Williams v. Blue Cross of Idaho

260 P.3d 1186, 151 Idaho 515, 2011 Ida. LEXIS 126
CourtIdaho Supreme Court
DecidedSeptember 2, 2011
Docket37623
StatusPublished
Cited by14 cases

This text of 260 P.3d 1186 (Williams v. Blue Cross of Idaho) is published on Counsel Stack Legal Research, covering Idaho Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Williams v. Blue Cross of Idaho, 260 P.3d 1186, 151 Idaho 515, 2011 Ida. LEXIS 126 (Idaho 2011).

Opinion

J. JONES, Justice.

Patrick Williams appeals the Industrial Commission’s determination that I.C. § 72-802 does not prohibit Blue Cross of Idaho from seeking to exercise its contractual right of subrogation against Williams’ lump sum settlement proceeds. We affirm.

I.

Factual and Procedural Background

Patrick Williams suffered two injuries to his left shoulder while he was an employee of AAA Plumbing. Williams underwent two surgeries in an effort to repair these injuries. The State Insurance Fund (the SIF) initially provided Williams with workers’ compensation benefits to cover a portion of his medical expenses, but later refused to provide additional coverage on the ground that any medical treatment Williams received for his left shoulder was not for work-related injuries but, rather, for a pre-existing shoulder condition. 1 As such, the SIF refused to cover the expenses associated with the two shoulder surgeries.

After the SIF refused to provide further workers’ compensation benefits, Williams sought payment for his remaining medical expenses in the amount of $31,195.14 2 from *517 Blue Cross of Idaho, his personal medical insurance provider. As a benefit of his employment with AAA Plumbing, Williams was insured through a non-occupational group insurance policy with Blue Cross for which AAA Plumbing paid a portion of the premium. Blue Cross accepted responsibility for payment of these medical expenses, and after making contractual adjustments with the medical providers, Blue Cross was able to satisfy Williams’ medical bills for $11,181.08.

Williams’ insurance contract with Blue Cross contains several subrogation and reimbursement provisions. With regard to Blue Cross’ rights of subrogation and reimbursement, the insurance policy provides:

The benefits of this Policy will be available to an Insured when he or she is injured, suffers harm or incurs loss due to any act, omission, or defective or unreasonably hazardous product or service of another person, firm, corporation or entity (hereinafter referred to as “third party”). To the extent that such benefits for Covered Services are provided or paid for by Blue Cross of Idaho under this Policy or any other Blue Cross of Idaho plan, agreement, certificate, contract or policy, Blue Cross of Idaho shall be subrogated and succeed to the rights of the Insured or, in the event of the Insured’s death, to the rights of his or her heirs, estate, and/or personal representative.

In addition to seeking payment from Blue Cross, Williams filed a complaint with the Industrial Commission seeking workers’ compensation for the medical expenses incurred as a result of the two shoulder surgeries, as well as benefits for temporary and permanent disability as a result of such injuries. On February 20, 2008, Williams entered into a lump sum settlement agreement with the SIF. Pursuant to the settlement agreement, Williams received $70,000 in exchange for releasing the SIF from liability for any and all claims associated with the industrial accidents. The settlement agreement provides:

There are genuine and substantial disputes and differences between the parties as to the degree, if any, of Claimant’s impairment and disability, the need for retraining benefits, the need for the surgeries of September 5, 2006 and March 20, 2007 which Defendants assert are due to preexisting conditions, and the need for future medical benefits. The parties, however, wish to settle their differences on a full and final basis advising the Commission that it is in the best interest of the parties to do so. Therefore, as provided by Idaho Code section 72^404, in an effort to settle this disputed matter, the Surety tenders to the Claimant and the Claimant accepts the sum of $70,000.00 in full and final settlement of any and all claims he has or may have as a result of any of the alleged injuries described herein. Further, the parties agree to waive any underpayment of total temporary disability benefits and temporary partial disability benefits which may exist for any reason, including any underpayments that may exist as a result of the method used to calculate the compensation rate(s).

The portion of the settlement agreement regarding the allocation of the settlement proceeds contains the following provision:

ITEMIZED LIST OF OUTSTANDING MEDICALS TO BE PAID BY CLAIMANT FROM THE LUMP SUM SETTLEMENT BALANCE: (List provider and amounts)
None

However, the settlement agreement specifically states that the $70,000 is to be paid in settlement of all potential claims by Williams, including claims for “[disputed past medical expenses and future medical benefits.” Nothing in the agreement resolves the question of whether the medical care that Williams received was causally related to any of the industrial accidents, nor does the agreement establish what portion of the settlement proceeds are allocated for payment of the disputed medical bills. After the Commission approved the settlement agreement, the SIF paid Williams $70,000, thereby discharging its obligations under the agreement.

While Williams was negotiating the settlement with the SIF, counsel for Blue Cross contacted counsel for Williams on several occasions to inform him that Blue Cross intended to exercise its contractual right of *518 subrogation in the event Williams succeeded in obtaining workers’ compensation benefits. After the agreement was finalized before the Commission, Blue Cross sent a letter to counsel for Williams demanding that, pursuant to Blue Cross’ right of subrogation, he withhold money from the workers’ compensation proceeds for payment to Blue Cross.

In response to these communications from Blue Cross, Williams filed a declaratory judgment action with the Commission arguing that pursuant to I.C. § 72-802, the lump sum proceeds paid to an injured worker are exempt from the claims of all creditors, including Blue Cross. Williams asked the Commission to enter an order directing Blue Cross to take no further action against Williams to collect any portion of the workers’ compensation proceeds.

Before the Commission considered the merits of Williams’ petition for declaratory judgment, it requested briefing from both parties regarding whether the Commission had jurisdiction to issue a declaratory ruling in the matter. While both parties asserted that the Commission did not have jurisdiction to decide the matter, the Commission disagreed and proceeded to the merits of the claim.

The Commission ultimately concluded that I.C. § 72-802 does not prohibit Blue Cross from seeking to exercise a contractual right of subrogation because Blue Cross is a subrogee, and not a creditor, within the meaning of the statute. However, the Commission found it did not have jurisdiction to consider a breach of contract claim by Blue Cross against Williams and, therefore, determined that Blue Cross must pursue its remedy in district court. Williams timely appealed the Commission’s decision to this Court.

II.

Issues on Appeal

I.

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Cite This Page — Counsel Stack

Bluebook (online)
260 P.3d 1186, 151 Idaho 515, 2011 Ida. LEXIS 126, Counsel Stack Legal Research, https://law.counselstack.com/opinion/williams-v-blue-cross-of-idaho-idaho-2011.