MATTSON v. AETNA LIFE INSURANCE CO.
1:14-cv-06809
D.N.J.Aug 31, 2015Background
- Mattsons sue as a class for allegedly improper subrogation of medical expenses paid due to Eric Mattson's motor vehicle accident; the Fund, Aetna, and Rawlings administer, fund, or service subrogation claims; Cooper billed patients and sent notices demanding payment; Rawlings issued letters stating the health plan could recover from any recovery; plaintiffs amended to include CRA, CFA, and TCCWNA counts against Fund, Aetna, and Rawlings; Cooper’s claims were dismissed as moot, leaving three subrogation-related claims; court granted motions to dismiss under Rule 12(b)(6).
- Plaintiffs’ underlying tort action against the tortfeasor and insurer was filed in Gloucester County, with Eric asserting PIP/UM/UIM-related claims; the NJCSS and AICRA interplay is central to whether subrogation is permitted; the Amended Complaint asserts subrogation violations by the Fund and by Aetna/Rawlings under CRA, CFA, and TCCWNA.
- The court analyzes whether NJCSS, as well as N.J.S.A. 39:6A-9.1, prohibit subrogation here, noting the NJCSS is procedural and does not confer substantive rights on plaintiffs; the AICRA framework may govern the underlying personal injury action; the court need not determine applicability of statutes to the merits but nonetheless finds the claims inadequately pled.
- The court ultimately holds that the NJCSS and 39:6A-9.1 do not give plaintiffs a cognizable substantive right to be free from subrogation, and that plaintiffs fail to plead valid CRA, CFA, or TCCWNA claims against the defendants; leave to amend is denied.
- Conclusion: Defendants’ motions to dismiss are granted as to all remaining claims (CRA against Fund, CFA and TCCWNA against Aetna/Rawlings).
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether NJCSS or 39:6A-9.1 prohibit subrogation here | Mattsons contend NJCSS blocks subrogation; 39:6A-9.1 bars reimbursement; Fund argues applicability and bylaw requirements | Fund/defendants argue NJCSS not applicable to Fund and that 9.1 applies with limits | Both statutes do not confer a substantive right to be free from subrogation; dismissal affirmed |
| Whether CRA claim against Fund is viable | NJCSS or 9.1 create rights that Plaintiffs allege were violated | No substantive rights created by NJCSS/9.1; windfall to plaintiffs not shown | CRA claim dismissed |
| Whether CFA claim against Aetna/Rawlings is viable | Subrogation letters and improper liens caused ascertainable loss | Letters did not create a cognizable loss; claims illusory | CFA claim dismissed for lack of ascertainable loss |
| Whether TCCWNA claim against Aetna/Rawlings is viable | Notice letters violated clearly established rights | No consumer contract rights or clearly established rights at time of notices; not a bailment scenario | TCCWNA claim dismissed |
| Whether Plaintiffs exhausted administrative remedies | Not necessary to proceed in federal court | Administrative remedies may be required | Court does not reach exhaustion given dismissal on merits |
Key Cases Cited
- Perreira v. Rediger, 169 N.J. 399 (N.J. 2001) (NJCSS limits double recovery; health insurers benefit from subrogation relief)
- County of Bergen Emp. Benefit Plan v. Horizon Blue Cross Blue Shield of N.J., 412 N.J. Super. 126 (App. Div. 2010) (NJCSS applies to public entities; no distinction from private insurers)
- Levine v. UnitedHealthcare Corp., 402 F.3d 156 (3d Cir. 2005) (NJCSS is procedural; CRA claim limits)
- Thiedemann v. Mercedes-Benz USA, LLC, 183 N.J. 234 (N.J. 2005) (Ascertainable loss requires calculable damages under CFA)
- Cox v. Sears Roebuck & Co., 138 N.J. 2 (N.J. 1994) (Improper debt/lien can support CFA loss)