A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS AWARD OF DISPUTE RESOLUTION PROFESSIONAL

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1 CASE NO. 18 Z A M E R I C A N A R B I T R A T I O N A S S O C I A T I O N NO-FAULT/ACCIDENT CLAIMS In the Matter of the Arbitration between (Claimant) AAA CASE NO.: 18 Z v. INS. CO. CLAIMS NO.: N6 C N A PERSONAL INSURANCE DRP NAME: Maria I. Daniskas (Respondent) NATURE OF DISPUTE: Reasonble & medically necessary 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: DT. 1. ORAL HEARING held on 9/24/ 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). Based on payments issued by respondent, the Demand was amended as follows: claim for Paterson Chiro was amended to $6,986 and the claim for Atlantic Rehab was amended to $7, FINDINGS OF FACTS AND CONCLUSIONS OF LAW: Claimant, DT, was involved in a motor vehicle accident on 5/19/00, in which he sustained injuries to his neck and back. Thereafter, he began chiropractic care with Paterson Chiropractic Center (Dr. Kazan) which continued through 10/11/00. Thereafter, he returned with complaints of exacerbation of symptoms for which he treated from 1/2/01 to 1/24/01; 7/2/01 to 7/16/01; 10/1/01 to 10/12/01; 1/2/02 to 1/15/02 and 4/5/02 through 4/30/02.

2 CASE NO. 18 Z Dr. Kazan referred claimant to Jadan Abbassi, M.D. of Atlantic Rehab Center where claimant was treated with physical therapy from 9/20/00 through 12/1/00, and cervical epidural injections on 10/4/00, 10/9/00 and 10/20/00. Respondent has paid bills for treatment from 9/20/00 through 10/2/00, leaving in dispute bills for dates of service 10/3/00 through 12/1/00. On 1/11/01, claimant was referred by Dr. Kazan to Roberto Sozzi, M.D., where he received psychiatric treatment from 1/11/01 through 7/12/01. Respondent paid for all chiropractic treatment through 10/11/00, at which time chiropractic PIP benefits were terminated based on the 9/7/00 IME of Kenneth Gross,D.C. who found that no treatment would be warranted as it would offer no further medical improvement and a home strengthening/stretching program would complete the patient's rehabilitative treatment. On 1/26/01, respondent terminated benefits for neurological care based on the IME of Dr. Carmickle. Respondent also argues that the return to treatment after 10/11/00 was not based on medical necessity, but rather in response to a letter from Dr. Kazan. According to claimant's EUO testimony, his return to treatment was in response to a letter from Dr. Kazan. Respondent further contends that the bills of Paterson Chiropractic Center should not be reimbursed as they are in violation of the Board of Chiropractic Examiners' regulations. Specifically, it was alleged that the treatment records violate regulations of the Board of Chiropractic Examiners, N.J.A.C. 13:44E-2.2(a) and N.J..A.C. 13:44E-2.4, on the basis that the treatment entries are not initialed and do not indicate which of the chiropractors provided treatment. Where there is a dispute, the burden rests on the claimant to establish that the services for which he seeks PIP payments were reasonable, necessary and causally related to an automobile accident. Miltner v. Safeco Ins. Co. of America, 175 N.J. Super. 156, 158 (Law Div. 1980). While the fact that a treatment is only intended to provide relief from symptoms is not alone a reason to deny benefits, such treatment must still be reasonable and necessary. Elkins v. New Jersey Mfrs. Ins. Co., 244 N.J. Super. 695 (App. Div. 1990) Based on all the documentation, I find that claimant has sustained his burden of proof as to medical necessity with respect to the post PIP termination treatment rendered by Dr. Kazan from 1/2/01 through 1/24/01, only. The medical records establish that this treatment was necessary to treat the relapse of symptoms related to the original injury. However, thereafter there was a six (6) month gap prior to his return for the first of four (4) additional courses of treatment ending in April All treament rendered from 7/2/01 and beyond is hereby denied. I futher find that the claimant substantially complied with the Code requirements, and any shortcomings do not justify denial of the bills. Claimant also seeks payment of bills for physical therapy rendered by Atlantic Rehabilitation (Dr. Abassi) from 10/3/00 through 12/1/00. Claimant's maintains that according to the reports of Dr. Abassi, dated 9/20/00 and 10/17/00, the physical therapy at issue was medically necessary. Additionally, claimant asserts that there is support for the treatment found in the report of an examination performed by Dr. Todd Koppel at the

3 CASE NO. 18 Z request of respondent. Neither the reports of Dr. Abassi nor Dr. Koppel were submitted in connection with this arbitration. Respondent has already paid the bills from 9/20/00 thorugh 10/2/00, and contends that the additional threapy at issue was not reasonable, medically necessary and causally related. According to the 7/26/00 neurological consultation performed by Dr. Jayram, the lower back pain had resolved by the examination and any cervical complaints were minimal. Thereafter, on 9/20/02, claimant begins a course of physical therapy with Dr. Abassi, to whom he was referred by Dr. Kazan. It was argued that Dr. Abassi's findings of continued lower back pain, as well as cervical and lumbar radiculopathy justifying continued treatment are directly contradicted by the findings of the treating neurologist, Dr. Jayram, the chiropractic IME physician Dr. Gross, the respondent's expert neurologist Dr. Carmickle, as well as claimant's own EUO testimony. Further it was noted that claimant admitted at his EUO that he received similar treatment at both facilities, i.e. elctrical stimulation and massage. The bills demonstrate that on some days, claimant was receiving spinal manipulation, manual traction and mechanical vibtration at Paterson Chiropractic and receiving massages, electrical stimulation, hot packs and therapeutic exercises at Atlanitc Rehabilitation. Respondent also raised issues involving violations of record-keeping requirements under Board of Medical Examiners' and Board of Physical Therapy regulations. Based on the documentation submitted in this matter, I find that the claimant has not established by a preponderance that the physical therapy at issue was reasonable, medical necessity and causally related. Neither the reports of Dr. Abassi nor Dr. Koppel were submitted connection with this arbitration. Claimant has not maintained his burden of proof. Lastly, claimant seeks payment of bills for psychiatric treatment rendered from `1/11/01 through 7/12/01. According to claimant's EUO, he was referred to Dr. Sozzi by Dr. Kazan due to trouble sleeping at night. Specifically, claimant testified that he would awake at night feeling restless and uncomfortable due to pain in his neck and back. He did not indicate to Dr. Sozzi that he was experiencing any psychological problems. Dr. has provided treatment records which are largely illegible, but no narrative report. Moreover, the doctor's Attending Physician's Reports only diagnosed cervical and lumbosacral sprian/strain. Based on the documentation submitted, including the EUO transcript, I find that the claimant has not maintained his burden of proving that the treatment rendered by Dr. Sozzi was reasonable, medically necessary and causally related. Claimant has submitted a certification of services in the amount of $2,300. Having considered respondent's objections and pursuant to AAA Rule 30, I find that $1,500 is a reasonable attorney's fee in this matter. This matter involved claims of multiple providers, and necessitated the patient's EUO. Claimant waived interest.

4 CASE NO. 18 Z MEDICAL EXPENSE BENEFITS: Awarded Provider Amount Claimed Amount Awarded Payable to Dr. Kazan $6, $2, claimant & provider Atlantic Rehab $7, $0.00 Center Dr. Sozzi $1, $0.00 Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. Subject to the application of fee schedule, copayments and deductibles. 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. 39:6A-5h. (A) Other COSTS as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $325 (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $1,500 (C) INTEREST is as follows: waived per the Claimant.. This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. 3/2/04 Date Maria I. Daniskas, Esq.

5 CASE NO. 18 Z