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Minerley v. Aetna, Inc.

United States District Court, D. New Jersey

June 27, 2019

JAY MINERLEY, individually and as class representative, Plaintiff,


          ANTHONY M. CHRISTINA, RICHARD W. COHEN, GERALD LAWRENCE, URIEL RABINOVITZ, LOWEY DANNENBERG, P.C. Attorneys for Defendants Aetna, Inc., Aetna Health, Inc. (a N.J. corp.), Aetna Health Insurance Co., Aetna Life Insurance Co., and the Rawlings Company, LLC.


          NOEL L. HILLMAN, U.S.D.J.

         This case concerns the interpretation of an insurance policy and whether the insurer may require the insured to reimburse medical costs paid by the insurer when the insured receives an award from a third-party tortfeasor. Currently before the Court is Plaintiff's Motion for Reconsideration and Defendants'[1] Motion for Summary Judgment. For the reasons discussed herein, Plaintiff's Motion for Reconsideration will be denied and Defendants' Motion for Summary Judgment will be granted.


         Our recitation of the facts is taken from Plaintiff's and Defendants' newly filed statements of material facts and those facts which the Court previously found undisputed in its September 29, 2018 Opinion. This Court notes factual disputes where relevant. Plaintiff Jay Minerley was an employee of Weiss-Aug Company Inc. (“Weiss-Aug”), a New Jersey company, from February 2007 through April 2017. During that time, Minerley enrolled in employer-sponsored health benefits provided by Weiss-Aug. Of relevance, Minerley attended a Weiss-Aug employee benefits meeting on October 27, 2009 and received a plan design document, which provided a top-level overview of the benefits offered. This document did not contain any discussion of a subrogation right.[2]

         Minerley participated in the Weiss-Aug sponsored healthcare benefits plan (the “ERISA Plan”). Debra Myshkoff was the plan administrator for the ERISA Plan and Weiss-Aug was the plan sponsor. Weiss-Aug received copies of the relevant policies provided by Aetna. It is unclear whether Myshkoff provided copies of the policies at the October 2009 benefits meeting, but it is undisputed that Minerley had access to plan documents through an electronic portal provided by Aetna.

         As part of the Weiss-Aug Plan, Minerley received benefits under an Aetna Citizen Choice Point of Service HMO Plan (the “Aetna insurance policies” or the “Aetna policies”). Minerley's insurance benefits consisted of two policies: the Pennsylvania HMO policy (the “Aetna PA Policy”), underwritten by Aetna Health Inc., and the New Jersey Non-Referred policy (the “Aetna N.J. Policy”), underwritten by the Aetna Health Insurance Company. The Aetna PA Policy provided in-network benefits and emergency services while the Aetna N.J. Policy provided out-of-network and non-referred medical services.

         This Court previously determined that the Aetna PA Policy is the insurance policy that controls in this case.[3] The Aetna PA Policy contains two documents. The first document was an agreement between Weiss-Aug and the underwriting Aetna entity. The second document was a Certificate of Coverage (“Certificate”). Within this Certificate is a section pertaining to the underwriting Aetna entities' right of recovery against an insured in specific situations. In relevant part, the Aetna PA Policy's Certificate stated:

The Member also specifically acknowledges HMO's right of reimbursement. This right of reimbursement attaches, to the fullest extent permitted by law, when HMO has provided health care benefits for injuries or illness for which a third party is and the Member and/or the Member's representative has recovered any amounts from the third party or any party making payments on the third party's behalf. By providing any benefit under this Certificate, HMO is granted an assignment of the proceeds of any settlement, judgment or other payment received by the Member to the extent of the full cost of all benefits provided by HMO.

(emphasis in original). This was amended effective November 1, 2009, to state:

By accepting benefits under this Plan, the Member also specifically acknowledges HMO's right of reimbursement. This right of reimbursement attaches when this Plan has provided health care benefits for expenses incurred due to Third Party injuries and the Member or the Member's representative has recovered any amounts from any sources, including but not limited to: payments made by a third Party or any insurance company on behalf of the Third Party . . . .

(emphasis in original).

         Myshkoff, the Employee Retirement Income Security Act (“ERISA”) plan administrator for Weiss-Aug, stated that the Aetna PA Policy was the relevant ERISA plan document for the time period at issue. Weiss-Aug submitted a single Form 5500 for the year 2010, received one plan identification number, 502, and identified through various schedules that Aetna Health, Inc., Sun Life and Health Insurance Company, and Unum Life Insurance Company of America would provide various benefits.

         On May 20, 2010, Minerley was involved in a motor vehicle accident in Morris County, New Jersey. He sustained multiple injuries, including fractured ribs, fractured vertebrae, and herniated disks. He was treated at St. Clare's Hospital and Morristown Memorial Hospital. Minerley's medical treatments totaled $3, 512.82 and were paid for by his Aetna PA Policy.

         Minerley retained a personal injury attorney, Charles Kannebecker. Defendant Rawlings, which was Aetna's subrogation and reimbursement claims vendor at the time, notified Kannebecker on July 21, 2010 of the Aetna PA Policy's reimbursement provision discussed supra. Minerley later successfully recovered from the third-party tortfeasor in this accident. On January 9, 2013, Rawlings received a reimbursement check from Kannebecker, sent on Minerley's behalf, in the amount of $3, 512.82 - the amount of the health benefits provided.

         Sometime after Minerley received Rawlings' subrogation demand, Minerley asked the Weiss-Aug Human Resources Department to provide him with a copy of his insurance policy. Minerley claims now that he received the Aetna N.J. Policy, not the Aetna PA Policy. Defendants' dispute the veracity of this assertion, citing previous declarations in which Minerley did not state he received the Aetna N.J. Policy and appears to be unsure of what he received. Solely for purposes of deciding the pending motions, this Court will assume that only the Aetna N.J. Policy was given to Minerley by Weiss-Aug.

         To the extent relevant, Minerley asserts that “Aetna never advised Debra Myshkoff or Weiss-Aug that it sought repayment of medical benefits paid to Weiss-Aug employees in the event that the employees receive a personal injury recovery.” (Pl.'s SOMF ¶ 12.) Nor, according to Plaintiff, did Myshkoff or Weiss-Aug advise Weiss-Aug employees that Aetna may possess a subrogation right. Defendants dispute this assertion, stating the Court has already found (1) that Aetna sent the Aetna PA Policy to Weiss-Aug and (2) that Minerley had access to the Aetna PA Policy online. Thus, here there appears to be no dispute. While Aetna may not have explicitly stated to Weiss-Aug that there was a reimbursement right, and Weiss-Aug may not have explicitly told Minerley the same, both Weiss-Aug and Minerley had access to this information.

         Minerley did not contest this policy provision through the administrative procedures set forth in the Aetna PA Policy (or the Aetna N.J. Policy) as described supra. Minerley claims he did not do so because he never received a “Notice of Adverse Benefit Determination.” Defendants do not contest that Minerley did not receive a document with that title, but do state that the July 21, 2010 letter from Rawlings and their own filings in this case serve as notice of their adverse benefit determination. Instead of pursuing his administrative remedies, Minerley, along with Michelle Roche and Tim Singleton, filed a complaint against Defendants in the New Jersey Superior Court, Law Division, Atlantic County. Defendants removed the action to this Court on March 7, 2013. Motion practice, multiple opinions, and discovery ensued.

         Currently, Minerley is the only Plaintiff in this case. Minerley, through his amended complaint, claimed the following:

• Aetna violated 29 U.S.C. § 1132(a)(1)(B) by denying benefits to which Minerley was entitled; and
• Aetna violated 29 U.S. § 1004(a)(1)(A) and 29 U.S.C. § 1132(a)(3) (concerning breaches of fiduciary duty) by requiring reimbursement of Minerley's tort claim, for allegedly misrepresenting its right to reimbursement, and by failing to avoid the alleged conflict of interest in demanding reimbursement.

         On September 29, 2018, upon cross-motions for summary judgment filed by the parties, the Court dismissed all claims against all Defendants except for those claiming a breach of fiduciary duty. On October 15, 2018, Plaintiff filed a Motion for Reconsideration on certain factual and legal findings of this Court's September 29, 2018 Opinion and Order. On January 25, 2019, Defendants filed a Motion for Summary Judgment on the remaining claims for breach of fiduciary duty. These motions were fully briefed and are now ripe for adjudication.


         A. Subject Matter Jurisdiction

         This Court exercises jurisdiction pursuant to 28 U.S.C. § 1331 and 29 U.S.C. § 1132(f).

         B. Motion for ...

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