Robert A. Cappuzzo and Daniel R. Lagana successfully defended Allstate against an appeal by a medical provider who sought to overturn an award which denied the provider’s claim for medical benefits. In the underlying case, the provider’s claim was denied based upon the termination of benefits by Allstate’s orthopedic IME. Claimant appealed and argued that the carrier failed to respond to the provider’s post-termination requests for precertification of additional surgery. Mr. Cappuzzo and Mr. Lagana argued that once the provider and insured are notified that orthopedic benefits are terminated, there is no longer any obligation to request or respond to pre-certification since the parties are aware of the termination. The Appellate Panel agreed and upheld the denial of the provider’s $17,100 claim. The Award is available on the Forthright website (http://www.nj-no-fault.com) under case # 1261717.
A second appeal was successfully obtained by Robert A. Cappuzzo and Richard W. Fogarty on an arbitrator’s award where a DRP made a mistake of law in applying the Entire Controversy Doctrine. In the underlying case, Allstate’s defense was that claimant failed to include several dates in a prior arbitration demand –therefore barring their second Demand for Arbitration. The arbitrator ruled in claimant’s favor finding that Allstate had to prove claimant waived it’s right to proceed on other unpaid bills for the Entire Controversy Doctrine to apply. Mr. Cappuzzo and Mr. Fogarty argued that the claimant’s failure to include all unpaid treatment in its’ pending arbitration matter is a bar to future recovery for such dates since claimant knew or should have known such treatment was unpaid. The Appellate Panel agreed with our arguments and reversed the original Award – thereby denying the entire claim. The Award is available on the Forthright website (http://www.nj-no-fault.com) under case # 1281121.