Court Opinion

ID: 3720738
Source: CourtListenerOpinion
Date Created: 2016-07-06 06:51:52.359567+00
Date Added: 2024-06-11T13:54:48.103886
License: Public Domain

The trial court erred in granting summary judgment under the unusual facts of this case. The group benefit plan provided the following: *Page 850 
"If you are injured and have the right to recover the cost of your hospital, medical or dental care or receive loss-of-income payments from any person or organization, this PLAN may recover from you the amount of any benefits which we have paid in connection with that injury." (Emphasis added.)
The emphasized portion of such plan clearly contemplates recovery from a third party to compensate appellant for injuries caused by a tortfeasor. Appellant's "right to recover" in this case would have produced a fund of only $25,000, but even then only if appellant retained an attorney and successfully pursued the tortfeasor, proving his "right to recover," both as to liability and damages. In the real world it is clear that appellant would have been required to pay his retained attorney, and would have netted considerably less than the sum of $25,000 available from the person who caused his injuries. In the casesub judice, appellant was required to pay one third to his lawyer, and therefore netted only $16,667. He paid the entire balance to appellee.
Fortunately, however, by virtue of his own foresight and payment of an insurance premium, appellant owned a liability insurance policy which provided him with coverage of an additional $75,000 if the tortfeasor who injured him was underinsured. Such recovery was not from the tortfeasor, and the usual rules of subrogation, whereby one is substituted in the place of another so that he succeeds or is "subrogated" to the rights of the other, are simply not applicable.
The Dualite health insurance plan agreement was simply a conventional subrogation agreement, i.e., one "premised on the contractual obligations of the parties." State v. Jones (1980),61 Ohio St. 2d 99, 101, 15 O.O.3d 132, 133, 399 N.E.2d 1215,1217. In determining the parties' subrogation rights under an insurance contract, the usual rules of contractual interpretation apply. See U.S. Patriot Life Ins. Agency, Inc. v.Swesey (June 23, 1989), Trumbull App. No. 4007, unreported, 1989 WL 70070. Thus, any ambiguous language should be construed against the insurer. Id.; Sterling Merchandise Co. v. HartfordIns. Co. (1986), 30 Ohio App. 3d 131, 137, 30 OBR 249, 255,506 N.E.2d 1192, 1198.
The plan does not specify whether the "cost" which one has the right to recover includes the gross cost or is limited to that amount which is actually recovered after subtracting the expense of obtaining said recovery. In this respect, I would distinguish Provident Life  Acc. Ins. Co. v. Thomas (Nov. 25, 1991), Butler App. No. CA91-05-083, unreported, 1991 WL 247541, on the basis that Thomas fails to specify whether the "full settlement" for which the insurance company requested reimbursement included the insured's expenses of recovering from the tortfeasor. The language in the case sub judice is not so clear or unambiguous as the majority claims and I would construe such *Page 851 
against appellee. Accordingly, appellee's right to reimbursement is limited to any amount actually recovered from the tortfeasor against whom appellant had a "right to recover." Appellant "recovered" only $16,667 from such tortfeasor.
The trial court's decision will be a blessing to the negligent driver and a blow to the innocent victim and his medical insurance carrier. Assume a scenario in which A incurs $33,000 in medical expenses as the result of an automobile accident with B. Assume further that B's liability is questionable, and it is known that B's financial responsibility is limited to $25,000. Assume further that C, A's medical provider, is entitled to be reimbursed by A for any recovery against B. Given such facts, is there any possible reason A should retain an attorney and pursue B? Obviously not! If the decision in the trial court is correct, B is free as a bird while neither A nor C recovers a penny.
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