In a lengthy unpublished decision from the Law Division, a beneficiary of the state funded health insurance plan (NJ Direct Plan) was denied the ability to sustain a legal action filed in the Superior Court. At issue was a benefit determination by the insurer, by no fault of the insured, which resulted in double payment being made to an out of network healthcare provider. Subsequent to the health insurer making double payment for one date of service, the insurer began reducing further payments to this beneficiary and her other healthcare providers. This left the insured to settle each account out-of-pocket.
The error which this insured made was that she did not try to file an internal appeal with the health insurer, and did not follow the steps required by the insurance Plan or the statutory constructs which enables a state funded health insurance plan. Following an adverse benefit determination by a state funded health insurer, the aggrieved insured must file an internal appeal/s, proceed to the State Benefits Healthcare Commission and then the Appellate Division which has original jurisdiction in such matters.
Although in the instant case the insured tried to circumvent the statutory law and the insurer's Plan by asserting a tort occurred, this Court saw through the ruse and held the legal issue here was an adverse benefit determination. The case was dismissed with prejudice and it remains to be seen if the insured can still timely file an appeal and begin the process as outlined in the insurer's Plan. (Tomaszewski v. Horizon Healthcare Services, Inc.)
Peter J. Vazquez, Jr.