requiring the employer defendants "to litigate precisely the sort of claim that the WCA is supposed to prevent." Id. The Court added that the trial court would also likely have to consider the effect of the employer's subrogation right on any recovery in the underlying suit, as well as whether to reduce accordingly any verdict against the employer. Id. The Court acknowledged Martin, which it said "arguably softened" Kuney II's holding. Id. at *8 n.50. The Franczyk Court to pains to clarify, however, that it did not "aim to abrogate Martin," adding that it did "not presume to anticipate or foreclose claims arising in future cases that an appellate court finds more like Martin than Kuney II or this case." Id.
Guided by Franczyk, I would conclude that this case is "more like Martin than Kuney II." The injuries here are "truly separable" because in this case we are faced with a lawsuit between strangers to the employment relationship for fraudulent conduct to evade payment of bills. Elite Care has sued for Appellants' failure to pay for medications that patients/employees undisputedly received, by alleged use of a fraudulent scheme. The suit is not for the unpaid bills themselves, "but rather for the distinct (and preventable) aggravation of the original injury"-the alleged fraudulent scheme to avoid paying the bills.
Furthermore, Franczyk's concerns about the employer becoming embroiled in the sort of litigation the exclusivity provision seeks to prevent will not occur here. No "trial within a trial" will be necessary, the insurer's subrogation rights will not come into play, and nothing will draw the employer into the litigation. I would affirm on the foregoing basis and respectfully concur.
Murray, J. joins this Concurring Opinion.
DISSENTING OPINION
OLSON, J.
I respectfully dissent from the learned Majority's determination in this matter.
The exclusivity provision of the Workers' Compensation Act ("WCA") declares:
The liability of an employer under [the WCA] shall be exclusive and in place of any and all other liability to such employes, his legal representative, husband or wife, parents, dependents, next of kin or anyone otherwise entitled to damages in any action at law or otherwise on account of any injury or death as defined in section 301(c)(1) and (2) or occupational disease as defined in section 108.77 P.S. § 481(a).
Under this section, the WCA "is a worker's exclusive remedy against his employer for an injury sustained in the course and scope of employment." Lewis v. Sch. Dist. Of Phila., 538 A.2d 862, 867 (Pa. 1988). In other words, "[t]he exclusivity provision of the [WCA] essentially 'bars tort actions flowing from any work-related injury.'" American Road Lines v. W.C.A.B. (Royal), 39 A.3d 603, 610 (Pa. Cmwlth. 2012), quoting Kline v. Arden H. Verner Co., 469 A.2d 158, 160 (Pa. 1983).
Our Supreme Court has concluded that the exclusivity provision of the WCA offers co-extensive immunity to both employers and their insurance carriers. Specifically, the Supreme Court declared, under the WCA, "[t]he employer's immunity from tort action extends to its workers' compensation insurance carrier, protecting the insurer to the full extent of the employer's protection." Kuney v. PMA Ins. Co., 578 A.2d 1285, 1286 (Pa. 1990); see also 77 P.S. § 501(a)(1) ("[the WCA] insurer shall assume the employer's liability hereunder and shall be entitled to all of the employer's immunities and protection hereunder"). Thus, "[a]n employer's liability for work-related injuries is governed solely by the [WCA], and the same is true of a compensation insurance carrier." Kuney, 578 A.2d at 1286. Further, as our Supreme Court has held, "[t]he exclusivity provisions of the [WCA] prohibit a tort action against the insurance carrier for damages caused by the insurer's allegedly intentional mishandling of the injured employee's compensation claim." Id. at 1288.
In the case at bar, Elite Care, Rx, LLC (hereinafter "Plaintiff"), filed suit against Appellants, all of whom are workers' compensation insurance carriers or the agents of such insurers. Plaintiff's Complaint, 4/9/19, at ¶¶ 8-9. Within its complaint, Plaintiff averred that "certain employees whose employers were insured by [Appellants] were injured during the course and scope of their work." Id. at ¶ 35. The employees were prescribed medications for their injuries and a pharmacy, named Patient Direct RX, filled these prescriptions. See id. at ¶¶ 11, 21, and 35. According to Plaintiff, "[a]fter Patient Direct RX fill[ed] the prescriptions of these patients, certain Providers then purchase[d] the claims arising from these prescriptions (i.e. the right to bill and collect from the carrier) from Patient Direct RX, paying fair market value for the same." Id. at ¶ 14. Plaintiff is "the manager and billing agent" for these Providers. Id. at ¶ 16.
As Plaintiff claimed, Appellants failed to pay for the prescription medications that "each insured's injured employee has received." Id. at ¶ 20. Further, Plaintiff claimed, Appellants "have alleged that they are not required to pay [for the prescription medications] because [Plaintiff is] . . . not a Health Care Provider as defined by the" WCA. Id. at ¶ 22. According to Plaintiff, Appellants "have denied payment for 110 different injured employees resulting in $548,035.28 of unpaid medical prescriptions." Id. at ¶ 38.
Moreover, in an attempt to resolve the claim, Appellants demanded that Plaintiff file an application for fee review under the WCA. Id. at ¶ 29. Plaintiff claims, however, that after it obtained favorable administrative decisions, Appellants requested hearings before the Bureau of Workers' Compensation, and, in front of the hearing officer, Appellants "frivolously and in bad faith asserted that [the fee review] process [was] improper." Id. at ¶ 37.
Plaintiff's complaint contains four counts: 1) a demand for declaratory relief; 2) fraud; 3) civil conspiracy; and 4) unjust enrichment. Specifically, in Count 1, Plaintiff requested that the trial court declare that it "is a valid agent of [the] Health Care Providers and [Appellants] must pay for these medications . . ., plus 10% per annum, per 77 P.S. § 717.1." Id. at Declaratory Relief "Wherefore" Clause.
In relevant part, 77 P.S. § 717.1(a) provides:
The employer and insurer shall promptly investigate each injury reported or known to the employer and shall proceed promptly to commence the payment of compensation due either pursuant to an agreement upon the compensation payable or a notice of compensation payable as provided in section 407 or pursuant to a notice of temporary compensation payable as set forth in subsection (d), on forms prescribed by the department and furnished by the insurer. The first installment of compensation shall be paid not later than the twenty-first day after the employer has notice or knowledge of the employe's disability. Interest shall accrue on all due and unpaid compensation at the rate of ten per centum per annum.77 P.S. § 717.1(a). Under this section of the WCA, "[i]f an insurer fails to pay the entire bill within 30 days of receipt of the required bills and medical reports, interest shall accrue on the due and unpaid balance at 10% per annum." 34 Pa.Code § 127.210.
In Count 2, Plaintiff claimed that Appellants fraudulently asserted that Plaintiff "was not an agent of [the Health Care] Providers, and thus payment did not need to be made for the prescriptions their injured employees received." Id. at ¶ 45. Moreover, Plaintiff claimed that Appellants "furthered this fraud by claiming that [Plaintiff's] exclusive remedy to resolve this issue was to file [an application for fee review, but then, after Plaintiff received a favorable administrative decision, Appellants] . . . argued that the fee review process" was inappropriate. See id. at ¶¶ 47-49. For this alleged fraud, Plaintiff sought $548,035.28 in "unpaid medical prescriptions," plus the additional costs it expended during the fee review process. Id. at Fraud "Wherefore" Clause.
Plaintiff's civil conspiracy claim, at Count 3, reiterated the allegations that supported its fraud claim and, in its Wherefore Clause, Plaintiff again demanded that Appellants pay the $548,035.28 as "unpaid medical prescriptions," plus the additional costs Plaintiff expended during the fee review process. See id. at Civil Conspiracy "Wherefore" Clause.
Finally, in the unjust enrichment claim at Count 4, Plaintiff alleged that it provided "the necessary prescriptions to the insureds' injured employees without receiving payment for the same" and that Plaintiff "conferred a financial benefit upon" Appellants in the amount of $548,035.28. Id. at ¶ 59.
As is evident from the above, Plaintiff's claims all seek payment for treatment that was provided under the WCA or compensation for damages caused by Appellants' alleged intentional mishandling of workers' compensation claims, both of which occurred while Appellants acted within their roles as workers' compensation insurers under the WCA. As stated above, the WCA establishes the exclusive forum for resolution of both payment disputes and alleged mismanagement of workers' compensation claims. See, e.g., 77 P.S. § 531(1)(i) ("[t]he employer shall provide payment in accordance with this section for reasonable surgical and medical services, services rendered by physicians or other health care providers"); Kuney, 578 A.2d at 1288 ("[t]he exclusivity provisions of the [WCA] prohibit a tort action against the insurance carrier for damages caused by the insurer's allegedly intentional mishandling of the injured employee's compensation claim"). As such, Plaintiff is bound by the exclusive remedies of the WCA and Appellants enjoy statutory immunity from Plaintiff's current action before the court of common pleas. Therefore, I would vacate the trial court's order and hold that Plaintiff's civil action is barred by the WCA.
The learned Majority holds otherwise. As the Majority notes, one of the main issues in this case is whether Plaintiff - the agent of a putative health care provider - may receive compensation for treatment that Patient Direct RX provided under the WCA. Further, the Majority cites to the Commonwealth Court's opinion in Armour Pharmacy v. Bureau of Workers' Compensation Fee Review Hearing Office (Wegman's Food Markets, Inc.), 206 A.3d 660 (Pa. Cmwlth. 2019) (en banc) (hereinafter "Armour I"), where the Commonwealth Court held that, in a fee review proceeding under the WCA, the Hearing Office has jurisdiction to determine whether a putative provider serves or functions as an actual "provider" under the WCA. Nevertheless, the Majority holds: that Armour I was incorrectly decided; that the scope of the fee review process is limited to the "amount or timeliness of payment for medical treatment;" and, that the determination of whether an entity is a "provider" is beyond the scope of a fee review. See, e.g., Majority Opinion at **8-11. The Majority then reasons that, because the issue of whether Plaintiff is a "provider" is beyond the scope of the fee review process, Appellants do not enjoy immunity from Plaintiff's claims. See id. at **10-12.
Respectfully, I believe the Majority is incorrect. I express no opinion on whether Armour I was correctly or incorrectly decided. However, regardless of whether Armour I was correctly decided, the issue of whether Plaintiff is a provider entitled to relief under the WCA can always be decided, under the WCA, by a workers' compensation judge. Indeed, as the Commonwealth Court explained:
[A c]laimant can file a petition to establish [the i]nsurer's liability to [a putative provider], such as a review petition or a penalty petition. . . . Claimants have an incentive to file a petition on behalf of a provider because when an insurer violates the [WCA] by failing to make proper payment to a
medical provider, the penalty is payable to the claimant [as a statutory incentive]. The absence of a direct statutory remedy for providers does not mean that [an appellate court] may expand the scope of a fee review to create a remedy. The matter is one for the legislature, assuming there is a need for a provider to have another remedy.Selective Ins. Co. of Am. V. Bureau of Workers' Comp. Fee Review Hearing Office (The Physical Therapy Institute), 86 A.3d 300, 305 n.9 (Pa. Cmwlth. 2014) (citations omitted), overruled, in part, by Armour I; see also Armour I, 206 A.3d at 672 ("Our holding does not limit the determination of the status of a 'provider' to a fee review proceeding. In appropriate cases, this question may also be determined by a workers' compensation judge in the course of a claim or penalty petition proceeding").
Having a workers' compensation judge make the determination of who is a "provider" under the WCA makes eminent sense. Workers' compensation judges are uniquely qualified to make such decisions due to their expertise in the area of workers' compensation law. Under the Majority decision, the interpretating of the WCA and determinations that impact this highly specialized body of law would be made by judges on the courts of common pleas who are generally not experienced in this field. Hence, the reason for the WCA's exclusivity provisions.
Further, and more to the point, even if the determination of whether an entity is a "provider" is beyond the scope of the fee review process, this holding would not diminish Appellants' statutory immunity from Plaintiff's tort action, where Plaintiff's claims either seek payment for treatment that was provided under the WCA or compensation for damages caused by the insurer's alleged intentional mishandling of the workers' compensation claim. As explained above, the WCA provides the exclusive forum for resolving both types of disputes and, thus, Plaintiff's current action is barred by the WCA. Therefore, I respectfully dissent.