Searching over 5,500,000 cases.


searching
Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.

Clevenger v. First Option Health Plan of New Jersey

March 22, 2002

MICHAEL J. CLEVENGER, PLAINTIFF,
v.
FIRST OPTION HEALTH PLAN OF NEW JERSEY, NOW KNOWN AS PHS HEALTH PLANS, PRUDENTIAL PROPERTY AND CASUALTY INSURANCE COMPANY, AMERIHEALTH HMO, INC., DEFENDANTS, AMERIHEALTH HMO, INC., CROSS-CLAIMANT,
v.
PRUDENTIAL PROPERTY AND CASUALTY INSURANCE COMPANY AND PHS HEALTH PLANS, CROSS-DEFENDANTS, PRUDENTIAL PROPERTY AND CASUALTY INSURANCE COMPANY, CROSS-CLAIMANT,
v.
AMERIHEALTH HMO, INC. AND PHS HEALTH PLANS, CROSS-DEFENDANTS.



The opinion of the court was delivered by: Simandle, District Judge

OPINION

This action is before the Court on plaintiff Michael Clevenger's motion for summary judgment [Docket Item 16-1] against defendant Prudential Property and Casualty Insurance Company ("Prudential"), in which defendants Amerihealth HMO, Inc. ("Amerihealth") and First Option Health Plan, now known as PHS Health Plans ("PHS") join, *fn1 and also on defendant Prudential's cross-motion for summary judgment on the Complaint and all cross-claims [Docket Item 19-1]. Oral argument was heard on Friday, March 1, 2002. The central issue in all three pending motions is whether plaintiff's mother's primary health care provider, first PHS and then Amerihealth, both of which are governed by the Employee Retirement Income Security Act, 29 U.S.C. § 1001, et seq. ("ERISA"), or her automobile insurer, Prudential, is responsible for payment of personal injury protection ("PIP") benefits for plaintiff Michael Clevenger arising out of a June 17, 1996 automobile accident. Because the Court finds that there are genuine issues of material fact that remain, plaintiff's motion, PHS's motion, and Prudential's cross-motion for summary judgment will all be denied.

I. Factual Background

Many of the facts in this case are undisputed. On June 17, 1996, plaintiff Michael Clevenger was involved in an automobile accident and sustained severe bodily injuries. At the time of the accident, Michael was an insured driver under his parent's Prudential automobile policy. (See Kossar Cert., Ex. A, Yee Cert., ¶¶ 2, 3, 8.) Also at the time of the accident, Michael was a named beneficiary in his mother's then health insurance carrier, PHS. (Costa Cert., ¶¶ 9-10, Ex. E.) On November 20, 1996, when his mother's health insurance carrier changed, Michael was enrolled as a dependent in her new plan with Amerihealth.

At the time of the accident, the declarations page of the Clevenger's Prudential automobile policy indicated that the "coordination of benefits option" applied to their coverage. (See Kossar Cert., Ex. B.) Plaintiff asserts that this was an error on Prudential's part and his parents have stated that they never opted for the "coordination of benefits" option and only became aware of the designation after the accident. (Costa Cert., Ex. C, D. Clevenger Aff., ¶¶ 4-8; M. Clevenger Aff., ¶¶ 4-8.) Prudential asserts that elections are only made when an insured requests that they be done (Kossar Cert., Ex. A, Yee Aff., ¶ 5) and therefore concludes that because the "coordination of benefits" option was indicated on the Clevenger's policy, they must have opted for the coverage. (Id. ¶ 4.) Prudential has not produced an election of coverage form selecting the "coordination of benefits" option completed by the Clevengers.

After the accident, plaintiff submitted all medical bills to Prudential for payment. Prudential advised plaintiff that all bills should be submitted to the health insurance provider, pursuant to the election of coordinated coverage. On July 7, 1996, plaintiff's mother contacted Prudential to correct the alleged error regarding the designation of a PIP provider and submitted a Coverage Selection Form rejecting the PIP coordination of benefits option.

From June 17, 1996 until November 30, 1996, plaintiff's then health insurance provider, PHS, relying on the election of coverage form provided by plaintiff, made payment on plaintiff's medical bills. From December 1, 1996 until February 1, 1997, when plaintiff turned 18 and was no longer covered under his mother's plan, Amerihealth made payment on plaintiff's medical bills, in reliance on Prudential's election of coverage form. Prudential has paid all of plaintiff's medical bills related to this accident since plaintiff turned 18 and became ineligible for coverage under his mother's health care plans.

Plaintiff, PHS, and Amerihealth now seek to have a declaratory judgment identifying Prudential as the responsible insurer and requiring Prudential to pay for plaintiff's medical expenses incurred from June 17, 1996 through February 1, 1997. PHS seeks reimbursement from Prudential in the approximate amount of $143,933.95, and Amerihealth seeks reimbursement from Prudential in the approximate amount of $23,193.93.

II. Discussion

A. Jurisdiction

At oral argument on March 1, 2002, counsel for Prudential challenged this Court's jurisdiction over this matter, arguing that plaintiff lacks standing to sue and also that there is no case or controversy because all of plaintiff's medical bills have been paid, and therefore this Court would be prohibited to issue an advisory opinion by Article III, Section 2 of the United States Constitution. This Court disagrees and finds that this Court has jurisdiction over this matter.

This action, originally filed on March 6, 2001 in the Superior Court of New Jersey, Law Division, Burlington County, was timely removed by defendant PHS on April 10, 2001. The basis for removal and exclusive federal jurisdiction was interpretation of an ERISA plan. (See Notice of Removal, ¶ 5.) Plaintiff alleges breach of contract against defendant Prudential. Defendant Amerihealth's cross-claim seeks contribution and indemnification from co-defendants Prudential and PHS. Defendant Prudential seeks contribution and indemnification from co-defendants PHS and Amerihealth. There is no diversity jurisdiction as defendant PHS and plaintiff Clevenger are both citizens of the State of New Jersey. No challenge has been made to the removal of this action and, because plaintiff alleged in his complaint that defendants PHS and Amerihealth have "wrongfully refused and continue to refuse to honor the claims of plaintiff for payment of medical expenses as a result of [plaintiff's] accident" (see Compl. at 2-3), this Court finds that the action was properly removed pursuant to Section 502(a)(1)(B). *fn2 See 29 U.S.C. 1132(a)(1)(B).

This Court, therefore, has subject matter jurisdiction over the ERISA complaint pursuant to 28 U.S.C. § 1331. The Court also has supplemental jurisdiction over plaintiff's breach of contract claim against Prudential, which does not involve an ERISA policy, pursuant to 28 U.S.C. § 1367(a), *fn3 because plaintiff's claim against Prudential forms part of the same case or controversy.

Prudential asserts that because plaintiff's medical bills have been paid, they lack standing and there is no case or controversy before this Court. Standing is an important element in the case or controversy inquiry. See Federal Kemper Ins. Co. v. Rauscher, 807 F.2d 345, 350 (3d Cir. 1986). A plaintiff must allege an injury that can be fairly traced to defendant's conduct, and which can be redressed by the requested relief. See Vermont Agency of Nat. Resources v. United States, 529 U.S. 765, 120 S. Ct. 1858 (2000); Valley Forge Christian College v. Americans for Separation of Church & State, Inc., 454 U.S. 464, 472, 102 ...


Buy This Entire Record For $7.95

Download the entire decision to receive the complete text, official citation,
docket number, dissents and concurrences, and footnotes for this case.

Learn more about what you receive with purchase of this case.