Selective Insurance v. Hudson East Pain Management Osteopathic Medicine

46 A.3d 1272, 210 N.J. 597, 2012 WL 2913768, 2012 N.J. LEXIS 769
CourtSupreme Court of New Jersey
DecidedJuly 18, 2012
StatusPublished
Cited by63 cases

This text of 46 A.3d 1272 (Selective Insurance v. Hudson East Pain Management Osteopathic Medicine) is published on Counsel Stack Legal Research, covering Supreme Court of New Jersey primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Selective Insurance v. Hudson East Pain Management Osteopathic Medicine, 46 A.3d 1272, 210 N.J. 597, 2012 WL 2913768, 2012 N.J. LEXIS 769 (N.J. 2012).

Opinion

Judge WEFING

(temporarily assigned) delivered the opinion of the Court.

This appeal presents a discrete, narrow legal question: is a health care provider who has received an assignment of personal injury protection (PIP) benefits from an insured obligated upon request to furnish to the insurer broad information with respect to the provider’s ownership structure, billing practices, and regulatory compliance? The trial court held that the provider was obligated, but the Appellate Division reversed. Selective Ins. Co. of Am. v. Hudson E. Pain Mgmt, 416 N.J.Super. 418, 421, 5 A.3d 166 (App.Div.2010). We granted plaintiffs petition for certification to consider whether this determination was correct.1 Selective Ins. Co. of Am. v. Hudson E. Pain Mgmt., 206 N.J. 64, 17 A.3d 1245 (2011). We also granted the motion of Insurance Council of New Jersey and Property Casualty Insurers Association of America to appear as amici curiae. We affirm, but for reasons other than those stated by the Appellate Division.

[601]*601I.

Because this matter arose when defendants filed a motion under Rule 4:6-2(e) to dismiss plaintiffs complaint, the record before us is not voluminous. It consists of plaintiffs verified complaint and the pleadings and documents submitted to the trial court in connection with defendants’ motion. According to that record, individuals insured by Selective sought medical treatment from defendants for injuries received in automobile accidents. Those insureds assigned to defendants the benefits to which they were entitled under their PIP coverage, giving defendants the contractual right to seek PIP reimbursement under those policies. Defendants, on the basis of those assignments, submitted claims for payment to Selective for the services they had provided to Selective’s insureds.

In reviewing the claims submitted, Selective detected what it considered to be suspicious patterns in both the treatments defendants had provided and the corporate links among the treating entities. Wanting to pursue the questions generated by those perceived patterns, Selective requested that defendants supply to it a variety of data with respect to their ownership structure, billing practices, and compliance with certain regulations. In support of its request, Selective cited the provision within the insureds’ insurance policies requiring the insureds to cooperate with Selective in the investigation of any claim under the policy. When defendants did not agree to supply the material Selective sought, Selective filed a verified complaint in which it alleged that defendants’ failure to supply the information was a breach of the duty to cooperate and a violation of the PIP discovery statute, N.J.S.A. 39:6A-13(b). Selective sought a declaratory judgment that defendants were obligated to provide the information and documents it sought and that if they failed to do so, they would be ineligible to receive PIP reimbursement. Selective attached to its complaint a “Demand for Discovery” that included a set of interrogatories and a notice to produce documents.

[602]*602After hearing oral argument, the trial court denied defendants’ motion to dismiss and granted Selective the relief it had requested by directing defendants to respond to Selective’s discovery requests. In the course of its oral opinion, the trial court referred to New Jersey as “the insurance fraud capital of the world.” It stated:

I’m satisfied that ... Selective Insurance Company ... has a ... sufficient articulable predicate for requesting this information from the various defendants who are named.
I’m satisfied that a review of the billing information submitted raises questions concerning the use of the [tax identification number], whether it’s inadvertent or otherwise ... in the case of multiple billing entities, which raises the specter of some type of ... conduct warranting further investigation____It may very well ... fall short of actionable fraud, but the public policy of the State requires that insurance companies investigate and take steps to try to prevent fraud at the earliest opportunity.

Defendants thereafter moved for reconsideration, but the trial court denied that motion, together with defendants’ request for a stay.

Defendants appealed to the Appellate Division, and that court granted a stay of the trial court’s order pending resolution of the appeal. Selective Ins., supra, 416 N.J.Super. at 425, 5 A.3d 166. In its published opinion, the Appellate Division concluded that Selective was not entitled to the discovery it sought. Ibid. The panel set forth three grounds in support of its decision. First, it determined that Selective’s reliance on the cooperation clause in its policies was unavailing. Id. at 425-29, 5 A.3d 166. It also analyzed N.J.S.A. 39:6A-13, which sets forth the statutory framework for discovery of facts with respect to PIP coverage, and held that Selective’s discovery demands sought information far beyond what was statutorily authorized. Id. at 429-32, 5 A.3d 166. Finally, while acknowledging the State’s strong interest in combating insurance fraud, the Appellate Division panel held that Selective could not seek the information through the vehicle of a declaratory judgment complaint, which sought no substantive relief other than discovery. Id. at 433-35, 5 A.3d 166.

[603]*603II.

Before this Court, Selective restates the arguments it presented to the Appellate Division. It contends that defendants, who are relying on assignments of benefits executed by policyholders, are bound to the terms of the policies under which they are seeking payment. Selective argues that the Appellate Division erroneously concluded that Selective was restricted under N.J.S.A. 39:6A-13 to obtaining no more than the records of the patients that the providers treated. Further, it asserts that it can demand the material it sought even in the absence of filing a complaint alleging fraudulent conduct. It points to earlier decisions in the Law Division that permitted a PIP insurer to seek such information from medical providers. See generally, Selective Ins. Co. of Am. v. Med. Alliances, LLC, 362 N.J.Super. 392, 827 A.2d 1188 (Law Div.2003); Prudential Prop. & Cas. Ins. Co. of N.J. v. Nardeme, 332 N.J.Super. 126, 752 A.2d 859 (Law Div.2000).

Defendants counter those arguments by asserting that the appellate panel correctly declined to permit assignments of benefits to be used as a vehicle to subject medical providers to an insurer’s expansive discovery demands. They argue that Selective is seeking to circumvent the discovery framework provided by the PIP statute. They point out that in the two cases upon which Selective relies, the complaints filed by the carriers requested substantive relief as well as discovery. They contend that those cases are distinguishable on that basis and do not support the legal method Selective adopted here.

Amici urge that we reverse the decision of the Appellate Division in this matter. According to amici, that decision places significant hurdles on the ability of insurers to detect and root out improper billing practices and insurance fraud.

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46 A.3d 1272, 210 N.J. 597, 2012 WL 2913768, 2012 N.J. LEXIS 769, Counsel Stack Legal Research, https://law.counselstack.com/opinion/selective-insurance-v-hudson-east-pain-management-osteopathic-medicine-nj-2012.