Court Opinion

ID: 4952892
Source: CourtListenerOpinion
Date Created: 2021-09-24 13:19:58.030326+00
Date Added: 2024-06-11T08:15:27.891725
License: Public Domain

FORD ELLIOTT, Judge,
dissenting.
I respectfiiEy dissent.
As indicated by the majority, the courts of this Commonwealth have alluded that some form of judicial review is available as to disputes resolved under 40 Pa.C.S.A. § 6324. See Kline v. Pennsylvania Blue Shield, 383 Pa.Super. 347, 556 A.2d 1365 (1989), and Pennsylvania Blue Shield v. Commonwealth Department of Health, 93 Pa.Cmwlth. 1, 500 A.2d 1244 (1985), appeal denied, Com., Dept. of Health v. Pa. Blue Shield, 514 Pa. 632, 522 A.2d 560 (1987). Today, the majority limits that review to those instances where fraud or some other misconduct inherent to the in-house proceeding is alleged. I disagree with this interpretation and must respectfully dissent.
I believe that the majority has misper-ceived the nature and purpose of the statute at issue. The intent of the Legislature in enacting 40 Pa.C.S.A. § 6301 et seq. was to ensure access and availability of professional health services to all citizens of this Commonwealth regardless of economic ability to pay. Within this context, the resulting statute sought to regulate the burgeoning health insurance industry. Pursuant thereto, the Legislature created a statutory scheme whereby health service plan corporations would be certified and policed. Section 6324 in particular appears to have been enacted to protect doctors from the worst potential transgressions by health service plan corporations, occurring where the corporation attempts to limit the treatment choices of participating health service doctors on the basis of economy.
This scheme is reflected in § 6324(a), which allows any doctor who complies with the approved regulations of the corporation to register with the corporation for the provision of covered medical services. This subsection also prohibits the corporation from refusing to register such doctor or from removing such doctor from the register without the approval of the Department of Health. The protective scheme is also seen in *812§ 6324(b) which prevents the corporation from imposing any restrictions upon registered doctors as to methods of diagnosis or treatment in order to preserve the doctor/patient relationship as it ordinarily exists in the community. Finally, the protective scheme is manifested in § 6324(c) which attempts to ensure that internal disputes regarding services or ethics, between the corporation and its registered doctors, will be resolved by doctors and not by accountants or bureaucrats, who might exalt cost effectiveness over medical necessity or propriety. It seems improper to me to stand this subsection on its head and employ it to limit the rights of doctors in favor of bestowing an enormous benefit on the health service plan corporations it was meant to police. I find myself in complete agreement with the analysis of Judge Hoffer of the Cumberland County Court of Common Pleas:
The purpose of section 6324 is illustrated by its heading: ‘Rights of health service doctors.’ Subsection (a) provides that every doctor has the right to register with any professional health service corporation; the corporation may refuse to accept such only with the Department of Health’s approval. Subsection (b), entitled ‘Freedom from control,’ prohibits the corporation from infringing on the normal doctor-patient relationship, including the patient’s choice of a doctor and the doctor’s methods of treatment.
Subsection (c) provides that disputes are to be considered and determined only by health service doctors. Considering its context, its purpose seems to be similar to that of the Peer Review Protection Act, 63 P.S. § 425.1 et seq., i.e., ‘to encourage peer evaluation of the health care_’ Robinson v. Magovern, 83 F.R.D. 79, 87 (W.D.Pa.1979). ‘[OJnly by health service doctors’ is meant to keep laymen from deciding the disputes, not to keep doctors out of court.
RRS Imaging Associates Ltd. v. Medical Service Association of Pennsylvania, 49 Pa. D. & C.3d 339, 334-35 (1988) (emphasis added).
Nevertheless, even if I agreed with the majority as to the nature and purpose of 40 Pa.C.S.A. § 6324, I would be compelled to dissent in this case for reasons which are far more profound. Simply stated, the dispute resolution mechanism as interpreted by the majority, and as implemented by appellant, runs afoul of due process of law.
Citing Greenstein v. Commonwealth Dept. of Health, 98 Pa.Cmwlth. 445, 512 A.2d 739 (1986), appeal denied, 516 Pa. 636, 533 A.2d 94 (1987), the majority finds that the essential elements of due process are notice and the opportunity to be heard and to defend in an orderly proceeding before a tribunal with jurisdiction. The majority then quotes relevant excerpts from Pennsylvania Blue Shield’s Review Committee Guidelines and finds the notice and opportunity to be heard components of due process to be satisfied.1 However, I believe the majority has overlooked the most basic aspect of due process; to have any value, notice and hearing must lead to review by an impartial tribunal. The necessity for a hearing by an impartial tribunal has been recognized on both the federal and state levels. See Peters v. Kiff, 407 U.S. 493, 92 S.Ct. 2163, 33 L.Ed.2d 83 (1972), and Lyness v. Commonwealth, State Board of Medicine, 529 Pa. 535, 605 A.2d 1204 (1992). This due process right attaches in administrative proceedings as well as in courts. Sherman v. Kaiser, 664 A.2d 221, 224 n. 4 (Pa.Cmwlth.1995). This vital aspect of due process, however, is missing instantly.
The majority has likened the review process at hand to that of arbitration. Arbitration jurisprudence demonstrates the lack of due process in the case sub judice. This court has previously ruled:
*813The hearing to which each party is entitled must be one that is ‘full and fair.’ Abramovich v. Pennsylvania Liquor Control Bd., supra 490 Pa. at 294, 416 A.2d at 476; Smaglio [Smaligo] v. Fireman’s Fire [Fund] Insurance Co., 432 Pa. 133, 247 A.2d 577 (1968); Mellon v. Travelers Insurance Co., 267 Pa.Super. 191, 406 A.2d 759 (1979). Procedural due process requires that a fair hearing be conducted by one not involved with a party to the proceeding.’ Abramovich v. Pennsylvania Liquor Control Bd., supra citing Dussia v. Barger, 466 Pa. 152, 351 A.2d 667 (1976). See also: [James D.J Morrisey [Inc.] v. Gross Construction Co., Inc., 297 Pa.Super. 151, 159-160, 443 A.2d 344, 348-349 (1982). But cf. Morris Lapidus Associates v. Airportels, Inc., 240 Pa.Super. 80, 84, 361 A2d 660, 663 (1976).
A hearing which comports with procedural due process must be full and fair and must be held before impartial and disinterested arbitrators. ‘Since arbitrators are generally selected to act in a quasi-judicial capacity in place of a court, they must ordinarily be impartial and nonparti-san_’ 5 Am.Jr.2d, Arbitration and Award, § 98.
If parties are to be encouraged to arbitrate, arbitration proceedings must be conducted with the same degree of impartiality as the courts afford. Public policy requires, therefore, that arbitrators not only be completely impartial but also that they have no connection with the parties or the dispute involved which might give the appearance of their being otherwise. Obviously a person is disqualified to act as an arbitrator if he is himself a party to the dispute. And, in the ordinary case, a close relative, servant, employee, or agent of one of the parties to the controversy, or one who has any secret interest in the result or decision thereof, may not properly act as an arbitrator.
5 Am. Jr .2d Arbitration and Award, § 99.
Donegal Insurance Co. v. Longo, 415 Pa.Super. 628, 632-633, 610 A.2d 466, 468 (1992). Furthermore, it has been held that the requirement of an impartial arbitrator is even more compelling where a party must consent to arbitration as the method of resolving disputes. See Abramovich v. Pennsylvania Liquor Control Board, 490 Pa. 290, 416 A.2d 474 (1980).
The bylaws of Pennsylvania Blue Shield make the following provisions for the selection of members of its Medical Review Committee:
Section 2. Medical Review Committee. There shall be a Medical Review Committee consisting of at least five (5) members, each of whom shall be appointed by the Chairman of the Board of Directors of the Corporation and each of whom shall serve until his successor is appointed. A majority of the members of the Medical Review Committee shall be doctors who are either members of the Board of Directors of the Corporation or members of the Corporation.
Bylaws, Article X, Section 2. It is readily apparent that the ease under review presents the most egregious situation possible from a due process point of view: a party to a dispute is effectively sitting in judgment of that dispute. The “arbitrators” in this case are hand selected by the Chairman of the Board of Pennsylvania Blue Shield. Moreover, the majority of the Medical Review Committee must be comprised of other members of the Board of Directors of Pennsylvania Blue Shield or members of the Corporation. The issue in Donegal Insurance, supra, was whether a lawyer can serve as an arbitrator while he simultaneously represents one of the parties to the arbitration in an unrelated matter. We answered that the lawyer cannot so serve. I find the instant situation to be a far more flagrant abuse of the due process rights of doctors such as appellee. If, indeed, the Legislature intended the dispute review procedure described in 40 Pa.C.S.A. § 6324(c) to be a doctor’s “only bite of the apple” to recover the value of his services (except under circumstances of fraud or misconduct as the majority allows), then the review process as implemented by Pennsylvania Blue Shield fails to meet the constitutional requirements of due process of law.
*814I also reject the comparison of the review procedure described by § 6324(c) to that enacted pursuant to the Uniform Arbitration Act, 42 Pa.C.S.A. § 7301 et seq. Arbitration generally provides a much fairer forum. Commonly, where contracting parties have agreed to settle disputes by arbitration, each party is entitled to select one arbitrator and a third is selected by the parties’ arbitrators or by the court. This provides an impartial tribunal. Moreover, the Uniform Arbitration Act is much more detailed in establishing the parameters of that dispute resolution mechanism. Contrary to the analysis of the majority, I find no such indication that the Legislature intended to craft a similar mechanism with § 6324(c). The Uniform Arbitration Act is quite explicit in spelling out that the Legislature intended arbitration under the Act to be the only forum of review and resolution except under certain circumstances. See 42 Pa.C.S.A. §§ 7314, 7315, and 7341. When the Legislature has previously shown great care and consideration in crafting an exclusive statutory remedy, I cannot find that the Legislature evinced a similar intent in the limited language set forth in § 6324(c).
For all of these reasons, I am constrained to dissent.

. While the Guidelines do appear to provide for notice, an opportunity to be heard, a right to counsel, and a right to present evidence, the statute requires review procedures to be contained in the corporate bylaws. However, the bylaws of Pennsylvania Blue Shield appear to provide for notice, the right to counsel, the right to call witnesses and present evidence, as well as other rights, only in disputes where the doctor’s status as a participating (registered) doctor is at issue. As to other types of disputes, the bylaws make no such due process guarantees. The instant review process is thus flawed in this respect also.