County of Bergen v. HORIZON BLUE

988 A.2d 1230, 412 N.J. Super. 126
CourtNew Jersey Superior Court Appellate Division
DecidedFebruary 24, 2010
DocketA-0616-09T1
StatusPublished
Cited by13 cases

This text of 988 A.2d 1230 (County of Bergen v. HORIZON BLUE) 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
County of Bergen v. HORIZON BLUE, 988 A.2d 1230, 412 N.J. Super. 126 (N.J. Ct. App. 2010).

Opinion

988 A.2d 1230 (2010)
412 N.J. Super. 126

COUNTY OF BERGEN EMPLOYEE BENEFIT PLAN and the county of Bergen, Plaintiffs-Respondents,
v.
HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY, ACS Recovery Services, Inc., Primax Recoveries, Inc., Defendants-Appellants, and
Insurance Design Administrators, Defendant.

Docket No. A-0616-09T1

Superior Court of New Jersey, Appellate Division.

Argued January 20, 2010.
Decided February 24, 2010.

*1232 Edward S. Wardell, Haddonfield, argued the cause for appellant Horizon Blue Cross Blue Shield of New Jersey (Wardell, Craig, Annin and Baxter, LLP, attorneys; Mr. Wardell and Ekta Patel, on the brief).

Lorin M. Subar (Sumner, Schick and Pace) of the Texas bar, admitted pro hac vice, argued the cause for appellants ACS Recovery Services, Inc., and Primax Recovery Services, Inc. (McCarter & English, LLP, attorneys; David J. Cooner, of counsel; Mr. Subar and Natalie S. Watson, Newark, on the brief).

Leonardo M. Tamburello argued the cause for respondents County of Bergen Employee Benefit Plan and the County of Bergen (Kalison, McBride, Jackson & Hetzel, PC, attorneys; Mr. Tamburello, of counsel; Mr. Tamburello and Rebecca M. Szelc, on the brief).

Before Judges CARCHMAN, PARRILLO and LIHOTZ.

The opinion of the court was delivered by

PARRILLO, J.A.D.

We granted leave to appeal to determine whether plaintiffs' claims against defendants, for failure to pursue subrogation actions to recover medical expenses plaintiffs paid to certain insureds who brought personal injury claims against third-party tortfeasors, are barred by the Collateral Source Rule, N.J.S.A. 2A:15-97 (Section 97). For reasons that follow, we conclude that the trial court erred in denying defendants' Rule 4:6-2(e) motion to dismiss plaintiffs' complaint and therefore reverse.

Plaintiff Bergen County (County) is a public entity of the State which, pursuant to N.J.S.A. 40A:10-6(e), established plaintiff County of Bergen Employee Benefit Plan (Plan), a self-insured benefits plan for its employees' and their dependents' healthcare. Effective July 1, 2006, defendant Horizon Blue Cross Blue Shield of New Jersey (Horizon) and the County entered into an Administrative Services Agreement (ASA) pursuant to which Horizon became the Plan's Administrator.[1] In this role, Horizon provided claims processing, adjudication, and other services related to the Plan. Although Horizon was the Plan's Administrator, it subcontracted subrogation issues to defendants Affiliated Computer Services, Inc. (ACS) and Primax Recoveries, Inc. (Primax) (jointly ACS/Primax). The Plan's insuring agreement contains a provision permitting it to recover amounts paid to its insureds as a result of third-party negligence:

If you or your dependent incur medical expenses as a result of the actions of a Third Party (anyone other than you) or the Plan and that Plan has made payment for those expenses, the Plan has the right to recoup those payments.
This means that if your medical expenses are reimbursed by a Third Party, satisfied judgment or other means, you are required to return any health benefits paid for illness, Accidental Injury, Biologically-based Mental Illness and Non-Biologically Based Medical Illness or substance abuse to the Plan
. . . .
*1233 This repayment agreement will be binding whether the payment received from the Third Party is the result of a legal judgment, arbitration award, a compromise settlement, or any other arrangement, or whether the Third party has admitted liability for the payment.

The instant lawsuit arose out of plaintiffs' efforts to seek reimbursement for medical expenses they paid under the Plan on behalf of an employee, Andres Tineos. In August of 2002, his wife, Wanda, became pregnant and advised her physician that she was predisposed to bear a child inflicted with myotubular myopathy (MTM), "a congenital muscular disease which causes severe physical disability." Wanda underwent an amniocentesis procedure to detect MTM and other abnormalities. Justin was born on April 7, 2003, with MTM.

In 2004, the Tineos filed a medical malpractice lawsuit, alleging that due to the negligence of physicians, laboratory workers, and possibly others, the test samples were either not tested or reported to be false-negative for MTM. In February 2007, a jury returned a verdict for $28,000,000, and the case was settled, post-judgment, for $18,000,000.

The Plan paid approximately $575,701.91 in net benefits associated with Justin Tineos' care. In December 2003, the Tineos' inquired of Horizon and IDA as to any lien they intended to pursue on plaintiffs' behalf, on the Tineos' recovery. Horizon forwarded counsel's request to its subrogation consultant, ACS/Primax. In February and May 2006, ACS/Primax advised the Tineos' counsel that it would not seek subrogation against any recovery from the medical malpractice litigation.

Plaintiffs claim not to have had any direct knowledge of the Tineos' lawsuit at the time it was filed. Nor were they aware of any of the correspondence between the Tineos' attorney and either Horizon or ACS/Primax. According to plaintiffs, Horizon failed to inform them that it did not intend to seek subrogation or reimbursement on their behalf. In October 2007, when plaintiffs first learned about the Tineos' settlement and defendants' decision not to seek subrogation, plaintiffs filed an action against defendants, alleging breach of contract, breach of fiduciary duty, and negligence in failing to pursue plaintiffs' claimed right of subrogation to recover from third-party tortfeasors funds which the Plan paid for Justin Tineo's healthcare and which, they allege, are recoverable by participants under the Plan.

On August 5 and 6, 2009, Horizon and ACS/Primax, respectively, filed motions to dismiss, pursuant to Rule 4:6-2(e), maintaining that Section 97 bars Plan participants, and therefore defendants, from seeking reimbursement of medical expenses paid to the Plan participant through the Plan. Plaintiffs cross-moved for declaratory judgment that the reimbursement limitations of Section 97 do not apply to self-insured municipalities. Following argument, the trial court denied both motions, unable, on the one hand to "conclude that [Section 97] and Perreira [v. Rediger, 169 N.J. 399, 778 A.2d 429 (2001)] foreclose Plaintiff's ability to recover the damages alleged[,]" yet, on the other hand, unable to "enter a declaratory judgment holding that neither [Section 97] nor Perreira bar these claims[,] as insufficient evidence has [been] presented to suggest that public entities are exempted from [Section 97] and Perreira." We granted defendants' motion for leave to appeal, and now reverse.

Here, the essential issue is whether the Collateral Source Rule bars plaintiffs, who expended funds on behalf of their insured, to recoup those payments through subrogation or contract reimbursement when the insured recovers against a tortfeasor in *1234 a post-verdict settlement. Statutory interpretation is a question of law for the court, subject to independent review. In re Liquidation of Integrity Ins. Co., 193 N.J. 86, 94, 935 A.2d 1184 (2007); Manalapan Realty, L.P. v. Twp. Comm. of Manalapan, 140 N.J. 366, 378, 658 A.2d 1230 (1995); New Jersey Mfrs. Ins. Co. v. Horizon Blue Cross Blue Shield of New Jersey, 403 N.J.Super. 518, 523-24, 959 A.2d 858 (App. Div.2008).

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Cite This Page — Counsel Stack

Bluebook (online)
988 A.2d 1230, 412 N.J. Super. 126, Counsel Stack Legal Research, https://law.counselstack.com/opinion/county-of-bergen-v-horizon-blue-njsuperctappdiv-2010.