CASE NO. 18 Z 600 17519 01 2
AMERICAN ARBITRATION ASSOCIATION
In the Matter of the Arbitration between
AAA CASE NO.: 18 Z 600 17519 01
v. INS. CO. CLAIMS NO.: 30V331456
STATE FARM INSURANCE COMPANY DRP NAME: Scott G. Sproviero
(Respondent) NATURE OF DISPUTE: medical
necessity of treatment provided; pre-
certification; fee schedule
AWARD OF DISPUTE RESOLUTION PROFESSIONAL
I, THE UNDERSIGNED DISPUTE RESOLUTION PROFESSIONAL (DRP),
designated by the American Arbitration Association under the Rules for the Arbitration
of No-Fault Disputes in the State of New Jersey, adopted pursuant to the 1998 New
Jersey “Automobile Insurance Cost Reduction Act” as governed by N.J.S.A. 39:6A-5, et.
seq., and, I have been duly sworn and have considered such proofs and allegations as
were submitted by the Parties. The Award is DETERMINED as follows:
Injured Person(s) hereinafter referred to as: the "Injured Party".
1. ORAL HEARING held on November 6, 2002 and June 17, 2003.
2. ALL PARTIES APPEARED at the oral hearing(s) .
NO ONE appeared telephonically.
3. Claims in the Demand for Arbitration were AMENDED and permitted by the DRP at
the oral hearing (Amendments, if any, set forth below). STIPULATIONS were not made
by the parties regarding the issues to be determined (Stipulations, if any, set forth below).
Claim amended at hearing to seek medical benefits in the amount of $4,925.96
4. FINDINGS OF FACTS AND CONCLUSIONS OF LAW:
Claimant, Kramer Chiropractic Center, is the assignee of the Injured Party, which Injured
Party suffered bodily injuries when involved in a motor vehicle collision on March 21,
2001. As a result of the injuries so sustained, the Injured Party complained of headaches,
vertigo, TMJ pain and dusfunction, knee pain and sever neck pain. In response to such
complaints, the Injured Party sought treatment by and through Dr. Diane Kramer of
Kramer Chiropractic Center.
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The record of the within matter confirms that the Injured Party herein had undergone
prolonged chiropractic treatment under the direction of Dr. Kramer prior to the date of
loss herein. In point of fact, both the Injured Party and the Claimant herein readily admit
that the majority of the injuries suffered in the within matter constitute an exaccerbation
of prior injuries suffered as a result of the prior motor vehicle collision.
Following the March 21, 2001 incident, the Injured Party resumed treatment with Dr.
Kramer on March 22, 2001, when and at which time the Injured Party was diagnosed as
suffering from a moderate cervical whiplash injury, cervical subluxation at C1, 2, 4, 5
and 6, cervical myalgia, thoracic subluxation at T1 through T6, concussion and cervical
radiculitis. In response to such diagnosis, Dr. Kramer recommended that the Injured
Party pursue a conservative course of chiropractic treatment, which recommendation was
abided by the Injured Party. Dr. Kramer administered chiropractic treatment in
accordance with the foregoing treatment plan until the discharge of the Injured Party was
chiropractic care on November 14, 2002.
Medical benefits were provided by the Respondent in response to the treatment provided
by the Claimant through December 31, 2001, purportedly in accordance with New Jersey
fee schedule rates. Respondent has denied the provision of medical benefits for all
treatment provided on and after January 2, 2002, contending the same to be medically
The within action followed.
Oral hearings were conducted in the within matter on November 6, 2002 and June 17,
2003. At the time of the conduct of the oral hearings, the parties acknowledged that the
within dispute was governed by the New Jersey Automobile Insurance Cost Reduction
Act. Each party submitted pre-and post-hearing memoranda, as well as various exhibits
for consideration by the arbitrator, the principal of which are referred to herein. In
addition, Claimant relied upon the oral testimony of the Injured Party and Dr. Diane
Kramer at the time of the June 17, 2003 hearing.
Respondent posits that the termination medical benefits relative to the treatment
administered by Dr. Kramer in the within matter was supported by various decision point
review determinations and the opinion of Dr.Gaetano Buttitta, D.C. upon Independent
Chiropractic Examination conducted on November 19, 2001, pursuant to which, Dr.
Buttitta opined that as of the date of examination, the Injured Party had achieved "pre-
accident status". Thereafter, on December 4, 2001, Claimant submitted a request for pre-
certification of continued chiropractic treatment through January 2, 2002. Such request
was denied on the basis of the November 19, 2001 IME. Claimant continued to submit
pre-certification request, in four to five week intervals, relative to all treatment provided
through November 14, 2002. Each such request was denied by the Respondent.
The arbitrator is pursuaded by the testimony of the Injured Party and the treating
physician adduced at the June 17, 2003 hearing. On the basis of that testimony, the
arbitrator finds that any pre-existing injuries suffered by the Injured Party were
CASE NO. 18 Z 600 17519 01 4
exaccerbated as a result of the March 21, 2001 collision, that the treatment administered
by Dr. Kramer was in direct response to the loss that was suffered on March 21, 2001,
and that the Injured Party deminstrated a continuing pattern of medical improvement
throughout the entire course of the treatment so provided.
Accordingly, on the basis of the foregoing, the arbitrator is satisfied that the
preponderance of the credible evidence adduced at hearing in the within matter supports
the conclusion that the chiropractic treatment provided by Claimant in the within matter
during the period January 2, 2002 through November 14, 2002 was reasonable, medically
necessary and directly resulted in the continuing improvement of the medical condition of
the Injured Party. Medical benefits with respect to the same shall be awarded in
accordance with the maximum daily billing limitation permitted in accordance with
The arbitrator further finds that the record of the within proceeding reveals that sporatic
payments were paid by the Respondent on account of treatment administered from March
20, 2002 through November 11, 2002, including benefits for the periodic re-examinations
conducted by Dr. Kramer. The arbitrator cannot discern from the record if the within
matter the basis or calculus for the payment made on account of such treatment. As
such, Respondent shall be given credit for all such payment made for the affected period
of time in the calculation of the medical benefits due in the within matter.
As the Claimant is a prevailing party in the within matter, counsel fees shall be awarded
in accordance with the criteria set forth at RPC 1.5, and in an amount consonant with the
underlying award of medical benefits, together with cost. In applying such criteria, the
arbitrator notes the extraordinary work effort involved in the prosecution of the within
claim, including the submission of multiple pre-hearing memoranda, the conduct of
multiple hearing and the presentation of live testimony. As no interest calculation was
submitted in the within matter, interest is deemed waived.
5. MEDICAL EXPENSE BENEFITS:
Provider Amount Claimed Amount Awarded Payable to
Kramer Chiropractic $4,925.96 $4,925.96 Provider
Explanations of the application of the medical fee schedule, deductibles, co-payments, or
other particular calculations of Amounts Awarded, are set forth below.
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Award subject to adjustment for co-payment and deductable requirements only.
6. INCOME CONTINUATION BENEFITS: Not In Issue
7. ESSENTIAL SERVICES BENEFITS: Not In Issue
8. DEATH BENEFITS: Not In Issue
9. FUNERAL EXPENSE BENEFITS: Not In Issue
10. I find that the CLAIMANT did prevail, and I award the following
COSTS/ATTORNEYS FEES under N.J.S.A. 39:6A-5.2 and INTEREST under N.J.S.A.
(A) Other COSTS as follows: (payable to counsel of record for CLAIMANT unless
otherwise indicated): $325.00
(B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT
unless otherwise indicated): $2,250.00
(C) INTEREST is as follows: waived per the Claimant. .
This Award is in FULL SATISFACTION of all Claims submitted to this arbitration.
August 5, 2003 ________________________
Date Scott G. Sproviero, Esq.