Northern Buckeye Education Council Group Health Benefits Plan v. Lawson

103 Ohio St. 3d 188
CourtOhio Supreme Court
DecidedSeptember 29, 2004
DocketNo. 2003-1880
StatusPublished
Cited by20 cases

This text of 103 Ohio St. 3d 188 (Northern Buckeye Education Council Group Health Benefits Plan v. Lawson) is published on Counsel Stack Legal Research, covering Ohio Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Northern Buckeye Education Council Group Health Benefits Plan v. Lawson, 103 Ohio St. 3d 188 (Ohio 2004).

Opinions

Moyer, C.J.

{¶ 1} The Northern Buckeye Education Council Group Health Benefits Plan (“Plan”), appellee, is a self-funded governmental1 group health-care plan sponsored by the Northern Buckeye Education Council. The Plan provided Karen W. Lawson, appellant, and certain of her dependents with health insurance by virtue of her employment.

{¶ 2} The health-benefits contract negotiated between Lawson’s employer and the Plan included a reimbursement and subrogation provision as Section 3.7 of the contract:

{¶ 3} “Any payments made by this Plan for injury or illness caused by the negligent or wrongful act of any third party are made with the agreement and understanding that the covered person will reimburse the Plan for any amounts which are later recovered from the third party by way of settlement or in satisfaction of any judgement [sic]. The amount which must be reimbursed to the Plan will be the lesser of the payments actually made by the Plan, or the amount received by the covered person from the third party. As security for the Plan’s rights to reimbursement, the Plan will be subrogated to all of the covered person’s rights of recovery against a third party (or the party’s insurers) to the extent of any payments made by the Plan. The Claims Administrator will withhold payments of claims made under this Plan, to the extent that the Claims Administrator has actual knowledge of a negligent or wrongful act of a third party, until the covered person or the covered person’s legal representative executes a subrogation reimbursement agreement.”

{¶ 4} Lawson’s minor daughter, Emily, was injured in an auto accident and suffered serious injuries. In accordance with Section 3.7 of the contract, the Plan refused to pay Emily’s medical bills until Lawson signed a subrogation reimbursement agreement. Although initially reluctant, Lawson ultimately signed a document that provided:

{¶ 5} “I am a Covered Person under the Northern Buckeye Education Council Employee Benefits Plan (‘the Plan’) and have applied or will apply for benefits [190]*190under the Plan. I acknowledge and agree that my right to have benefits paid from the Plan on my behalf is subject to certain terms of the Plan which provide that the Plan shall be entitled to reimbursement from third parties, the Plan shall have certain subrogation rights, and the Plan shall not pay any benefits on my behalf unless and until I execute this Reimbursement and Subrogation Agreement.

{¶ 6} “Accordingly, I agree that if benefit payments are made on my behalf under the Plan and such payments are or may have been for treatment required due to the act of any third party, I will reimburse the Plan (or Northern Buckeye Education Council, as Plan sponsor) for any amounts which are later recovered from any third party, third party’s insurer, or any other person, by way of settlement or in the satisfaction of any judgment of or upon any claims arising from said act, irrespective of whether any such settlement or judgment may or may not provide reimbursement to me for all injuries, illnesses, or other damages (including, without limitation, pain and suffering, consequential, punitive, exemplary or other damages, whether alleged, proven in court of law or otherwise substantiated); that the Plan is subrogated to my rights of recovery against any third party’s insurer, or any other person to the extent of any of the benefit payments made by the Plan or the amount of recovery whichever is less.

{¶ 7} “I have completed the attached Reimbursement and Subrogation Rights Information Request Form to the best of my knowledge and belief. I also acknowledge and agree that I will not take any action prejudicing or otherwise damaging the subrogation rights of the Plan and will be liable to the Plan for any losses to the Plan caused by such actions.”

{¶ 8} After Lawson signed this agreement, the Plan paid medical expenses on Emily’s behalf totaling $85,945.37.

{¶ 9} Lawson recovered insurance benefits of $100,000 from the tortfeasor’s liability insurance and $150,000 from her own underinsured motorist coverage. Lawson refused, however, to reimburse the Plan the $85,945.37 it had paid for Emily’s medical treatment, asserting that Emily had not been “made whole” by the $250,000 she had received. The Plan then filed the case now before us, demanding judgment against Lawson for $85,945.37.

{¶ 10} The trial court entered summary judgment in favor of Lawson. Citing Newcomb v. Cincinnati Ins. Co. (1872), 22 Ohio St. 382, 1872 WL 17, and quoting Barnes v. Indep. Auto. Dealers Assn. of California Health & Welfare (C.A.9, 1995), 64 F.3d 1389, 1394, it recognized the “ ‘general equitable principle of insurance law that, absent an agreement to the contrary, an insurance company may not enforce a right to subrogation until the insured has been fully compensated for her injuries, that is, has been made whole.’ ” In addition, the trial court recognized that this court has held that this equitable limit on subrogation, [191]*191commonly denominated the “made whole” or “make whole” doctrine, may be overridden by a clear and unambiguous agreement between an insured and an insurer that the insurer shall have priority to any recovery from the tortfeasor. Ervin v. Garner (1971), 25 Ohio St.2d 231, 54 O.O.2d 361, 267 N.E.2d 769.

{¶ 11} The trial court nevertheless ruled in favor of Lawson, finding that the language employed in the agreement she signed did not specifically state that the Plan’s subrogation right would take priority over the participant’s right to be made whole. It contrasted the language of the agreement before it with an agreement considered in Stephens v. Emanhiser (Aug. 24,1999), Seneca App. No. 13-99-03, 1999 WL 692408. That agreement specifically used the words “make whole,” stating, “The Plan shall be subrogated * * * whether or not those monies are sufficient to make whole the Participant to whom or on whose behalf this Plan made its payments.” The trial court concluded that the clause before it was uncertain or ambiguous, and therefore did not override the make-whole doctrine. It held that because “the recovery to the injured did not result in making her whole,” the Plan was not entitled to priority pursuant to the subrogation agreement signed by Lawson.

{¶ 12} The court of appeals reversed. Citing Ervin, it held that subrogation rights would not be enforced before full recovery by the insured “unless the terms of a subrogation agreement clearly and unambiguously provide otherwise.” 154 Ohio App.3d 659, 2003-Ohio-5196, 798 N.E.2d 667, ¶ 29. Like the trial court, the court of appeals recognized that a health insurer and a recipient of health-insurance benefits could contractually avoid application of the make-whole doctrine. In contrast to the trial court, however, it held that the language in the agreement signed by Lawson did clearly and unambiguously state that the Plan would be entitled to reimbursement regardless of whether Emily was made whole through recovery from collateral sources. Hence, it held that the Plan was entitled to summary judgment on its claim against Lawson for reimbursement of medical bills regardless of whether the Lawsons had been made whole by receipt of funds from other insurance companies.

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Cite This Page — Counsel Stack

Bluebook (online)
103 Ohio St. 3d 188, Counsel Stack Legal Research, https://law.counselstack.com/opinion/northern-buckeye-education-council-group-health-benefits-plan-v-lawson-ohio-2004.