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June 16, 2016

Health insurance company’s claim for reimbursement for certain medical cost it incurred from a “no fault” automobile insurance carrier denied

Health insurance company’s claim for reimbursement for certain medical cost it incurred from the “no fault” automobile insurance carrier denied
Aetna Health Plans v Hanover Ins. Co., 2016 NY Slip Op 04658, Court of Appeals

In this action brought pursuant to the Comprehensive Motor Vehicle Reparations Act [Insurance Law §5101, et seq. -- the "No-Fault" Law]
Aetna Health Plans alleged that it paid certain bills that should have been paid by Hanover Insurance Company, the no-fault insurer involved in this action, that were submitted to Aetna by the medical providers. Ultimately Hanover refused to reimburse Aetna for all of the payments Aetna made to the medical providers.

The resolution of this action by the Court of Appeals may, under certain circumstances, impact on the administration of General Municipal Law §§207-a and 207-c with respect to medial expenses paid by a municipality on behalf of a police officer or firefighter injured in the line of duty.

Aetna, as its insured’s assignee, sued Hanover seeking a court order directing Hanover to fully reimbursement it for all of the medical expenses it paid directly to the medical providers. Hanover, in response, moved to dismiss the complaint based upon Aetna’s “lack of standing,” contending that Aetna was not entitled to direct reimbursement because, citing 11 NYCRR 65-3.11(a),* Aetna was an insurance company and not a provider of health care services. Hanover argued that the only type of assignee permitted were those set out in the regulation and Aetna was not in privity of contract with Hanover.

The Court of Appeals agreed with Hanover, holding that that the Comprehensive Motor Vehicle Reparations Act [Insurance Law §5101, et seq. -- the "No-Fault" Law] does not contemplate that reimbursement for expenses paid by a “health insurer” is to be paid to the “health insurer” in contrast to providing for such a payment to be made to a “health care provider.”

The Doctrine of Unintended Consequences might have been be triggered by this ruling.

General Municipal Law §§207-a and 207-c, respectively, provide that the employer shall be liable for the payment of the salary or wages payable to a firefighter or police officer who suffers disability as the result of an injury or disease suffered in course of performing his or her official duties and for the cost of medical or hospital care or treatment furnished such personnel until the appropriate health authority or physician shall certify that such injured or sick fireman or police officer has recovered and is physically able to perform his or her regular duties.

Further, these sections provide that “Notwithstanding any provision of law contrary thereto contained herein or elsewhere, a cause of action shall accrue to the municipality for reimbursement in such sum or sums actually paid as salary or wages and or for medical treatment and hospital care as against any third party against whom the policeman shall have a cause of action for the injury sustained or sickness caused by such third party.”

The Court of Appeals’ ruling in Aetna Health Plans could have an impact, in whole or in part, on a municipality as the police officer’s or firefighter’s employer in situations where the municipality seeks reimbursement for medical and, or, hospital expenses it incurred pursuant to the mandates of §§207-a and 207-c in providing “medical or hospital care” for police and fire personnel in situations where the Comprehensive Motor Reparations Act would otherwise be operative.

* 11 NYCRR 65-3.1, Applicability, provides that “The following are rules for the settlement of claims for first-party and additional first-party benefits on account of injuries arising out of the use or operation of a motor vehicle, a motorcycle or an all-terrain vehicle. These rules shall apply to insurers and self-insurers, and the term insurer, as used in this section, shall include both insurers and self-insurers as those terms are defined in this Part and article 51 of the Insurance Law, the Motor Vehicle Accident Indemnification Corporation (MVAIC), pursuant to section 5221(b) of the Insurance Law and any company or corporation providing insurance pursuant to section 5103(g) of the Insurance Law, for the items of basic economic loss specified in section 5102(a) of the Insurance Law;” and

11 NYCRR 65-3.11(a) provides “An insurer shall pay benefits for any element of loss other than death benefits, directly to the applicant or, when appropriate, to the applicant's parent or legal guardian or to any person legally responsible for necessities, or, upon assignment by the applicant or any of the aforementioned persons, shall pay benefits directly to providers of health care services as covered under section 5102(a)(1) of the Insurance Law, or to the applicant's employer for loss of earnings from work as authorized under section 5102(a)(2) of the Insurance Law. Death benefits shall be paid to the estate of the eligible injured person.

The decision is posted on the Internet at:

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