Providence Health Plan v. Winchester

288 P.3d 13, 252 Or. App. 283, 2012 WL 3985521, 2012 Ore. App. LEXIS 1124
CourtCourt of Appeals of Oregon
DecidedSeptember 12, 2012
DocketCV080258; A142272
StatusPublished
Cited by2 cases

This text of 288 P.3d 13 (Providence Health Plan v. Winchester) is published on Counsel Stack Legal Research, covering Court of Appeals of Oregon primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Providence Health Plan v. Winchester, 288 P.3d 13, 252 Or. App. 283, 2012 WL 3985521, 2012 Ore. App. LEXIS 1124 (Or. Ct. App. 2012).

Opinion

DUNCAN, J.

In this civil case, plaintiff, Providence Health Plan (Providence) filed suit against defendant Winchester, its insured,1 alleging that defendant is required to reimburse Providence for amounts that Providence paid for defendant’s medical care after defendant was injured in a car accident while she was a pedestrian. Defendant received settlements under the driver’s liability insurance policy and under her own underinsured motorist (UIM) policy, and Providence asserts that, under its policy with defendant, defendant must reimburse it from those settlements for the money that it spent on medical care for her injuries arising from the accident. Both parties moved for summary judgment, and the trial court granted summary judgment in favor of Providence. Defendant appeals the resulting judgment, arguing that the trial court erred in entering summary judgment for Providence and in denying summary judgment for her. For the reasons explained below, we agree and, therefore, reverse.2

I. FACTS AND PROCEDURAL HISTORY

The relevant facts are not in dispute. On September 26, 2006, defendant was struck by a motor vehicle while she was a pedestrian. Defendant sustained extensive injuries to her head and leg. In a declaration submitted with her motion for summary judgment, defendant asserted that her injures caused her to incur a total of $116,219.73 in medical expenses and $422,000.00 in other economic damages. Pursuant to its policy with defendant, Providence paid $86,417.25 in medical expenses on defendant’s behalf.

[286]*286The driver of the vehicle that struck defendant had an auto liability insurance policy with State Farm with a policy limit of $25,000. Defendant had an auto insurance policy, also with State Farm, that provided $15,000 in personal injury protection (PIP) and $100,000 in UIM coverage.

In December 2006, Providence sent a letter to defendant indicating that, pursuant to the “Third Party Liability/Subrogation” provision of the policy, defendant should hold any recovery that she received from State Farm in trust for Providence. It enclosed a copy of its Subrogation Trust Agreement for that purpose. Defendant did not complete and return the Subrogation Trust Agreement, and she continued to negotiate with State Farm about payment under the driver’s liability policy and her own PIP and UIM policies.

As relevant here, the employer group contract that, according to Providence,3 represents the terms of defendant’s policy provides:

“8.1 THIRD-PARTY LIABILITY/SUBROGATION
«* * * * *
“8.1.2 Proceeds of Settlement or Recovery
“To the fullest extent permitted by law, We [(Providence)] are entitled to the proceeds of any settlement or any judgment that results in a recovery from a third party, whether or not responsibility is accepted or denied by the third-party for the condition. We are entitled up to the full value of the benefits provided by Us for the condition, calculated using Our providers’ usual charges for such Services, less the Member’s out of pocket expenses. Prior to accepting any settlement of Your claim against the third party, You must notify Us in writing of any terms or conditions offered in settlement and shall notify the third party of Our interest in the settlement established by this provision.
“You must cooperate fully with Us in recovering amounts paid by Providence Health Plan. If You seek damages against the third party for the condition and retain an [287]*287attorney or other agent for representation in the matter, You must agree to require Your attorney or agent to reimburse Providence Health Plan directly from the settlement or recovery an amount equal to the total amount of benefits paid.
“You must execute the agreement by signing, and returning to Us, Our Subrogation Trust Agreement by which You and/or Your attorney or agent agrees to reimburse Us directly from the funds of the settlement or recovery. We will withhold benefits for Your condition until a signed copy of this agreement is delivered to Us. The agreement must remain in effect and We will withhold payment of benefits if, at any time, Your authorization or the agreement should be revoked. While this document is not necessary for Us to exercise Our rights to subrogation, it does serve as a good reminder and documents an understanding of Our rights to the parties involved.
“To the maximum extent permitted by law, We are subrogated to Your rights against any third party who is responsible for the condition, have the right to sue any such third party in Your name, and have a security interest in and lien upon any recovery to the extent of the amount of benefits paid by Us and for Our expenses in obtaining a recovery.
“8.1.3 Suspension Of Benefits And Reimbursement
íjí ❖ %
“We are entitled to reimbursement from any settlement or recovery from any third party even if the total amount of such settlement or recovery does not fully compensate You for other damages, particularly including lost wages or pain and suffering; any settlement arising out of an injury or illness covered by this Plan will be deemed first to compensate You for Your medical expenses, regardless of any allocation of proceeds in any settlement document that We have not approved in advance. In no event shall the amount reimbursed to Providence Health Plan be less than the maximum permitted by law.”

(Italics, boldface, and underscoring in original.)

In early 2008, defendant reached a tentative settlement with State Farm for the policy limits of her policy and the driver’s policy. Under the agreement, defendant would recover the $25,000 from the driver’s policy, $75,000 [288]*288from her UIM (her $100,000 limit minus her recovery from the driver’s policy), and the $15,000 limit from her PIP policy, for a total of $115,000. After defendant reached that agreement with State Farm, her attorney sent a letter to Providence, informing it of the proposed settlement and requesting Providence to clarify its position regarding reimbursement. Providence replied that it intended to “[follow] our contractual rights of third party liability/ subrogation as documented in our group service agreement.”

After receiving Providence’s letter, defendant settled with State Farm on the terms described above. Providence then filed this action, seeking a declaration that defendant “is obliged under the [policy] to repay Providence both out of the liability and underinsured portions of any settlement she has received” and damages for breach of contract in the amount that Providence paid toward defendant’s medical expenses minus a pro rata share of defendant’s legal expenses. Defendant counterclaimed, seeking declarations that, among other things, Providence was not entitled to recover under the contract and that ORS 742.538

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Cite This Page — Counsel Stack

Bluebook (online)
288 P.3d 13, 252 Or. App. 283, 2012 WL 3985521, 2012 Ore. App. LEXIS 1124, Counsel Stack Legal Research, https://law.counselstack.com/opinion/providence-health-plan-v-winchester-orctapp-2012.