Board of Trustees, State Employees Group Benefits Program v. LeBlanc

827 So. 2d 537, 2002 La.App. 3 Cir. 0414, 2002 La. App. LEXIS 2966, 2002 WL 31207074
CourtLouisiana Court of Appeal
DecidedOctober 2, 2002
DocketNo. 02-0414
StatusPublished

This text of 827 So. 2d 537 (Board of Trustees, State Employees Group Benefits Program v. LeBlanc) is published on Counsel Stack Legal Research, covering Louisiana Court of Appeal primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Board of Trustees, State Employees Group Benefits Program v. LeBlanc, 827 So. 2d 537, 2002 La.App. 3 Cir. 0414, 2002 La. App. LEXIS 2966, 2002 WL 31207074 (La. Ct. App. 2002).

Opinion

I,AMY, Judge.

The plaintiff insurer filed suit against the defendants, seeking reimbursement for medical expenses paid by their health benefits policy following an automobile accident. The insurer seeks a portion of the settlement entered into between the insured and the tortfeasor. The parties filed cross-motions for summary judgment, with the insurer contending that the insurance policy contains both subrogation and reimbursement provisions while the insured parties assert that the policy contains only a subrogation provision. As the insurer failed to exercise any rights to pursue recovery of the medical expenses, the insured parties contend it cannot now seek reimbursement. The trial court found in favor of the insurer. The insured parties appeal. For the following reasons, we affirm.

Factual and Procedural Background

The record indicates that John A. Le-Blanc was an employee of the Louisiana Department of Public Safety and Corrections. As an employee with family coverage, he and his wife, Jo Ann LeBlanc, had health benefits coverage under the State Employees Group Benefits Program (Group Benefits). In February 1994, Mrs. LeBlanc sustained injury from an automobile accident. Group Benefits paid medical expenses on Mrs. LeBlanc’s behalf.

Group Benefits filed suit on January 31, 1997, alleging that the LeBlancs failed to satisfy the subrogation and reimbursement provision of their policy by entering into a settlement with the tortfeasor to the prejudice of Group Benefits. The petition contains the allegation that the defendants “first notified the Program of this claim on or about November 26, 1996, and then immediately proceeded to settle the claim to the prejudice of the Program.” Group Benefits prayed for reimbursement of the medical expenses it paid under the policy.

li»Mr. and Mrs. LeBlanc filed a Peremptory Exception of No Cause of Action, [539]*539asserting that Group Benefits was subro-gated to all of their rights of recovery and that the insurer failed to pursue the recovery available. The LeBlanes contend that, because Group Benefits failed to exercise this independent right to recover, the petition failed to state a cause of action. The exception was denied by the trial court.

The LeBlanes and Group Benefits filed cross motions for summary judgment. The LeBlanes contend that the policy contains a subrogation clause, to the exclusion of any reimbursement language. They argue that since Group Benefits failed to file its own action against the tortfeasor, Group Benefits was left with no recourse, ie., it could not pursue reimbursement from the LeBlanes. In support of its summary judgment, Group Benefits alleges that the policy contains both subrogation and reimbursement language. Since, the insurer contends, the LeBlanes did not give notice of a pending suit until the time of the settlement, it was unable to pursue its subrogation rights and was left with a right of reimbursement under the language of the policy. In opposition, the LeBlanes contend that Group Benefits was provided with notice as the claim form initially completed in June 1994 indicated the injury resulted from an accident. Furthermore, they contend that information provided by Mrs. LeBlanc’s health care providers revealed that the medical expenses were incurred as the result of an automobile accident.

The trial court found in favor of Group Benefits, concluding that any subrogation provision in the policy was not in effect, due to the lack of notice, thereby permitting recovery under the reimbursement language of the provision.

LThe LeBlanes appeal, arguing that the trial court erred in denying the exception of no cause of action, denying their summary judgment and in granting the motion for summary judgment filed by Group Benefits.

Discussion

Central to each of the LeBlanes’ assignments of error is the question of whether the Group Benefits policy provided a right of subrogation or reimbursement, or both. The language at issue provides: 1

XIII. SUBROGATION AND REIMBURSEMENT
A. Upon payment of any eligible benefits covered under this Plan, the Program shall succeed and be sub-rogated to all rights of recovery of the covered Employee, his Dependents or other Covered Persons, or their heirs, or assigns, for whose benefit payment is made, and they shall execute and deliver instruments and papers and do whatever else is necessary to secure such rights, and shall do nothing after loss to prejudice such rights.
B. The Program shall be entitled, to the extent of any payment made to a covered Employee, his Dependents or other Covered Persons, to [540]*540the proceeds of any settlement or judgment that may result from the exercise of any rights of recovery of a Covered Employee, his Dependents, or other Covered Persons, against any person or entity legally responsible for the disease, illness, accident, or injury for which said payment was made. To this end, Covered Employees, their Dependents, or other Covered Persons agree to immediately notify the Program of any action taken to attempt to collect any sums against any persons or entity responsible for the disease, illness, accident or injury.

Whether considering this language in review of the trial court’s ruling on the exception of no cause of action or with regard to the motions for summary judgment, |4our review is de novo. See City of New Orleans v. Board of Com’rs, 93-0690 (La.7/5/94); 640 So.2d 237. See also Robinson v. Heard, 01-1697 (La.2/26/02); 809 So.2d 943.

In Barreca v. Cobb, 95-1651 (La.2/28/96); 668 So.2d 1129, the Louisiana Supreme Court considered a similarly worded policy in a case in which the insurer was notified by the insured of a pending suit. The insurer chose not to intervene.2 The insured entered into a settlement with the tortfeasor and informed the insurer of its intent to reimburse the medical expenses paid out, less attorney’s fees. When the insurer refused this offer, due to the reduction for attorney’s fees, the expenses were placed in the registry of the court. Although the central issue in Bar-reca was whether the insurer was required to reimburse the insured for attorney’s fees, a question the supreme court answered in the affirmative in that case, much of the discussion and finding is relevant to the present matter. In explaining its initial task of interpreting the language of the subrogation and reimbursement provisions of the insurance policy, the supreme court stated:

IsWhile subrogation and reimbursement are similar in effect, they are different principles. With subrogation, the insurer stands in the shoes of the insured and acquires the right to assert the actions and rights of the plaintiff, whereas with reimbursement, the insurer has only a right of repayment against the insured.
In determining whether a provision establishes subrogation or reimbursement we examine the language used in the provision, and, more importantly, the rights which it grants to the insurer. While this provision does make use of both terms, it very clearly grants Blue Cross the right to assert the actions and [541]*541rights of the plaintiff against the tortfea-sor. By definition this makes it a subro-gation provision. A true reimbursement provision does not allow the insurer to proceed against the tortfeasor.

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Related

Barreca v. Cobb
668 So. 2d 1129 (Supreme Court of Louisiana, 1996)
City of New Orleans v. Board of Com'rs
640 So. 2d 237 (Supreme Court of Louisiana, 1994)
Robinson v. Heard
809 So. 2d 943 (Supreme Court of Louisiana, 2002)

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Bluebook (online)
827 So. 2d 537, 2002 La.App. 3 Cir. 0414, 2002 La. App. LEXIS 2966, 2002 WL 31207074, Counsel Stack Legal Research, https://law.counselstack.com/opinion/board-of-trustees-state-employees-group-benefits-program-v-leblanc-lactapp-2002.