April 15, 2014

Aetna Health Plans v Hanover Ins. Co. (2014 NY Slip Op 02541)

Headnote

The relevant facts in Aetna Health Plans v Hanover Ins. Co. involved Aetna Health Plans, as the assignee of Luz Herrera, seeking payment of no-fault benefits from Hanover Insurance Company. However, the court found that Aetna was not a "health care provider" under the statute, but rather a health care insurer, and therefore not entitled to no-fault benefits. Additionally, the court ruled that the No-Fault Law provides a limited window of arbitration between no-fault insurers, but such language does not pertain to a health insurer like Aetna. The main issue decided was whether Aetna was entitled to maintain a claim against Hanover under the principle of subrogation or assert a breach of contract claim as an intended third-party beneficiary. The holding of the case was that Aetna cannot maintain a claim against Hanover under the principle of subrogation or assert a breach of contract claim, as it was not in privity of contract with Hanover and was not an intended third-party beneficiary of the contract.

Reported in New York Official Reports at Aetna Health Plans v Hanover Ins. Co. (2014 NY Slip Op 02541)

Aetna Health Plans v Hanover Ins. Co.

2014 NY Slip Op 02541 [116 AD3d 538]

April 15, 2014

Appellate Division, First Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, May 28, 2014

Aetna Health Plans, as Assignee of Luz Herrera, Appellant,
v
Hanover Insurance Company, Respondent.

—[*1] Shayne, Dachs, Sauer & Dachs, LLP, Mineola (Jonathan A. Dachs of counsel), for appellant.

Crisci, Weiser & McCarthy, New York (Jayashri C. Srinivasan Cuffey of counsel), for respondent.

Order, Supreme Court, Bronx County (Mary Ann Brigantti-Hughes, J.), entered on or about January 7, 2013, which granted defendant’s cross motion to dismiss the complaint, and denied plaintiff’s motion for summary judgment on the issue of liability, unanimously affirmed, with costs.

11 NYCRR 65-3.11 (a) provides, in relevant part, for the payment of no-fault benefits “directly to the applicant . . . or, upon assignment by the applicant . . . to [the] providers of health care services.” Plaintiff Aetna Health Plans is not a “health care provider” under the statute, but rather a health care insurer (see A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co., 101 AD3d 53, 62 [2d Dept 2012] Craig Antell, D.O., P.C. v New York Cent. Mut. Fire Ins. Co., 11 Misc 3d 137[A], 2006 NY Slip Op 50521[U] [App Term, 1st Dept 2006]).

While the No-Fault Law provides a limited window of arbitration between no-fault insurers (see Insurance Law §§ 5105, 5106 [d] Eagle Ins. Co. v ELRAC, Inc., 291 AD2d 272 [1st Dept 2002]), the statutory language does not pertain to a health insurer such as Aetna. Thus, Aetna cannot maintain a claim against defendant under the principle of subrogation (see Health Ins. Plan of Greater N.Y. v Allstate Ins. Co., 2007 NY Slip Op 33925[U] [Sup Ct, NY County 2007]). Nor may Aetna assert a breach of contract claim against Hanover, [*2]since it is not in privity of contract with Hanover, and there has been no showing that it was an intended third-party beneficiary of the contract. Concur—Tom, J.P., Acosta, Freedman and Kapnick, JJ. [Prior Case History: 2013 NY Slip Op 33221(U).]