Court Opinion

ID: 4180369
Source: CourtListenerOpinion
Date Created: 2017-06-23 14:15:24.162833+00
Date Added: 2024-06-11T14:38:35.605886
License: Public Domain

NOT FOR PUBLICATION WITHOUT THE
                      APPROVAL OF THE APPELLATE DIVISION
     This opinion shall not "constitute precedent or be binding upon any court."
      Although it is posted on the internet, this opinion is binding only on the
         parties in the case and its use in other cases is limited. R.1:36-3.

                                       SUPERIOR COURT OF NEW JERSEY
                                       APPELLATE DIVISION
                                       DOCKET NO. A-1669-15T3

CITIZENS UNITED
RECIPROCAL EXCHANGE,

        Plaintiff-Appellant,

v.

NORTHERN NJ ORTHO SPECIALISTS,

     Defendant-Respondent.
_______________________________

              Argued June 1, 2017 - Decided June 23, 2017

              Before Judges Lihotz, Whipple and Mawla.

              On appeal from Superior Court of New Jersey,
              Law Division, Morris County, Docket No. L-
              1933-15.

              Eric S. Poe argued the cause for appellant
              (Mr. Poe, of counsel; Sonya Lopez Bright, on
              the brief).

              Judd B. Shaw argued the cause for respondent
              (Shaw Kreizer, P.A., attorneys; Mr. Shaw, on
              the brief).

PER CURIAM

        In this appeal, plaintiff Citizens United Reciprocal Exchange

(CURE), appeals from a Law Division order affirming an arbitration

award that compelled CURE to arbitrate a Personal Injury Protection
(PIP) billing dispute with defendant Northern New Jersey Ortho

Specialists (Ortho).      Defendant sought CURE's pre-certification

approval for surgery upon its insured following an automobile

accident.     CURE denied the claim as not medically necessary,

stating independent medical examinations concurred its insured

reached     maximum   medical   improvement.         Notwithstanding     this

determination, defendant performed the surgery and filed a demand

for payment, which CURE denied.       Defendant initiated arbitration.

       At the hearing, CURE submitted a report by a medical review

organization (MRO), which concluded the surgery was not medically

necessary.     Defendant submitted its own expert medical report in

rebuttal, which reached a contrary conclusion.            Ultimately, the

arbitrator concluded defendant rebutted CURE's claim the surgery

was not medically necessary and entered an award for defendant.

CURE    requested     clarification       of   the   arbitrator's      award,

maintaining its MRO report was presumptively correct.                   After

completing the arbitral review process, CURE filed to vacate the

award with the Law Division, pursuant to N.J.S.A. 2A:23A-13(c).

The judge rejected CURE's claims of legal error and in a written

opinion concluded CURE failed to provide authority for its claim

defendant was barred from submitting its own report to rebut CURE's

MRO report. The judge declined to disturb the arbitrator's factual

findings and re-weigh the submitted proofs, and confirmed the

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arbitrator's decision was grounded in substantial evidence found

in the record.

     CURE now appeals from the November 2, 2015 order, asserting

the Law Division erred in in its application of the law.

     Although parties to an arbitration may appeal to the Law

Division   as   matter    of    right,    N.J.S.A.   2A:23A-13(a),     judicial

review of an arbitration award is limited.                    An arbitrator's

decision   is    binding,       subject   to   "vacation,     modification     or

correction" by the Superior Court in limited instances.                   Ibid.

First,   the    court    must    establish     jurisdiction    under   N.J.S.A.

2A:23A-18.1     Second, in matters where jurisdiction exists, an

1
     The appeal is from a proceeding conducted under the
Alternative Procedure for Dispute Resolution Act [APDRA], N.J.S.A.
2A:23A-1 to -30. Although proceedings under APDRA are frequently
referred to as "arbitrations," and are indeed similar in style and
substance to arbitrations, APDRA is distinct from the Arbitration
Act, N.J.S.A. 2A:23B-1 to -32.

           To be sure, there are differences between the
           Acts.   The Arbitration Act does not require
           any particular procedures, mandate discovery,
           compel the maintenance of a record, command a
           statement by the arbitrator regarding his
           findings and conclusions, or an expression of
           the reasons why he reached the result that he
           did. See N.J.S.A. 2A:23B-1 to -32.

           The APDRA differs from the Arbitration Act in
           that it is designed to balance "streamlined
           procedures necessary for efficient repose"
           with "substantive safeguards necessary to
           protect public rights." John V. O'Hara, Note,

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arbitration award may only be vacated if the rights of a party

were prejudiced by:

              (1) Corruption,       fraud      or
              misconduct in procuring the award;

              (2) Partiality    of    an           umpire
              appointed as a neutral;

              (3) In making the award, the
              umpire's exceeding their power or so
              imperfectly executing that power
              that a final and definite award was
              not made;

              (4) Failure     to    follow     the
              procedures set forth in [this Act],
              unless the party applying to vacate
              the   award   continued   with   the
              proceeding with notice of the defect
              and without objection; or

              (5) The      umpire's     committing
              prejudicial error by erroneously
              applying law to the issues and facts
              presented       for      alternative
              resolution.

         The New Jersey Alternative Procedure for
         Dispute Resolution Act: Vanguard of a "Better
         Way"?, 136 U. Pa. L. Rev. 1723, 1751 (1988).
         To that end, the APDRA includes procedures for
         factual    development   through    discovery,
         N.J.S.A. 2A:23A-10, -11(e), the taking of
         expert witness testimony, N.J.S.A. 2A:23A-
         11(f), the submission by the arbitrator of a
         written opinion stating findings of fact and
         conclusions of law, N.J.S.A. 2A:23A-12(a), and
         requires that awards be in accordance with
         applicable legal principles, N.J.S.A. 2A:23A-
         12(e), -13(c)(5), -13(e)(4).

         [Johnson     v.   Johnson,   204 N.J. 529,    546
         (2010).]

                                  4                               A-1669-15T3
           [Selective Ins. Co. of Am. v. Rothman, 414
N.J. Super. 331, 341 (App. Div. 2010) (quoting
           N.J.S.A. 2A:23A-13).]

    However, N.J.S.A. 2A:23A-18(b) makes clear, once the trial

court,   sitting   as   an   appellate   court,   has   issued   an     order

"confirming, modifying or correcting" an arbitrator's decision,

"[t]here shall be no further appeal or review of the judgment or

decree."   Ibid.

           Our Supreme Court upheld N.J.S.A. 2A:23A-18(b)
           in Mt. Hope Dev. Assocs. v. Mt. Hope
           Waterpower Project, L.P., 154 N.J. 141, 148-
           52 (1998). The Court ruled that "the language
           of APDRA unmistakably informs parties that by
           utilizing its procedures they are waiving
           [their] right" to appeal beyond the trial
           court, and that such a waiver generally must
           be enforced. Id. at 148.

           [Citizens United Reciprocal Exch. v. N. N.J.
           Orthopedic Specialists, 445 N.J. Super. 371,
           375-76 (App. Div. 2016).]

    While there are exceptions to the bar set by N.J.S.A. 2A:23A-

18(b), they are limited.

           While considering this section of the APDRA,
           the Supreme Court concluded that although
           appellate review is generally not available,
           there are exceptions. Mt. Hope[, supra,] 154
           N.J. [at] 152. One example identified by the
           Court is a child support order, ibid.; another
           example is an award of attorneys fees.
           Allstate Ins. Co. v. Sabato, 380 N.J. Super.
463, 472-76 (App. Div. 2005).      But in the
           course of its opinion in Mt. Hope, supra, the
           Court also said that there may be other
           circumstances "where public policy would

                                    5                                 A-1669-15T3
          require appellate court review." 154 N.J. at
          152.   In that regard, the Court gave as an
          example review necessary for it to carry out
          its "supervisory function over the courts."
          Ibid.

          [Morel v. State Farm Ins. Co., 396 N.J. Super.
472, 475-76 (App. Div. 2007).]

    Absent a case "where public policy would require appellate

court review," this court lacks jurisdiction to hear the appeal.

Id. at 475.

          [W]hen the trial judge adheres to the
          statutory grounds in reversing, modifying or
          correcting an arbitration award, we have no
          jurisdiction to tamper with the judge's
          decision or do anything other than recognize
          that   the  judge   has  acted   within  his
          jurisdiction. Accordingly, we review the
          decision of the trial judge here for the
          limited purpose of determining whether he
          exceeded the authority granted to him by
          APDRA.

          [N.J. Citizens Underwriting Reciprocal Exch.
          v. Kieran Collins, D.C., LLC, 399 N.J. Super.
40, 48 (App. Div.), certif. denied, 196 N.J.
344 (2008).]

    "Any broader view of appellate jurisdiction would conflict

with the Legislature's expressed desire in enacting APDRA to

eliminate appellate review in these matters."    Fort Lee Surgery

Ctr., Inc. v. Proformance Ins. Co., 412 N.J. Super. 99, 104 (App.

Div. 2010).   Only where it is apparent the trial court committed

"glaring errors" should this court review the merits of such an

                                6                          A-1669-15T3
appeal.   Riverside Chiropractic Grp. v. Mercury Ins. Co., 404 N.J.

Super. 228, 240 (App. Div. 2008).

     CURE    asserts   the   Law   Division   confirmed    an   erroneous

arbitration award by misapplying the law, which is a significant

public policy concern requiring this court's intervention.            CURE

argues "[a]ppellate review is appropriate because the [t]rial

[c]ourt failed to properly apply the standards as established by

N.J.S.A. 39:6A-5.1 when considering the rebuttable presumption and

the submission of additional documentation following the issuance

of the MRO report and further failed to follow the mandate of

N.J.A.C. 11:3-29.4(e)(1) . . . ."        We reject this argument as

unfounded.

     CURE is a New Jersey based auto insurer.             As such, it is

required to provide PIP benefits under its policies.

            The No-Fault Act, N.J.S.A. 39:6A-1 to -35,
            mandates that automobile liability insurance
            policies provide PIP coverage, including
            payment of "reasonable medical expenses,"
            N.J.S.A. 39:6A-4(a).

            [Cobo v. Market Transition Facility, 293 N.J.
            Super. 374, 384 (App. Div. 1996).]

     Disputes regarding the appropriateness and amount of PIP

coverage is determined in "dispute resolution."           N.J.S.A. 39:6A-

5.1(a); see Citizens United Reciprocal Exch., supra, 445 N.J.

Super. at 376-77 (stating disputes between health care providers

                                    7                             A-1669-15T3
and   insurers      over   billing     disputes      covered      by    PIP    insurance

provisions       are       typically       settled      through          arbitration).

Regulations      establish      health     care   providers       are        entitled    to

reimbursement from PIP insurers of no more than the "usual,

customary and reasonable" fee for services rendered.                             N.J.A.C.

11:3-29.4.

      Other    statutory        subsections       provide    the        mechanics       for

assuring a fair and independent review process, including the use

of MROs.      N.J.S.A. 39:6A-5.1(d).           Specifically, N.J.S.A. 39:6A-

5.1(d)     states      "[t]he     determination       of    the        medical     review

organization on the dispute referred shall be presumed to be

correct by the dispute resolution professional, which presumption

may be rebutted by a preponderance of the evidence."                          Ibid.

      CURE asserts defendant's submittal of an opinion addressing

the medical necessity of the surgery performed was insufficient

to rebut the presumptively correct MRO determination provided.

Not only is this a factual challenge to the sufficiency of the

evidence, it also ignores the arbitrator's and the Law Division

judge's detailed findings regarding the deficits of CURE's MRO

determination       and     why    the     medical     evidence         rebutted        the

presumption of correctness to prove the need for surgery.                          As the

judge's    opinion      makes     clear,    the    arbitrator          did    more    than

"determine which was more persuasive," the MRO or rebuttal report.

                                           8                                      A-1669-15T3
    This issue is not one presenting a significant public policy

question warranting our review.   Morel, supra, 396 N.J. Super. at

475-76.   Neither is the amount to be reimbursed.   Accordingly, the

appeal is dismissed.   N.J.S.A. 2A:23A-18(b).

    Dismissed.

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