Hines v. Blue Cross Blue Shield of Virginia

788 F.2d 1016, 54 U.S.L.W. 2581
Court of Appeals for the Fourth Circuit·Decided April 21, 1986·No. No. 85-1875·Published·Cited by 3 cases

Opinion

WILKINSON, Circuit Judge:

This case concerns the validity of a provision in a Blue Cross and Blue Shield contract which excludes payment for services already covered by workers’ compensation. Virginia law prohibits provisions in policies that deny recovery for services for which the insured has been reimbursed by “a third party responsible for such personal injuries.” Va. Code § 38.1-342.2 (1980). The district court decided that a “workers’ compensation carrier, who stands in the shoes of the employer, would be a third person responsible for personal injuries” within the meaning of the statute, and granted summary judgment for plaintiff. We do not subscribe to that interpretation, nor do we believe that in enacting § 38.1-342.2 the Virginia legislature intended to foreclose non-duplication provisions of the type used by Blue Cross here. We therefore reverse the decision of the district court.

I.

John Henry Hines was injured in a two-car accident in Virginia in 1982 while working for English Construction Company. English Construction, through its insurance carrier, reimbursed Hines for his medical expenses as required by the Virginia Workmen’s Compensation Act, Va.Code §§ 65.1-1 to 65.1-163 (1980). Hines also filed a civil action against Wallace Hern-don, the driver of the other car, and that suit was settled to the satisfaction of Hines, English Construction, and its carrier, Liberty Mutual. In addition, Hines asked Blue Cross to reimburse him for his medical expenses.

At the time of the accident, Hines had a Blue Cross contract, a Blue Shield contract, and a Major Medical contract in effect with Blue Cross. Each contained a non-duplication of benefits provision that excluded payment for services covered by workers’ [1018] compensation.1 Because Hines had already received workers’ compensation for his medical expenses, Blue Cross denied coverage for his injuries. Hines contends that Va. Code § 38.1-342.2 bars Blue Cross from denying him coverage on the basis of the exclusionary provisions.

Section 38.1-342.2 provides that no contract of insurance shall “contain any provision denying or limiting the recovery ... for services rendered for the treatment of personal injuries, for which services, payment or reimbursement has been or is to be received by or for the account of any such person, from any claim against or settlement with a third person responsible for such personal injuries.”

Whether the statute applies to the Blue Cross contracts turns on what the Virginia legislature meant by “responsible.” Hines contends that the legislature meant “financially responsible.” Since the workers’ compensation act compels English Construction to reimburse Hines for medical expenses for injuries in the course of employment, Hines argues that the employer is “responsible for such personal injuries.” Under Hines’ interpretation of the statute, Blue Cross would therefore be barred from enforcing its non-duplication provisions.

Blue Cross responds that the legislature meant “causally responsible.” Under this interpretation, the “third person responsible for such personal injuries” is the tort-feasor, not the employer which must pay workers’ compensation. If one reads the statute this way, it does not speak to the legal responsibilities fixed by workers’ compensation laws and would not prohibit the Blue Cross non-duplication provisions.

II.

We hold that Va. Code § 38.1-342.2 does not operate to prohibit provisions that exclude coverage when there has already been recovery under workers’ compensation law. We interpret “responsible” to mean “causally responsible,” in accordance with the usage of the Virginia Supreme Court. The history of the statute convinces us that it was enacted to address a specific problem raised by two recent Virginia cases, and not to overturn case law established some years before. Other statutes that assume the validity of such non-duplication provisions persuade us that the legislature did not intend to prohibit those that appear in Hines’ contracts.

The ordinary meaning of a “person responsible for such injuries” is the person who caused the injuries, who did the damage. The Virginia Supreme Court has used “responsible" in this way as well. The court has long recognized that in a workers’ compensation case, the tortfeasor will not necessarily be the employer, and the court calls the tortfeasor the responsible party. “His death was occasioned by the crash of an airplane under the control of BEAC, and was therefore due solely to its wrongful act, neglect, default and breach of duty. The party responsible for the death of Sheris is BEAC____” Sheris v. Sheris Co., 212 Va. 825, 188 S.E.2d 367, 373, cert. denied, 409 U.S. 878, 93 S.Ct. 132, 34 L.Ed.2d 132 (1972) (emphasis added). Other Virginia cases use the word “responsible” to describe the one who caused the injuries. See, e.g., Dwyer v. Yurgaitis, 224 Va. 176, 294 S.E.2d 792, 793 n. 2 (1982) (“the first tort feasor, Steward, is responsible for all of her injuries”); Lackey v. Brooks, 204 Va. 428, 132 S.E.2d [1019]*1019461, 464 (1963) (where plaintiff effected accord and satisfaction with one tortfeasor, “his claim against others responsible for his injuries was discharged”). See also Sheris v. Travelers Insurance Co., 491 F.2d 603, 604 (4th Cir.), cert. denied, 419 U.S. 831, 95 S.Ct. 54, 42 L.Ed.2d 56 (1974).

While the uses of the word “responsible” were not undertaken in the context of the problem posed by the present statute, they plainly reinforce the intuitive sense in tort law that the responsible person is the one who caused the injuries. Moreover, “responsible” here explicitly refers to responsibility for the injuries themselves, not to responsibility for their treatment or for other financial loss occasioned thereby.2

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Hines v. Blue Cross Blue Shield of Virginia, 788 F.2d 1016, 54 U.S.L.W. 2581 (4th Cir. 1986).

788 F.2d 1016 (Hines v. Blue Cross Blue Shield of Virginia) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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