Nott v. Aetna U.S. Healthcare

68 Pa. D. & C.4th 495, 2004 Pa. Dist. & Cnty. Dec. LEXIS 213
CourtPennsylvania Court of Common Pleas, Bucks County
DecidedOctober 14, 2004
Docketno. 03-03636-27-1
StatusPublished

This text of 68 Pa. D. & C.4th 495 (Nott v. Aetna U.S. Healthcare) is published on Counsel Stack Legal Research, covering Pennsylvania Court of Common Pleas, Bucks County primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Nott v. Aetna U.S. Healthcare, 68 Pa. D. & C.4th 495, 2004 Pa. Dist. & Cnty. Dec. LEXIS 213 (Pa. Super. Ct. 2004).

Opinion

MELLON, J.,

— Plaintiff, Arlene Nott (appellant) appeals this court’s order dated July 27, 2004, granting defendant Aetna Health Inc. (incorrectly identified as “Aetna U.S. Healthcare” by appellant in her complaint) judgment on the pleadings.

This opinion is filed pursuant to Pennsylvania Rule of Appellate Procedure 1925.

[497]*497FACTUAL AND PROCEDURAL HISTORY

The appellant is an individual residing at 3619 Meridian Drive, Bensalem, Pa.1 The defendant (Aetna) is a Pennsylvania corporation with its principal place of business in Blue Bell, Pa.2 At all relevant times, the appellant was a member of Aetna’s “Golden Medicare plan,” a health maintenance organization plan sponsored by Medicare.3

On September 18, 1998, appellant was involved in a car accident with a third-party tort-feasor.4 Subsequently, appellant received medical treatment for injuries, a portion of which was paid for by Aetna pursuant to appellant’s policy.5

Aetna’s policy with appellant included a subrogation provision stating Aetna had “the right to repayment of the full costs of all benefits provided by HMO on behalf of the member that are associated with the injury or illness for which the third party is or may be responsible.” This provision included a right to reimbursement by Aetna for “payment made by a third-party tort-feasor or any insurance company on behalf of the third-party tortfeasor.”

Subsequent to receiving money from Aetna for the injuries sustained in said car accident, appellant filed and settled a separate claim against the third-party tort-feasor in September 2001.6 Aware of appellant’s settlement [498]*498with the third-party tort-feasor and pursuant to Aetna’s policy, the Rawlings Company, an independent contractor representing Aetna, sought reimbursement of the medical bills already paid to appellant. After negotiations, appellant and Rawlings Company reached an agreement whereby appellant paid $1,000 to Rawlings as settlement of Aetna’s original claim.

In the action filed before this court on June 9, 2003, appellant now claims the repayment of monies to Aetna was contrary to the Motor Vehicle Financial Responsibility Law section 1720. They assert that under MVFRL section 1720, HMOs such as Aetna have no right to reimbursement for monies paid to policyholders for injuries sustained in motor vehicle accidents whether or not such accident victims also succeeded in claims against third-party tort-feasors for the same injuries.

Aetna argues that the MVFRL section 1720 does not apply to HMOs because section 1560(a) of the Health Maintenance Organization Act instructs that for a statute to apply to HMOs, it must reference HMOs in specific and exact terms.

After suit was filed, Aetna moved to remove the case to the United States District Court for the Eastern District of Pennsylvania on July 9, 20037 That court entered an order on January 23, 2004, remanding the case to the Court of Common Pleas, Bucks County, Pennsylvania.8 Appellant then filed an amended complaint on January 30,2004, in which five counts are alleged against Aetna.9

[499]*499In Count I, appellant alleges Aetna has violated MVFRL section 1720, which prohibits the right of subrogation for a tort recovery.10 Appellant alleges Aetna improperly subrogated medical bills from policyholder’s settlements and/or judgments in tort cases that were paid pursuant to the HMO plan.11

In Count II, appellant alleges that the subrogation and reimbursement provisions of Aetna’s policies are in conflict with Pennsylvania law and were so at the time appellant’s policy was issued,12 and therefore Aetna breached the lawful terms of said policies.13

In Count III, appellant alleges Aetna was unjustly enriched through its allegedly unlawful assertion of liens against policyholders, and therefore a constructive trust should be created as between Aetna and both appellant and class members.14

In Count IV, appellant alleges Aetna acted in bad faith towards its insured in that defendant knew its liens were prohibited.15

[500]*500In Count V, appellant seeks appropriate declaratory and injunctive relief from the court based on Aetna’s allegedly improper assertion of liens.16

Defendant filed an answer and new matter on February 27, 2004;17 appellant filed an answer to the new matter on March 18, 2004.18 Appellant subsequently filed a petition for class action certification on April 1, 2004,19 to which Aetna filed a reply on April 20,2004.20 Prior to a scheduled hearing on the class action certification petition,21 Aetna filed a motion for judgment on the pleadings on May 4, 2004.22 Appellant’s petition for leave to amend complaint for a second time was filed on May 27, 2004,23 and appellant’s opposition to Aetna’s motion for judgment on the pleadings was filed on May 28,2004.24

On July 27, 2004, upon consideration of Aetna’s motion for judgment on the pleadings, oral argument held on June 28, 2004, and all responses thereto, Aetna’s motion was granted and appellant’s complaint was dismissed.25 We dismissed the complaint because HMOA section 1560, which controls in this case, requires that any statute enacted after this Act must “specifically and in exact terms appl(y) to such health maintenance organ[501]*501ization.” MVFRL section 1720 fails to specifically prohibit subrogation by HMOs, and therefore we found the actions taken by Aetna to be proper. It is from this order that appellant appeals.

STATEMENT OF MATTERS

COMPLAINED OF ON APPEAL

Pursuant to an order of the court dated August 30, 2004,26 and Pennsylvania Rule of Appellate Procedure 1925(b),27 appellant filed a concise statement of matters complained of on September 7,2004.28 The matters complained of on appeal as alleged by appellant are as follows:

“(1) The trial court erred in granting Aetna’s motion for judgment on the pleadings because:
“(a) The trial court abused its discretion and committed an error of law in concluding that HMOs are exempt from MVFRL section 1720.
“(b) The trial court abused its discretion and committed an error of law in dismissing appellant’s claim that Aetna breached its contractual obligation with the appellant and all class members in collecting a subrogation/reimbursement lien.
“(c) The trial court abused its discretion and committed an error of law in dismissing appellant’s claim in equity in failing to conclude that subrogation would be inequitable and unjust because appellant and the plaintiff class were unable, as a matter of law, to collect medi[502]

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Related

Commonwealth v. Bell
516 A.2d 1172 (Supreme Court of Pennsylvania, 1986)
Peters v. Commonwealth
350 A.2d 812 (Supreme Court of Pennsylvania, 1976)

Cite This Page — Counsel Stack

Bluebook (online)
68 Pa. D. & C.4th 495, 2004 Pa. Dist. & Cnty. Dec. LEXIS 213, Counsel Stack Legal Research, https://law.counselstack.com/opinion/nott-v-aetna-us-healthcare-pactcomplbucks-2004.