In a lengthy unpublished decision from the Law Division, a beneficiary of the state funded health insurance plan (NJ Direct Plan) was denied the ability to sustain a legal action filed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.)
The NJ Supreme Court recently affirmed an Appellate Division's decision that medical providers' claims for reimbursement, related to and arising from treatment rendered in a workers' compensation context, are not time barred by the two-year statue of limitations as found in the enabling workers compensation statute but rather remain legally viable for the full six-year period allotted for contracts per N.J.S.A. § 2A:14-1.
The genesis of the challenge was a 2012 amendment to the WC enabling statute which "granted the Division of Workers' Compensation . . . exclusive jurisdiction over claims brought by medical providers for payment of services rendered to injured employees." The employers, by and through their insurance providers, argued that the Legislature must have also truncated the statue of limitations for medical providers' claims for reimbursement, related to and arising from treatment rendered in a workers' compensation context, because of the 2012 amendment.
The Court disagreed with that argument after an examination of the Legislature's intent when it amended N.J.S.A. § 34:15-51. Since the amended statute remained silent as to altering the statute of limitations, and because for many, many years prior the SOL was a six-year period, there could be no finding that the medical providers' claims should be time barred after two-years. The Court noted the Legislature can reexamine this issue and could truncate the SOL, however it did not do so with the 2012 amendment. (The Plastic Surgery Center, PA v. Malouf Chevrolet-Cadillac, Inc. )
In a recent opinion, the New Jersey Supreme Court held that a change in the trial testimony of a defendant-physician in a medical malpractice litigation did not warrant a new trial. In the underlying trial, the physician's testimony deviated from that given in his discovery responses, including his deposition. Plaintiff's counsel did not object to this deviation at trial, and ultimately a jury found in favor of the physician defendant. The Appellate Division, in as split opinion, overturned the verdict and ordered a new trial. However, the Supreme Court reversed the appellate court's decision, holding that there was no prejudice to Plaintiff in the failure of plaintiff's counsel to object at trial regarding the difference in testimony. On the contrary, they noted that counsel for Plaintiff indicated it was "strategic and tactical" why no objection was made. Specifically, Plaintiff's counsel believed that the changed testimony now favored the Plaintiff because the defendant-physician admitted to reviewing data from a clinical trial of the prescribed medication and same was rife with dangerous side effects. Thus, Plaintiff's counsel believed that Plaintiff's position that the physician must have known the dangers prior to prescribing was supported by the testimony. However, the jury ultimately denied compensation to the Plaintiff. The Supreme Court's main focus was on whether or not the change in testimony prejudiced the Plaintiff. Citing to a prior decision named McKenney that the Appellate Division relied upon, the Supreme Court recapitulated that in McKenney the change in testimony was "egregious and clearly prejudicial" while in the matter at bar, the change was "arguably favorable" to the Plaintiff. Consequently, the jury verdict was affirmed. (T.L. v. Jack Goldberg, M.D.)
If you lend your car to someone who you know does not have a driver's license, should they be covered by your automobile's insurance PIP policy if they drive your car and get into an accident? The New Jersey Appellate Division has ruled unlicensed drivers should not be covered and are therefore ineligible for recovery of medical benefits under the personal injury protection provisions of the owner's auto insurance policy.
This decision builds upon prior case law and continues to refine who a "permissive user" of an automobile can be. The Appellate Division held that public policy bars an owner from giving "permission" to someone who cannot, and should not, legally be operating a vehicle on the roadways. In this particular case, the owner was the mother of the unlicensed driver and both of them lived at the same residence. Not only was knowledge imputed to the mother, but she admitted that she knew the driver was unlicensed. Although the terms of the insurance policy did not explicitly exclude coverage of unlicensed drivers, the Court examined public policy which forbids unlicensed drivers from operating vehicles on the roadways of this State. If you are not entitled to drive but chose to do so, then you are not entitled to the benefits provided by an automobile's PIP insurance coverage, even if you are operating the vehicle with the owner's permission. (Norma Blanco-Sanchez v. Personal Service Insurance Company)
Peter J. Vazquez, Jr.