Citizens United Reciprocal Exchange v. Hackensack Umc A/S/O A.R.

CourtNew Jersey Superior Court Appellate Division
DecidedJuly 8, 2024
DocketA-3330-21
StatusUnpublished

This text of Citizens United Reciprocal Exchange v. Hackensack Umc A/S/O A.R. (Citizens United Reciprocal Exchange v. Hackensack Umc A/S/O A.R.) is published on Counsel Stack Legal Research, covering New Jersey Superior Court Appellate Division primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Citizens United Reciprocal Exchange v. Hackensack Umc A/S/O A.R., (N.J. Ct. App. 2024).

Opinion

NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION This opinion shall not "constitute precedent or be binding upon any court ." Although it is posted on the internet, this opinion is binding only on the parties in the case and its use in other cases is limited. R. 1:36-3.

SUPERIOR COURT OF NEW JERSEY APPELLATE DIVISION DOCKET NO. A-3330-21

CITIZENS UNITED RECIPROCAL EXCHANGE,

Plaintiff-Respondent,

v.

HACKENSACK UMC a/s/o A.R.,

Defendant-Appellant.

Argued December 18, 2023 – Decided July 8, 2024

Before Judges Mawla, Marczyk, and Chase.

On appeal from the Superior Court of New Jersey, Law Division, Mercer County, Docket No. L-1866-21.

Lynne A. Goldman argued the cause for appellant (Callagy Law, PC, attorneys; Lynne A. Goldman, of counsel and on the briefs).

Damian A. Scialabba argued the cause for respondent (Brennan & Sponder, attorneys; Stewart M. Martinez, of counsel and on the brief).

PER CURIAM Defendant Hackensack UMC a/s/o A.R. ("HUMC") appeals from the June

7, 2022 trial court order entered in favor of plaintiff Citizens United Reciprocal

Exchange ("CURE") vacating the Forthright arbitration award and Forthright

appellate award. Based on our review of the record and applicable legal

principles, we affirm.

I.

On October 8, 2018, CURE-insured A.R. sustained life-threatening

injuries in a car accident. Because of the severity of his injuries, he was taken

to HUMC, a state-designated Level II Trauma Center, where he underwent

emergency surgery and other extensive treatment over the course of eleven days

until his discharge on October 19, 2018.

On October 25, 2018, HUMC billed CURE $204,963.75 for A.R.'s

medical services pursuant to A.R.'s personal injury protection ("PIP") benefits

under his policy. On March 21, 2019, CURE sent a letter to HUMC's billing

and business addresses 1 that rejected the amount billed by HUMC and asserted

the proper payment to be that which was determined by CURE's auditor:

CURE has received your bill in the amount of $204,963.75 for the above claimant on October 29, 2018. Please be advised that CURE disputes the billed amount. Please provide support for your usual and

1 As discussed below, checks sent to HUMC's lock box (billing address) are automatically deposited. CURE emphasizes it also sent the same correspondence to HUMC's business address. 2 A-3330-21 customary fee for the services billed in the form of exemplary EOBs [explanation of benefits].

....

CURE has allowed $44,454.06 for payment of services rendered for the above[-]mentioned bill per independent audit. A copy of this audit is attached. A payment and/or [EOB] will be issued shortly.

Also on March 21, 2019, CURE issued an EOB, which approved the allowed

amount of $44,454.06 and contained a reference that "payment, if applicable,

[would] be processed and mailed separately." The EOB also contained an

explanation of CURE's PIP appeal process under CURE's Decision Point

Review Plan ("DPRP")—a plan approved by the New Jersey Department of

Banking and Insurance ("DOBI"). 2

Seven days later, on March 28, 2019, CURE sent to HUMC's post office

lock box an offer of settlement accompanied with a check for $45,479.04. The

payment description was: EOB ($44,454.07) with interest ($24.97) and

2 CURE's EOB stated the process as follows:

IN ACCORDANCE WITH N.J.A.C 11:3-4.7B AND THE PRE-CERTIFICATION/[DPRP] APPROVED BY THE NJ DOBI . . . ALL APPEALS (PRE- SERVICE AND POST-SERVICE) SHALL BE INITIATED USING THE FORMS ESTABLISHED BY THE DEPARTMENT BEFORE MAKING A REQUEST FOR ALTERNATE DISPUTE RESOLUTION.

3 A-3330-21 consideration ($1,000). The top part of the check stub stated, "CURE is offering

the attached check as full and final settlement of the dispute regarding amounts

owed for these services . . . [including] consideration for the settlement of this

dispute." It further stated that "depositing of the attached check constitutes

[HUMC's] acknowledgement that [it has] notice of this dispute and that [it

accepts] this check as a complete settlement of [its] claim with regards to these

services." The letter then provided an address for the check to be returned within

ninety days if HUMC did not accept the offer.

On April 5, 2019, HUMC deposited the check into the hospital's account.

On May 28, 2019, CURE sent a follow-up letter directly to HUMC's billing

address and principal place of business and advised:

CURE wishes to acknowledge that check #1852 in the amount of $45,479.04 was deposited by your office. Your deposit of the check constitutes your acceptance and acknowledgement of full and final settlement of the dispute regarding amounts owed for these services.

If this check was deposited in error, please be advised you have [ninety] days from the date on the check to refund CURE the amount paid or return the original check to: Mr. Greg Osborn, CURE, 214 Carnegie Center, Suite 101, Princeton, NJ 08540.

HUMC did not return the original check issued by CURE prior to June 28, 2019.

On May 28, 2019, HUMC filed for PIP arbitration, pursuant to the

Alternate Procedure for Dispute Resolution Act ("APDRA"), N.J.S.A. 4 A-3330-21 2A:23A-1 to -30, seeking payment for the amount it billed less the amount of

the check. The arbitration was assigned to a Dispute Resolution Professional

("DRP").

CURE initially filed an application for dismissal asserting a lack of

subject matter jurisdiction based on accord and satisfaction. HUMC opposed

the motion, relying on Zeller v. Markson Rosenthal & Co., 299 N.J. Super. 461,

463 (App. Div. 1977) (delineating the elements of accord and satisfaction), and

Loizeaux Builders Supply Co. v. Donald B. Ludwig Co., 144 N.J. Super. 556,

564-65 (Law Div. 1976) (also outlining the elements of accord and satisfaction),

to argue there was no accord and satisfaction. The DRP determined in his

August 20, 2019 order CURE did not establish the elements of accord and

satisfaction and denied CURE's application. The DRP also noted the "legal

issue[s] simply [could not] be determined on an [a]pplication for [d]ismissal, as

there are genuine issues of fact in dispute."

The parties proceeded to a Forthright3 arbitration in March 2021. During

the hearing for the Forthright award, CURE again raised the accord and

satisfaction defense and also argued: (1) HUMC had not proven its usual,

3 The Commissioner of Banking and Insurance has been authorized by the Legislature to designate an organization to serve as an arbitration forum for PIP disputes. N.J.S.A. 39:6A-5.1(b). Forthright currently serves in that capacity. Kimba Medical Supply v. Allstate Ins. Co., 431 N.J. Super. 463 (2013). 5 A-3330-21 customary, and reasonable ("UCR") charges; (2) CURE's payment was proper;

and (3) that N.J.A.C. 11:3-29.4(e)(1) applies to inpatient hospitals like HUMC

such that HUMC was mandated to submit exemplar EOBs to support its UCR

charges. The DRP found in favor of HUMC reasoning that, pursuant to accord

and satisfaction principles, HUMC did not manifest its intent to accept the offer

by depositing the check. In his Forthright award, the DRP explained:

Here, there was simply a partial payment sent in response to [HUMC]'s bill. [CURE] had not contested the billing prior to the time the check was submitted and, therefore, no bona fide dispute existed when the check was presented to the provider for payment.

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Citizens United Reciprocal Exchange v. Hackensack Umc A/S/O A.R., Counsel Stack Legal Research, https://law.counselstack.com/opinion/citizens-united-reciprocal-exchange-v-hackensack-umc-aso-ar-njsuperctappdiv-2024.