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New Jersey Dental Association v. Horizon Blue Cross Blue Shield of New Jersey

December 20, 2011


On appeal from the Superior Court of New Jersey, Law Division, Middlesex County, Docket No. L-2285-10.

Per curiam.


Argued November 1, 2011

Before Judges Fisher and Baxter.

In this appeal, we consider the enforceability of an anti-assignment clause in the stand-alone dental plans provided by defendant Horizon Blue Cross Blue Shield of New Jersey. In entering summary judgment in favor of Horizon, the trial judge rejected the argument of plaintiff New Jersey Dental Association that, in enacting N.J.S.A. 26:2S-6.1(c) in 2010, the Legislature expressed its approval of assignment of health care benefits and, thus, rendered invalid anti-assignment clauses such as that in question here. Because, however, N.J.S.A. 17:48E-10.2 more specifically deals with the subject matter and implicitly authorizes anti-assignment clauses in these circumstances, we reject plaintiff's arguments and affirm.

Both parties acknowledge there are no material facts in dispute and the issue presented was determinable by way of summary judgment. Indeed, the facts are uncomplicated. Horizon issues stand-alone dental benefits plans that contain what the parties have referred to as an anti-assignment provision, which renders unenforceable a patient's assignment of benefits to a dentist absent Horizon's consent.*fn1 Plaintiff forcefully but mistakenly asserts that this provision is rendered unenforceable by recently enacted legislation and Horizon must honor patients' assignments of benefits to their dentists.*fn2

The trial judge correctly concluded, as Horizon argued, that N.J.S.A. 17:48E-10.2 authorizes the use of the contractual provision in question. That statute deals specifically with the payment of dental benefits and implicitly governs the only manner in which dental benefits payments may be assigned; specifically, the statute declares that a health service corporation, such as Horizon, "that makes a dental benefit payment to a covered person for services rendered by an out-of-network dentist shall issue the payment to the covered person." N.J.S.A. 17:48E-10.2(a)(1) (emphasis added). This statute does not authorize an assignment of benefits due, only a "sign[ing] over" of the "payment received" by the covered person. N.J.S.A. 17:48E-10.2(b). The plain understanding of these provisions leads to the conclusion that any payments pursuant to a stand-alone dental plan must be made to the covered person, who may then "sign over" any such payments to the dentist. The unambiguous wording of the statute does not permit an interpretation that the covered person may provide the dentist with an assignment of benefits the covered person has not yet received. We are bound to resolve this controversy by resort to the plain language and meaning of the statute. See O'Connell v. State, 171 N.J. 484, 488 (2002) (holding that courts "will not rewrite a plainly-written enactment of the Legislature nor presume that the Legislature intended something other than that expressed by way of the plain language"); Gangemi v. Berry, 25 N.J. 1, 10 (1957) (holding that courts will presume "that the words employed have been carefully measured and weighed to convey a certain and definite meaning, with as little as possible left to implication"); see also N.J.S.A. 1:1-1.

In seeking to avoid the plain meaning of N.J.S.A. 17:48E-10.2, plaintiff urges our consideration of more recent legislation. To explain this argument, we must first consider Somerset Orthopedic Associates, P.A. v. Horizon Blue Cross and Blue Shield of New Jersey, 345 N.J. Super. 410, 420-23 (App. Div. 2001), where, in weighing a non-participating provider's similar argument about the Legislature's intent, we concluded that Horizon's right to impose an anti-assignment clause is authorized by the Health Service Corporations Act, N.J.S.A. 17:48E-1 to -48, and held that the anti-assignment clause constitutes "a critical tool to Horizon's efficient and effective functioning," id. at 422. Plaintiff argues that what the court in Somerset Orthopedic viewed as a public policy in favor of the enforcement of anti-assignment clauses unraveled with the enactment in 2010*fn3 of N.J.S.A. 26:2S-6.1(c), which directs that, with respect to a carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, in the event that the covered person assigns, through an assignment of benefits, his right to receive reimbursement for medically necessary health care services to an out-of-network health care provider, the carrier shall remit payment for the reimbursement directly to the health care provider in the form of a check payable to the health care provider, or in the alternative, to the health care provider and the covered person as joint payees, with a signature line for each of the payees. [Emphasis added.]

Plaintiff concedes that N.J.S.A. 26:2S-6.1(c) does not apply to stand-alone dental plans, such as those in question here, but argues that it "could not be clearer" that N.J.S.A. 26:2S-6.1(c) was intended to "nullify and supersede" Somerset Orthopedic and "render ineffective" anti-assignment clauses regarding both in-network and out-of-network benefits.

We need not consider the accuracy of plaintiff's broad contention regarding the impact of N.J.S.A. 26:2S-6.1(c) on Somerset Orthopedic. The narrow question presented by this appeal is whether N.J.S.A. 26:2S-6.1(c) was intended to eviscerate the reading we have attributed to N.J.S.A. 17:48E-10.2(a)(1). In other words, this appeal requires only that we determine whether N.J.S.A. 26:2S-6.1(c) overrides the unambiguous declaration of N.J.S.A. 17:48E-10.2(a)(1) that health insurers must make dental benefit payments directly "to the covered person" and the equally unambiguous declaration in N.J.S.A. 17:48E-10.2(b) (emphasis added) that the covered person may only "sign over the dental payment received."

To be sure, plaintiff's argument is plausible. A fair reading of N.J.S.A. 26:2S-6.1(c) suggests that anti-assignment clauses in medical plans may not be enforced as a general matter. Absent an express repudiation or rescinding of what N.J.S.A. 17:48E-10.2 plainly permits, however, we cannot conclude that the more general terms of N.J.S.A. 26:2S-6.1(c) eviscerate that which is plainly permitted in the more specific circumstance described and governed by N.J.S.A. 17:48E-10.2. The judicial function in resolving a controversy impacted by two allegedly conflicting statutory provisions requires an initial attempt to harmonize the provisions. See State v. Green, 62 N.J. 547, 554-55 (1973); Lewis v. Bd. of Trs., Pub. Emps. Ret. Sys., 366 N.J. Super. 411, 417 (App. Div.), certif. denied, 180 N.J. 357 (2004). If they cannot be harmonized, then the more specific provision must prevail over the general. Burnett v. Cnty. of Bergen, 198 N.J. 408, 424 (2009); Lewis, supra, 366 N.J. Super. at 417-18; City of E. Orange v. Essex Cnty., 362 N.J. Super. 440, 444 (App. Div. 2003).*fn4 Consequently, we conclude that the directive in N.J.S.A. 26:2S-6.1(c) that would preclude enforcement of an anti-assignment clause as a general matter does not govern where the Legislature also provided that in a dental plan such as the plan in question, the insurer must pay benefits directly to the patient -- a directive that implicitly permits enforcement of anti-assignment clauses in that limited circumstance.

For these reasons, we conclude that the trial judge correctly granted summary judgment in favor of Horizon.


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