798 N.E.2d 667 | Ohio Ct. App. | 2003
{¶ 2} Appellee had health insurance with appellant through her employer, Defiance City Schools. Appellant was a self-funded government group health care benefits plan, sponsored by the Northern Buckeye Education Council. Appellee's minor daughter, Emily Lawson, was injured in an auto accident. Pursuant to its plan of insurance, appellant paid medical expenses for Emily's injuries totaling $85,945.39. As a result of Emily's injuries, appellee recovered $100,000 from the tortfeasor's insurance company, which represented the tortfeasor's policy limits of liability, and $150,000 from appellee's underinsured motorist ("UM") carrier, which represented the UM policy limits ($250,000), less the amount paid by the tortfeasor's carrier ($100,000). On November 17, 2000, appellant filed a complaint against appellee seeking reimbursement of the medical benefits it provided. The parties filed cross-motions for summary judgment.
{¶ 3} Appellant argued in its motion for summary judgment that, pursuant to the plan and, specifically, the terms of the Reimbursement and Subrogation Agreement ("the agreement"), which appellee signed, it was entitled to full reimbursement of the $85,945.39 that it advanced on appellee's behalf for medical expenses. Appellant also argued that appellee was not entitled to deduct from the reimbursement amount any costs, including attorney's fees, appellee incurred in relation to the settlement amount she received from the tortfeasor's and her UM carriers. The language in the plan, upon which appellant relied, stated as follows:
{¶ 4} "3.7 Subrogation Rights
{¶ 5} "Any payments made by this Plan for injury or illness caused by the negligent or wrongful act of any third party are made with the agreement and understanding that the covered person will reimburse the Plan for any amounts which are later recovered from the third party by way of settlement or in the satisfaction of any judgment. The amount which must be reimbursed to the Plan will be the lesser of the payments actually made by the Plan, or the amount received by the covered *662 person from the third party. As security for the Plan's rights to reimbursement, the Plan will be subrogated to all of the covered person's rights of recovery against a third party (or the party's insurers) to the extent of any payments made by the Plan. The Claims Administrator will withhold payments of claims made under this Plan, to the extent that the Claims Administrator has actual knowledge of a negligent or wrongful act of a third party, until the covered person or the covered person's legal representative executes a subrogation reimbursement agreement."
{¶ 6} The Reimbursement and Subrogation Agreement, which appellee signed, following Emily's accident, states in pertinent part:
{¶ 7} "* * * I agree that if benefit payments are made on my behalf under the Plan and such payments are or may have been for treatment required due to the act of any third party, I will reimburse the Plan (or Northern Buckeye Education Council, as Plan sponsor) for any amounts which are later recovered from any third party, third party's insurer, or any other person, by way of settlement or in the satisfaction of any judgment of or upon any claims arising from said act, irrespective of whether any such settlement or judgment may or may not provide reimbursement to me for all injuries, illnesses, or other damages (including, without limitation, pain and suffering, consequential, punitive, exemplary or other damages, whether alleged, proven in court of law or otherwise substantiated); that the Plan is subrogated to my rights of recovery against any third party's insurer, or any other person or to the extent of any of the benefit payments made by the Plan or the amount of recovery whichever is less."
{¶ 8} Appellee argued in her motion for summary judgment that she and Emily had not been fully compensated by the insurance benefits received and, therefore, appellant was not entitled to reimbursement of the medical benefits it paid. Appellee argued that, pursuant to the make-whole doctrine in the state of Ohio, appellant is not entitled to reimbursement for the medical expenses it paid until appellee has received "full compensation," i.e. been made whole, for all injuries and damages. To the extent that federal case law concerning ERISA plans and the federal common law "make-whole doctrine" would apply, appellee additionally argued that, because appellant's plan fails to unambiguously "opt-out" of the make-whole doctrine, appellant would still not be entitled to reimbursement until appellee was fully compensated for the losses sustained.
{¶ 9} Alternatively, appellee argued that the agreement, which she signed after Emily sustained her injuries, was void for lack of consideration. Appellee argued that the agreement attempted to add contractual obligations, before providing coverage for Emily's medical treatment, when, in fact, appellant was already legally obligated to provide such coverage.
{¶ 10} In response to appellee's motion for summary judgment, appellant argued that the language of the policy and the signed agreement clearly and unambiguously provided that appellant was entitled to reimbursement of the *663 medical benefits it paid, irrespective of whether appellee made a full recovery. Appellant argued that its right to reimbursement exists under both Ohio and federal law.
{¶ 11} The trial court granted appellee's motion for summary judgment and denied appellant's. The trial court held that the terms of the plan were ambiguous insofar as they failed to "specifically state that the participant's right to be made whole is superseded by the plan's right to subrogation." As such, citing, Porter v. Tabern (Sept. 17, 1999), Champaign App. No. 98-CA-26, and Blue Cross and Blue Shield Mut.Of Ohio v. Hrenko (1995),
{¶ 12} Appellant raises the following assignments of error:
{¶ 13} "A. The lower court erred in holding that the terms of the Plan are uncertain or ambiguous.
{¶ 14} "B. The lower court erred in holding that there is no evidence that the terms of the subrogation reimbursement agreement were made available at the time the Plan was entered into.
{¶ 15} "C. The lower court erred in holding that the Plan's subrogation interest should not be given priority because Ms. Lawson received less than full compensation."
{¶ 16} Appellant's assignments of error each concern ways in which the trial court erred in granting appellee's motion for summary judgment. To the extent they are interrelated, we will consider them together.
{¶ 17} This court notes at the outset that in reviewing a motion for summary judgment, we must apply the same standard as the trial court. Lorain Natl. Bank v. Saratoga Apts. (1989),
{¶ 18} It is well-settled that an insurer can have a contractual right to subrogation, also called conventional subrogation, which is based upon the contractual obligations of the parties. Hrenko,
{¶ 19} In Hrenko, the Ohio Supreme Court held that "[p]ursuant to the terms of an insurance contract, a health insurer that has paid medical benefits to its insured and has been subrogated to the rights of its insured may recover from the insured after the insured receives full compensation by way of a settlement with the insured's uninsured motorist carrier." Hrenko, supra at syllabus. The insured in Hrenko had been fully compensated for his injuries; however, since Hrenko, a trend in Ohio developed wherein courts have held that "an insurer's subrogation interests will not be given priority where doing so will result in less than full recovery to the insured." Grine v. Payne (Mar. 23, 2001), 6th Dist. No. WD-00-044. See, also, e.g., Central Reserve Life Ins. Co. v.Hartzell (Nov. 30, 1995), Tuscarawas App. No. 94AP120094; Moellman v.Niehaus (Feb. 5, 1999), Hamilton App. No. C-971113; Porter v. Tabern
(Sept. 17, 1999), Champaign App. No. 98-CA-26; Johnson v. ProgressiveIns. Co. (Dec. 23, 1999), Lake App. No. 98L102 This doctrine has been referred to as the "made-whole doctrine." Huron Co. Bd. Of Commissionersv. Saunders (2002),
{¶ 20} The made-whole doctrine has even been applied where the insurer's subrogation clause stated that "[a]ll recoveries from a third party *** must be used to reimburse [the insurer] for benefits paid" and that "[the insurer's] share of the recovery will not be reduced because the [insured] did not recover the full amount of damages claimed ***." Hartzell, supra. In Hartzell, the Fifth Appellate District held that, by attempting to give the insurer claim priority over the injured party's claim, the subrogation clause was "unenforceable and contrary to public policy." The court reasoned as follows:
{¶ 21} "The purpose of insurance is to protect individuals from injury by permitting them to contract with insurance carriers. The carriers calculate and *665 distribute the risks and liabilities and set premiums. In the case at bar, [the insurer] has accepted premiums in return for the assurance that appellants would be protected in the event they incurred medical expenses. The subrogation clause subverts this by giving [the insurer] claims priority over the injured party's claims."
{¶ 22} Appellant, however, argues that the appellate cases cited above, which apply the made-whole doctrine, fail to strike a balance between well-established rules of contract interpretation and the equitable principles embodied in the made-whole doctrine. In support of its argument, appellant cites to a body of case law that applies the federal common law make-whole doctrine to cases involving insurance plans that are governed by the Employee Retirement Income Security Act of 1974,
{¶ 23} The federal make-whole doctrine is based upon the "general equitable principle of insurance law that, absent an agreement to the contrary, an insurance company may not enforce a right to subrogation until the insured has been fully compensated for her injuries, that is, has been made whole." Barnes v. Indep. Auto. Dealers of California (C.A. 9, 1995),
{¶ 24} "When the language of an ERISA plan is silent or ambiguous as to subrogation or reimbursement rights, federal common law requires that the insured be made whole before the insurer can recover. CopelandOaks v. Haupt (C.A. 6, 2000),
{¶ 25} In Community Ins. Co. v. Ohayon (1999),
{¶ 26} In applying the federal make-whole doctrine, the Sixth and Third Districts, in Galusha and Stephens, supra, determined that the following policy language was sufficient to give the insurers first priority over the insureds' rights of recovery, regardless of whether the insureds had been fully compensated for their injuries:
{¶ 27} "(1) *** when [payment] is made by the third party, this Plan is entitled to be repaid first for any and all benefits paid for the same injury, illness or other loss for which the payment is made. *** [T]he obligation to repay this Plan will be binding upon the Member, Eligible Dependent, beneficiary, or legal representative regardless of whether: *** the covered individual has been paid by the third party for all losses sustained or alleged."
{¶ 28} "(2) the plan shall be subrogated *** whether or not those monies are sufficient to make whole the Participant to whom this Plan made its payments ***."
{¶ 29} We are not bound by the federal make-whole doctrine in this case because appellant's plan is a "government plan," established for employees of a political subdivision of a state, and, therefore, exempted from ERISA. See
{¶ 30} The trial court held that appellant's policy was ambiguous because it failed to "specifically state that the participant's right to be made whole is superseded by the plan's right to subrogation." We, however, find that there is no requirement in Ohio that particular language must be used in a contract to *667 establish an insurer's priority; rather, so long as the policy clearly and ambiguously establishes the insurer's priority, we find that such a provision is enforceable. See Hrenko at 122.
{¶ 31} In this case, the agreement states that appellant's right to be reimbursed for any amount recovered by way of settlement from a "third party, third party's insurer, or any other person" exists "irrespective of whether any such settlement or judgment may or may not provide reimbursement to [appellee] for all injuries, illnesses, or other damages (including, without limitation, pain and suffering, consequential, punitive, exemplary or other damages, whether alleged, proven in court of law or otherwise substantiated) ***." We find that this language clearly and unambiguously states that appellant is entitled to reimbursement from any money received by appellee from a third party, third party's insurer, or any other person, regardless of whether appellee has been made whole by her recovery.
{¶ 32} Although we have explained and modified the made-whole doctrine as applied by Huron Co. Bd. Of Commissioners v. Saunders
(2002),
{¶ 33} We realize that the Fifth District in Hartzell, supra, held that it is against public policy to allow an insurer to contractually establish priority over an insured's claim against a tortfeasor before the insured has been made whole. However, we find that Hartzell failed to apply well-established rules of contract interpretation or follow the holding in Ervin, which stated that "[c]ases of contractual interpretation should not be decided on the basis of what is `just' or equitable." Ervin,
{¶ 34} Appellee, however, raises additional arguments in her brief which we must also consider. First, relying on Toledo Area Constr.Workers Health *668 Welfare Plan v. Lewis (N.D.Ohio 1998), 1998 U.S. Dist. LEXIS 21759, appellee argues that the agreement she signed after Emily was injured is void for lack of consideration. Appellee asserts that the agreement "attempted to impose new restrictions, add new terms, or relieve the plan of its existing obligations," without providing new consideration. We disagree.
{¶ 35} The subrogation provision in the contract stated that "[a]ny payments made by this Plan for injury or illness caused by the negligent or wrongful act of any third party are made with the agreement and understanding that the covered person will reimburse the Plan for any amounts which are later recovered from the third party by way of settlement or in satisfaction of any judgment." The provision further states that "[t]he Claims Administrator will withhold payments of claims made under this Plan, to the extent that the Claims Administrator has actual knowledge of a negligent or wrongful act of a third party, until the covered person or the covered person's legal representative executes a subrogation reimbursement agreement." Accordingly, we find that unlike the policy in Lewis, supra, appellant was only conditionally obligated to provide coverage for injury caused by the negligent or wrongful act of a third party, after the covered person or the covered person's legal representative executed a subrogation reimbursement agreement. Because appellant's obligation to provide coverage was conditioned on appellee first executing a subrogation reimbursement agreement, we find that no new consideration was required and, therefore, the signed agreement is enforceable.
{¶ 36} Second, appellee argues that appellant is not subrogated to any amount of UM coverage received by appellee. We agree. The agreement originally stated that appellant was entitled to reimbursement "for any amounts which are later recovered from any third party, third party's insurer, or any other person or insurer (including without limitation, Covered Person's own insurer) ***." The language "or insurer (including without limitation, Covered Person's own insurer)," however, was stricken from the agreement by appellee. Thus, appellant is only entitled to reimbursement "for any amounts which are later recovered from any third party, third party's insurer, or any other person." We find that "any other person" would not include appellee's UM insurance carrier, as it is a company and not an individual, as contemplated by the policy. Accordingly, we find that appellant is not entitled to any reimbursement for any amounts received by appellee from her UM carrier.
{¶ 37} Additionally, to the extent that we find appellant is entitled to reimbursement for amounts received from the third party or the third party's insurer, we note that appellant raised an additional issue in its motion for summary judgment that requires our consideration. Specifically, appellant asserted that appellee was "not entitled to deduct attorney fees from any amount *669 owed the Plan based upon the clear terms of the subrogation provision, which does not provide for a reduction for attorney fees." We disagree on the basis that the subrogation provision is ambiguous in this respect.
{¶ 38} The policy states that any payments made by appellant for injury "caused by the negligent or wrongful act of any third party are made with the agreement and understanding that the covered person will reimburse the Plan for any amounts which are later recovered from the third party by way of settlement or in the satisfaction of any judgment." However, the policy then states that the amount which must be reimbursed "will be the lesser of the payments actually made by the Plan, or the amount received by the covered person from the third party." Although it appears that appellant is entitled to be reimbursed for "any amounts" recovered from a third party, the section later limits that amount to "the amount received by the covered person from the third party." We find that these phrases create an ambiguity.
{¶ 39} There are inherent expenses associated with recovering a judgment against a tortfeasor, including, but not limited to, attorney fees. Appellant's policy fails to state what party is expected to incur such expenses. Thus, in the absence of such a specification, we find that "the amount received by the covered person from the third party" could mean either the full amount paid by the third party, or it could mean the actual amount the covered person received, i.e., the amount paid by the third party less the costs of prosecuting the claim, which would include attorney fees. Accordingly, we find that appellant's policy is ambiguous in this respect and, therefore, must be construed in favor of the insured. Hence, we find that appellant's subrogation and reimbursement rights are limited to the amount received by appellee from the third party or the third party's insurer, less the costs expended in prosecuting her claim against the third party. Based on the affidavit testimony of appellee's attorney, who stated he has a one-third interest in any recovery from the tortfeasor, we find that appellee established that she received only $66,666 from the third party's insurer.
{¶ 40} Based on the foregoing, we find that appellant was entitled to summary judgment, as a matter of law, on its claim against appellee for reimbursement of medical bills paid on behalf of Emily Lawson, in the amount of $66,666. Accordingly, we find that the trial court erred in granting appellee summary judgment. Appellant's assignments of error are therefore found well-taken, in part.
{¶ 41} The decision of the Lucas County Court of Common Pleas is therefore reversed in accordance with this decision. Judgment is entered in favor of appellant, Northern Buckeye Education Council Group Health Benefits Plan, against appellee, Karen W. Lawson, in the amount of $66,666. Costs of this appeal are to be paid by appellee. *670
{¶ 42} Insofar as we find the holding in this case to be in conflict with Central Reserve Life Ins. Co. v. Hartzell (Nov. 30, 1995), Tuscarawas App. No. 94AP120094, pursuant to Section
{¶ 43} "Is a subrogation and reimbursement clause which attempts to give an insurer claim priority over the insured's claim against a third party or other insurer, regardless of whether the insured has received full compensation for her injuries, against public policy and unenforceable?"