J. CURTIS JOYNER, District Judge.
Presently before the court for consideration are Defendants' Motion for Summary Judgment (Doc. 96-2), Plaintiffs' Response thereto (Doc. 100), Defendants' Reply to Plaintiffs' Response to Defendants' Motion for Summary Judgment (Doc. 104), Plaintiffs' Sur-Reply to Defendants' Reply to Plaintiffs' Response to Defendants' Motion for Summary Judgment (Doc. 109), as well as Plaintiffs' Motion for Partial Summary Judgment (Doc 97), Defendants' Response thereto (Doc. 98), Plaintiffs' Reply to Defendants' Response to Plaintiffs' Motion for Partial Summary Judgment (Doc. 105), and Defendants' Sur-Reply to Plaintiffs' Reply to Defendants' Response to Plaintiffs' Motion for Partial Summary Judgment (Doc. 108). As we explain in the paragraphs that follow, Defendants' Motion for Summary Judgment is DENIED and Plaintiffs' Motion for Partial Summary Judgment is GRANTED.
This case arises from allegations of a complex scheme of medical insurance fraud to induce payment by the insurer. Plaintiffs, State Farm Mutual Automobile Insurance Company and State Farm Fire and Casualty Company (State Farm), allege insurance fraud under 18 Pa.C.S.A. §4117
Summary judgment is appropriate when "the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). A court must construe "all evidence. . . .in the light most favorable to the party opposing summary judgment"
Defendants assert three arguments for summary judgment. First, Defendants argue that Plaintiffs' claim for relief under Statutory Insurance Fraud is barred by the statute of limitations. Second, Defendants argue Plaintiffs' claim for relief under common law fraud is barred because Plaintiffs cannot prove they `justifiably relied' on Defendants' records and therefore were not fraudulently induced to make payments. Third, Defendants raise the affirmative defense of laches on the grounds that they were prejudiced by Plaintiffs' `inexcusable delay' in bringing this fraud action.
Plaintiffs allege Defendants committed Statutory Insurance Fraud under 18 Pa.C.S.A. §4117
The time at which Plaintiffs knew or reasonably should have known of the alleged fraud is a material issue of fact in this case because whether the statute of limitations will be tolled depends on this question.
Defendants argue that the statute of limitations should not be tolled under the "discovery rule" or the doctrine of "fraudulent concealment."
Defendants present their argument for summary judgment against the statutory insurance fraud claim in four stages; each stage tries to establish that indisputably, Plaintiffs knew or should have known of the alleged fraud before October 30, 2015. (Def.'s Br. in Supp. of Mot. for Summ. J. at 32, Doc. No. 96-2). In the first stage of their argument for summary judgment on the commencement of the limitations period, Defendants show evidence that between 2005 and 2010, Plaintiffs referred claims involving Defendants to State Farm's fraud investigation unit (SIU); that Plaintiffs took note when attorney Adrien Reid represented a claimant because Reid was known by Plaintiffs to "solici[t] accident victims;" that Plaintiffs referred Defendants' claims to the law firm Goldberg, Miller & Rubin; and that Plaintiffs questioned Defendant Wang about his use of the WritePad software.
Plaintiffs dispute that the mere handling of a claim by their fraud investigation unit means they "knew" of the complex fraud scheme before the commencement of the limitations period in October, 2013. "The [SIU] unit in fact simply handles claims that may have suspicious indicators. . . .Defendants have not and cannot-show that the fact a claim is handled by SIU is tantamount to a determination by [Plaintiffs] that `fraud' has occurred.'" (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 17, fn. 2, Doc. No. 100). A reasonable factfinder, finding Plaintiffs' testimony credible, could conclude that sending a claim to the fraud unit did not mean Plaintiffs' investigators had "discovered" the alleged fraud scheme. Plaintiffs have established that this fact is genuinely disputed and relies on credibility determinations.
Along the same lines, Defendants rely on an inference that if Plaintiffs became aware as early as 2010 that Defendants used WritePad (Def. Ex. D, at 46), Plaintiffs must have known that Defendants were using WritePad to help falsify hundreds of treatment records. On the contrary, this Court already clarified in denying Defendants' Motion to Dismiss, "[t]he service provided by [WritePad]. . .does not violate Pennsylvania insurance fraud." State Farm Mut. Auto. Ins. Co. v. Stavropolskiy, No. 15-CV-5929, 2016 WL 2897427, at *2 (E.D.Pa. May 18, 2016). Although Plaintiffs learned in 2007 that Defendants were using WritePad, a reasonable factfinder could find that Plaintiffs did not at that point know that Defendants were using the software to conceal a complex fraud scheme.
The second stage of Defendants' argument that Plaintiffs' statutory fraud claim is time barred focuses on a 2011 treatment record (Def. Ex. G) that alerted Plaintiffs to the "cut and paste" method for falsifying treatment records. (Def.'s Br. in Supp. of Mot. for Summ. J. at 10-11, Doc. No. 96-2). Defendants infer that because Mr. Holland, an attorney helping Plaintiffs investigate potentially fraudulent claims, brought the possibility of a "cut and paste" method to the attention of Mr. Costanzo, (SIU fraud investigator and Plaintiffs' corporate designee), at that point Plaintiffs indisputably knew or reasonably should have known of the alleged fraud scheme. Plaintiffs dispute this, claiming that although Mr. Costanzo "had questions regarding Defendants, he did not suspect that Defendants were engaged in fraud at that time," (Pl. Ex. G, p. 60), and that it was not until one year later, in November, 2013, that Plaintiffs "open[ed] a `multi-claim investigation' or `project' regarding Defendants." (Pl. Ex. I). This question will turn on whether a jury finds Plaintiffs' testimony as to when they discovered the fraud credible, and is therefore not suitable for summary judgment.
In the third stage of their statute of limitations argument, Defendants show evidence that Goldberg, Miller & Rubin (one of multiple law firms to which Plaintiffs directed claims that had been flagged as potentially fraudulent, (Def. Ex. M), submitted invoices to Plaintiffs between 2011 and 2013 as part of a RICO investigation of Defendants. (Def. Ex. J). Defendants make a leap from the existence of these invoices to the assumption that "[t]here is simply no explanation for Goldberg, Miller & Rubin including Aquatic Therapy on its RICO Investigation invoices to John Costanzo other than the fact that Goldberg, Miller & Rubin and Mr. Costanzo had already been working in concert to `investigate' the treatment and billing being performed at both facilities." (Def.'s Br. in Supp. of Mot. for Summ. J. at 13, Doc. No. 96-2).
Furthermore, Plaintiffs dispute Defendants' suggestion that the act of referring third-party lawsuits involving potential fraud to Goldberg, Miller & Rubin proved a "shadow investigation." Plaintiffs claim they "routinely referred third-party lawsuits entirely unrelated to any `investigation' of a medical provider involving Defendants' patients to several other law firms during this time period and afterwards." (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 10, Doc. No. 100). Therefore, a reasonable factfinder could find that Plaintiffs' decision to involve the Goldberg, Miller & Rubin law firm did not, on its own, signal they had discovered the complex fraud scheme before October, 2013. "[T]he drawing of legitimate inferences from the facts are jury functions, not those of the judge."
In the fourth stage of their chain of inferences about when Plaintiffs discovered their injury, Defendants focus on Mr. Costanzo's 2012 review of three or four claims involving Defendants' treatment records, arguing he knew of the alleged fraud at this time. (Def.'s Br. in Supp. of Mot. for Summ. J. at 14, Doc. No. 96-2). However, Plaintiffs argue that these three or four claims "involved motor vehicle accidents and exhibited highly questionable facts that had nothing to do with Defendants' medical treatment...and thus were handled by [Plaintiff's fraud unit] for legitimate reasons which had nothing to do with Defendants." (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 17, Doc. No. 100; Def. Ex. C). In the same vein, Defendants argue that Plaintiffs' "lead file" was pretext for a multi-claim investigation into Defendants' alleged fraud. (Def.'s Br. in Supp. of Mot. for Summ. J. at 18, Doc. No. 96-2). Disputing this, Plaintiffs' witness testified that the "lead file" was opened for an administrative purpose, "to have a claim number against which to pay vendors' bills" (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 24, Doc. No. 100), and does not prove they then knew of the fraud.
Defendants impermissibly assume that "the continued entries [by Plaintiffs' fraud investigators] after January 2012 in the lead file demonstrate that State Farm was actively and continuously performing what its own lawyers were calling a RICO investigation into Eastern Approach and Aquatic Therapy." (Def.'s Br. in Supp. of Mot. for Summ. J. at 23, Doc. No. 96-2). Plaintiffs, however, draw attention to Mr. Costanzo's testimony that "neither [Plaintiff] nor [Goldberg, Miller & Rubin] was conducting a `RICO investigation' in 2011." (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 17, Doc. No. 100; Pl. Ex. G).
Disputing Defendants' inferences about when they knew of the alleged fraud, Plaintiffs claim that they were only able to discover the "non-credible patterns" of similar treatment after "considering the totality of treatment records of many patients, and then comparing them to each other in a systematic fashion" with the help of an expert medical reviewer and legal counsel. (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 7, 11, 15, Doc. No. 100). According to Plaintiffs, their delay in discovering the alleged fraud was due to Defendants' use of the WritePad software's `randomization' feature, which allowed Defendants to "hide that they were not legitimately evaluating and treating patients' individual symptoms and needs, and to conceal the fraudulent nature of their Initial Examinations, Daily Visit Notes, re-examinations, and Discharge Summaries." (Pl. Ex. E at 2, 6).
Two additional factors, Plaintiffs argue, contribute to the genuine dispute over when Plaintiffs became aware of the alleged fraud, and why, even if they used "reasonable diligence" to discover it, it evaded them. First, the method by which Defendants submitted their claims: piecemeal ("for only a portion of the treatment dates per patient at a time" (Pl. Ex. F)), making it difficult for "patterns across multiple patients over time" to be discerned by a claim specialist who "typically lack[s] the expertise to observe complex medical patterns" (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 10, Doc. No. 100). Second, Plaintiffs were required by Pennsylvania Law to issue payment within thirty days. 75 Pa. C.S.A. §1716. Id. at 9. Thus, a reasonable factfinder could determine that to comply with this law, Plaintiffs paid even those claims that were under investigation yet had not been identified as fraudulent.
We find that whether the two-year statute of limitations period for Plaintiffs' statutory insurance fraud claim should be tolled is genuinely disputed. Here, a reasonable factfinder could find that despite Plaintiffs' reasonable diligence in discovering their injury, they did not discover the alleged fraud until September, 2014, after reviewing hundreds of Defendants' records with the assistance of an expert medical reviewer and counsel. "[T]he ordinary rule should apply that factual issues pertaining to the plaintiff's notice and diligence are for the jury."
Defendants also contend that Plaintiffs' request for damages should be barred because 95% of Plaintiffs' claimed damages were incurred from payments they made before October 30, 2013; i.e. before the two-year statute of limitations period began. (Def.'s Br. in Supp. of Mot. for Summ. J. at 37, Doc. No. 96-2 at 3). We find that a reasonable factfinder could conclude that tolling is appropriate because Plaintiffs were unable to discover the alleged fraud as a result of the scheme's complexity and Defendants' efforts to conceal it. Accordingly, summary judgment is inappropriate; the matter of the commencement of the statute of limitations period under 18 Pa.C.S.A. §4117
Justifiable reliance is an element of common law fraud under Pennsylvania law,
Defendants infer that by 2011, at the disputed start of the RICO investigation, through 2012, when Plaintiffs referred all claims involving Defendants to its fraud investigation unit, Plaintiffs "actually believed that every treatment record of the Defendants was entirely false" (Def.'s Br. in Supp. of Mot. for Summ. J. at 39), therefore Plaintiffs could not have relied on these records. Yet, as we reasoned when denying Defendants' Motion to Dismiss, "[w]hether State Farm's reliance on the submissions by the Defendants was reasonable or justified is a question of fact; this is precisely the kind of inquiry that is best decided by a jury...."
Defendants argue that Plaintiffs' delay in bringing this suit has prejudiced them because it has "effectively deprived [the Defendants] of the critical factual defense" of patient memories of treatment they received. (Def.'s Br. in Supp. of Mot. for Summ. J. at 40, Doc. No. 96-2). "The party asserting laches as a defensive bar must establish (1) an inexcusable delay in bringing the action and (2) prejudice."
Plaintiffs counter that laches is inapplicable because any delay in bringing this suit resulted from Defendants' efforts to conceal the fraud from discovery, and that any loss of evidence would not prejudice Defendants. Thus, Plaintiffs argue that their "inability to immediately recognize the well-hidden and complex fraud at issue in this case is not `inexcusable.'" (Pl.'s Br. in Resp. to Def.'s Br. in Supp. of Mot. for Summ. J. at 31). Second, Plaintiffs argue that any patient recollections' that may have diminished during the time lapse between treatment and the start of litigation is merely one portion of relevant evidence to constitute Defendants' defense to fraud. The primary allegation is not that patients did not receive treatment. Rather, the central issue is "whether the records Defendants' used to seek payment from [Plaintiffs] were legitimate," and whether Defendants fraudulently concealed that they fabricated records for the purpose of inducing payment. Id.
There is no "[p]resumption of `inexcusable delay and prejudice'" because whether the "statutory limitations period that would bar legal relief has expired," is genuinely disputed. Id. at 337, (quoting
Defendants filed a separate action in the Pennsylvania Court of Common Pleas, (Doc. No. 97-4), alleging that since 1986, Plaintiffs "crafted and honed a business strategy of attacking and undermining the credibility of doctors who treat auto accident patients," id., that years of consultation with McKinsey & Company helped Plaintiffs use their Special Investigation Unit (SIU) "to identify doctors to be targeted" as "projects,"
"In a bad faith case, summary judgment [in favor of the insurer] is appropriate when there is no clear and convincing evidence that [its] conduct was unreasonable and that it knew or recklessly disregarded its lack of a reasonable basis in denying the claim."
Pennsylvania's Motor Vehicle Responsibility Law (MVFRL) requires "automobile insurers to provide medical benefit coverage `for reasonable and necessary medical treatment and rehabilitative services' after a motor vehicle accident."
In moving for partial summary judgment, Plaintiffs argue that their "conduct in denying bills for the same services by the same providers for which [State Farm] has alleged a widespread medical fraud, pending resolution of this case, cannot be `wanton' conduct. . . .under the MVFRL." (Pl.'s R. to Def.'s Resp. to Pl.'s Mot. for Part. Summ. J. at 5, Doc. No. 105). Defendants are unable to show `clear and convincing evidence' of Plaintiffs' bad faith; they have shown no evidence that the insurer, "(1) did not have a reasonable basis for denying benefits under the policy and (2) knew or recklessly disregarded its lack of a reasonable basis for denying the claim."
Defendants rely on evidence that Mr. Costanzo testified that after filing this litigation, Plaintiffs used a TIN (Tax Identification Number) Diversion to direct Defendants' bills to a designated adjuster and then deny payment. Even construing this evidence in the light most favorable to Defendants, evidence of diversion to an adjuster, absent any other evidence to support a claim of Plaintiffs' bad faith, does not establish a genuine dispute whether Plaintiffs denied payment "wantonly" or "in bad faith" under MVFRL §1797(b)(4). Mr. Costanzo in fact testified that "[a]t the time the TIN block was issued, State Farm made a decision to not pay those claims until they were reviewed and then once they're reviewed, if they're consistent with the [fraud action] allegations, then they would be denied." (Def.'s Ex. D. at 182). We find it beyond general dispute that Plaintiffs did not act in bad faith and did not lack a reasonable basis in denying Defendants claims that were received after the start of Plaintiffs' fraud litigation. Without "clear and convincing evidence that [an insurer's] conduct was unreasonable and that it knew or recklessly disregarded its lack of a reasonable basis in denying the claim,"
Defendants show no evidence in support of their assertion that Plaintiffs used "mere accusations of fraud to drive down claim payments." (Def.'s Resp. Pl.'s Mot. Part. Summ. J. at 7, Doc. No. 98). On the contrary, Defendants used the attorneyclient privilege to avoid testifying to "facts which allegedly support their State Court Action claim."
We find Plaintiffs have met their burden in showing there is no genuine dispute that they stopped payment to Defendants for post-litigation bills out of a "bona fide belief that Defendants' bills were fraudulent," after "observing noncredible patterns in Defendants' records" indicating to Plaintiffs that the records had been falsified in order to induce payment. (Pl.'s Mot. Part. Summ. J. at 14, Doc. No. 97). Since Defendants offer no competing evidence of Plaintiffs' alleged bad faith in denying their claims, no reasonable jury would be able to find that Plaintiffs' "wantonly" violated Pennsylvania's Motor Vehicle Financial Responsibility Law. The record establishes beyond genuine dispute that Plaintiffs had a basis for denying Defendants' claims submitted after the commencement of this litigation, when Plaintiffs were on alert that Defendants' claims could be fraudulent. We therefore grant Plaintiffs' motion for partial summary judgment and Defendants are precluded from seeking treble damages under §1797 of the Motor Vehicle Financial Responsibility Law ("MVFRL").
For the reasons stated in the preceding Memorandum Opinion, Defendants' Motion for Summary Judgment is denied and Plaintiffs' Motion for Partial Summary Judgment is granted. An appropriate Order will follow.