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.: 30V PRUDENTIAL INSURANCE COMPANY DRP NAME: Margaret Knuetter (Respondent) NATURE OF DISPUTE: Failure to Cooperate, Self referral, medical necessity 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: PA, ET & MT. 1. ORAL HEARING held on 12/10/ ALL PARTIES APPEARED at the oral hearing(s). NO ONE appeared telephonically. 3. Claims in the Demand for Arbitration were NOT AMENDED 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). 4. FINDINGS OF FACTS AND CONCLUSIONS OF LAW: This is a claim for payment of bills incurred by PA, MA and ET as a result of an auto accident of 6/29/01. Initially I note that the demand for MA is incorrect in that the bills submitted only total $1704 and not the $2964 that is listed in the demand. Claimant submitted the following: Police report For PA:

2 CASE NO. 18 Z HCFA for dates of service 5/21/02 through 8/6/02 from Raritan Pain Management & Rehab Assignment to Raritan HCFA from Convery Medical Group for DOS 8/7/01 through 9/18/01 Assignment to Convery Fax to Prudential from Convery for pre-certification of EMG/NCV testing, dated 8/29/01 with 4 pages attached Neurological evaluation of PA by Syed Jalal, MD, dated 8/7/01. Dr. Jalal states that PA first presented for consultation on that date with complaints of neck pain radiating to the shoulders, arms and hands. There was low back pain radiating to both legs and feet with occasional numbness in the left lateral leg. He examined him and his impression was of cervical myofascial pain with possible cervical radiculopathy and lumbosacral myofascial pain with possible lumbosacral radiculopathy. His plan was for EMG/NCV testing of the upper and lower extremities, and chiropractic therapy. Patient's medical history from Convery Letter from Prudential, signed by A Murugesan MD dated 9/8 01 denying the testing as not clinically supported. Results of testing, dated 9/18/01, signed by Shan Nagendra, MD with findings of left sided Carpal Tunnel Syndrome with bilateral C5-6 radiculopathy. Pre-certification request dated 6/11/02 from Raritan Pain Management for physical therapy and 4 paracervical trigger point injections with follow up exam with 19 pages attached. Follow up report of Shan Nagendra, MD, dated 5/21/02. Dr. Nagendra states that the patient has returned for a follow up visit. There has been minimal improvement in the neck pain and the low back pain after the chiropractic treatment. His current complaints are severe neck pain and low back pain. He examined him and recommended physical/ massage therapy 3x a week for 8 weeks with pain management 4 paracervical trigger point injections. Physical therapy initial evaluation, dated 5/21/02 Report of Howard Kessler, MD of Perth Amboy Diagnostic Imaging, dated 7/13/01 re studies of lumbar spine with findings of reduced lordosis, and developmental change, posterior elements, L5 Report of Dr. Kessler dated 9/15/01 re MRI of cervical spine with findings of reduced lordosis/ levoscoliosis suggesting muscular spasm. Physical therapy progress notes for DOS 5/21/02 through 7/31/02 Follow up visit dated 8/6/02 with notation "exercise at home". For ET: HCFA from Raritan Pain Management & Rehab. for DOS 5/21/02 through 8/6/02 Assignment to Raritan HCFA from Shan Nagendra, MD (Convery Medical Group) for DOS 8/7/01 through 9/5/01 Fax from Convery to Prudential dated 8/30/01 for pre-certification of EMG/NCv testing of upper and lower extremities. with 4 pages attached. Neurological consultation of Shan Nagendra, MD dated 8/7/01. Dr. Nagendra states that ET presented on that date with complaints of neck pain, throbbing in nature, frontal in origin radiating to the occiput, neck pain radiating to both shoulders and lower back pain

3 CASE NO. 18 Z radiating to the thighs. She also had numbness and tingling in the left hand. He examined her and his impression was cervical myofascial pain, possible cervical radiculopathy, lumbosacral myofascial pain, possible lumbosacral radiculopathy. His plan was EMG/ NCV testing of upper and lower extremities to find the extent of nerve and root injury and to continue chiropractic care. Letter from Prudential, dated 9/4/01 certifying EMG and NCV of the let upper and right lower extremities and if results of abnormal, the remaining limbs may be tested. Results of testing of all upper extremities dated 9/5/01 and signed by Dr. Nagendra with findings of bilateral C5-6 nerve root irritation Pre-certification request dated 6/11/02 from Raritan Pain Management for physical therapy and 4 paracervical trigger point injections with follow up exam with 19 pages attached. Follow up visit of Raritan Pain Management, signed by Dr. Nagendra, dated 5/21/02. Dr. Nagendra states that ET presented due to persistent neck pain, radiating to both shoulders and severe low back pain with radiation to the thighs. He examined her and recommended that she start physical therapy 3x a week for 8 weeks and pan management with 4 trigger point injections. Physical therapy initial evaluation dated 5/21/02 from Raritan Patient's medical history Report of Howard Kessler, MD of Perth Amboy Diagnostic dated 9/15/ 01 re MRi of cervical spine with normal results, and one dated 7/13/01 re x-ray studies of cervical spine with findings of reduced lordosis suggestive of spasm Physical therapy progress notes for DOS 5/21/02 through 7/31/02 Follow up visit of 8/6/02. For MA: HCFA from Convery Medical Group for DOS 8/7/01 through 9/18/01 Assignment Pre-certification request from Convery, dated 9/1/01 for EMG/NCV of upper and lower extremities and physical therapy 3 x a week for 6 weeks with 5 pages attached. Neurological consultation of Syed Jalal, MD, dated 8/7/01. Dr. Jalal states that MA presented on consultation with complaints of neck pain radiating to both shoulders and hands and lower back pain radiating to both thighs and right leg. He examined him and his impression was cervical myofascial pain and possible cervical radiculopathy, lumbosacral myofascial pain and possible radiculopathy, left knee sprain, possible carpal tunnel syndrome, and possible ulnar neuropathy at elbow, left. His plan was EMG/ NCV testing of upper and lower extremities and chiropractic care along with physical therapy for the wrist and elbow. Letter from Prudential dated 9/6/01 approving the EMG/ NCV of left upper extremity and of the right if the left is positive and physical therapy for wrist and elbow, 3x a week for 6 weeks. Result of testing of upper extremities, by Dr. Nagendra, dated 9/18/01 with findings of bilateral carpal tunnel syndrome with bilateral C5-6 nerve root irritation. Respondent submitted the following: For PA Copies of requests for EUO for 8 occasions, starting on 5/28/03 For MA:

4 CASE NO. 18 Z Copies of request for EUO for 4 occasions starting on 5/28/03 Respondent argues that the demand for both PA and MA should be dismissed for failure to cooperate. Several citations are included including New Jersey Auto. Full Ins. Underwriting Assn. v Jallah, 256 NJ Super 134 (App. Div 1993). I find that the delay of two years in the request for the EUO of those two parties is untimely and therefore the request to deny on those grounds is denied. Prudential was aware from 9/6/01 that there were claims outstanding and did nothing to obtain statements until May Respondent further argues that Dr. Nagendra is engaged in self referrals in violation of NJSA 45: Respondent states that Dr. Nagendra is a health care facility in which he has a significant beneficial interest and his referral of these patients to that facility after treating them at Convery violates that statute. Attached is the Certificate of Incorporation of Convery Medical Group, dated 10/18/99 showing that the sole Director fo that corporation is Dr. Nagendra and the Certificate of Incorporation of Raritan Pain Management, dated 3/2/02 showing that the sole director is again Dr. Nagendra. I find that argument persuasive. Dr. Nagendra had a significant beneficial interest in both groups and his self referral to Raritan Pain Management violates the statute in question. For that reason, I am denying all claims on behalf of that provider. I further find however that the treatment by Convery Medical Group all predated the incorporation of Raritan and that there was no self referral involved. I find that the testing and treatment at that facility was medically necessary and that part of the demand is allowed subject to reduction for deductible, copayment and fee schedule as applicable. Interest is awarded as are costs and counsel fees. 5. MEDICAL EXPENSE BENEFITS: Awarded Provider Amount Claimed Amount Awarded Payable to For MA: Convery Medical Group For ET: Raritan Pain Management & Rehab Convery Medical Group For PA: Convery Medical Group Raritan Pain Management $2, $1, Convery Medical Group $1, $0.00 $2, $2, " " $1, $1, " " $1, $0.00

5 CASE NO. 18 Z Explanations of the application of the medical fee schedule, deductibles, co-payments, or other particular calculations of Amounts Awarded, are set forth below. Award subject to reduction for deductible, copayment and fee schedule as applicable. 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): $285 filing fee (B) ATTORNEYS FEES as follows: (payable to counsel of record for CLAIMANT unless otherwise indicated): $1050 (C) INTEREST is as follows: Awarded in the amount of $ This Award is in FULL SATISFACTION of all Claims submitted to this arbitration. 1/20/04 Date Margaret Knuetter, Esq.