Court Opinion

ID: 4654884
Source: CourtListenerOpinion
Date Created: 2021-01-27 15:09:12.961417+00
Date Added: 2024-06-11T07:59:00.019068
License: Public Domain

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                                NOT FOR PUBLICATION WITHOUT THE
                               APPROVAL OF THE APPELLATE DIVISION
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                                                        SUPERIOR COURT OF NEW JERSEY
                                                        APPELLATE DIVISION
                                                        DOCKET NO. A-5660-18T3

M.M. and S.O.,1

          Appellants,

v.

CATASTROPHIC ILLNESS IN
CHILDREN RELIEF FUND
COMMISSION,

     Respondent.
___________________________

                   Submitted November 9, 2020 – Decided January 27, 2021

                   Before Judges Sabatino and Currier.

                   On appeal from the New Jersey Catastrophic Illness in
                   Children Relief Fund Commission.

                   M.M. and S.O., appellants pro se.

                   Gurbir S. Grewal, Attorney General, attorney for
                   respondent (Melissa H. Raksa, Assistant Attorney
                   General, of counsel; Francis X. Baker, Deputy Attorney
                   General, on the brief).

1
  We use initials and pseudonyms to preserve the child's privacy. The matters
are sealed. R. 1:38-11(b)(2).
PER CURIAM

      This case returns to us after remand in which we required defendant, the

Catastrophic Illness in Children Relief Fund Commission (the Commission), to

explain why it reimbursed plaintiffs for their uncovered medical expenses

incurred by their daughter's hyperbaric oxygen therapy (HBOT) in 2015 but not

in 2016.

      The Commission informed this court on the first appeal that HBOT

treatments have not been approved by the Food and Drug Administration (FDA)

for this child's condition. On remand, the Commission explained it erred in

reimbursing the HBOT treatments in 2015.            Therefore, it denied the

reimbursement of costs for HBOT treatments incurred in 2016 and thereafter.

Given the deference we grant an administrative agency, we affirm.

      Plaintiffs' daughter Susan suffered severe brain injuries during her birth

in 2010.   Her diagnosis is hypoxic ischemic encephalopathy.        Her parents

describe Susan as being a "quad cerebral palsy" with "medication resistant

seizures, visual impairments, respiratory insufficiencies, digestive problems,

auditory impairments, and many developmental delays."         After Susan was

prescribed HBOT treatments by her physician, her parents reported seeing

"remarkable results."

                                                                        A-5660-18T3
                                       2
      In 2016, the Commission reimbursed plaintiffs for approximately $50,000

in expenses incurred in 2015 for HBOT and other treatment. In 2017, plaintiffs

again applied for reimbursement of expenses for 2016 HBOT treatments. The

request was denied as an ineligible expense.

      Plaintiffs appealed, contending HBOT treatments should be considered

eligible expenses. We remanded to the Commission for an explanation as to

why HBOT expenses were reimbursed in 2015 and not in 2016.

      In a June 13, 2019 letter, the Commission advised plaintiffs:

            For any experimental medical treatment or drug, such
            as HBOT, to qualify for reimbursement, the
            Commission requires, among other things, that the
            treatment or drug at issue be used in connection with an
            FDA[2]-approved clinical trial (N.J.A.C. 10:155-
            1.14(a)(14)). . . . The Commission has an interest in
            ensuring that families seek high quality medical care.
            In that vein, the Commission discourages experimental
            treatment that is not based on scientific evidence and
            may not be safe and effective. With respect to HBOT
            treatment, the FDA specifically states that the safety
            and effectiveness of HBOT has not been established for
            a number of conditions, including, but not limited to,
            cerebral palsy.

            (https://www.fda.gov/consumers/consumer-
            updates/hyperbaric-oxygen-therapy-dont-be-misled).

2
  The FDA is tasked with regulating clinical trials of drugs and medical devices
"in human volunteers to see whether they should be approved for wider use in
the general population." Conducting Clinical Trials, U.S. Food and Drug
Administration (last updated June 15, 2016).
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                                       3
           In following these above guidelines, the Commission
           has consistently not approved reimbursement for
           HBOT in cases where the child's diagnosis, such as
           cerebral palsy, is not established by the FDA to benefit
           from HBOT. After careful review, the Commission
           acknowledges that the reimbursement of [Susan's]
           HBOT treatment in your 2016 application was an error
           because such treatment was experimental and not
           administered in connection with an FDA-approved
           clinical trial. In reviewing subsequent applications, the
           Commission has consistently denied reimbursement for
           HBOT treatment based on the fact that the FDA has
           neither approved this treatment for cerebral palsy nor
           provided it in connection with an FDA-approved
           clinical trial.

                  ....

           Because the reimbursement of [Susan's] HBOT
           treatment in your 2016 application was in error, the
           Commission has not and will not seek to recover such
           funds that were paid in error. . . . All families should
           understand that the approval for reimbursement of
           services in one year in no way guarantee[s] that the
           same service will be reimbursed in the same manner or
           at all in subsequent years. Funding is limited and may
           vary from year to year. . . . For these reasons, the
           Commission again denies your 2017 application for
           reimbursement of [Susan's] HBOT expenses incurred
           between January 1, 2016 and December 31, 2016.

     Plaintiffs appeal again, contending it is not fair for the Commission to

deny their reimbursement requests for HBOT treatments in 2016 because the

same treatments were reimbursed in 2015.

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      The scope of appellate review of an administrative decision is limited.

Lewis v. Catastrophic Illness in Children Relief Fund Comm'n, 336 N.J. Super.

361, 369 (App. Div. 2001). In reviewing a final agency decision, we must defer

to an agency's expertise and superior knowledge of its field. Dep't of Children

& Families, Div. of Youth & Family Servs. v. T.B., 207 N.J. 294, 301 (2011);

see also Campbell v. N.J. Racing Comm'n, 169 N.J. 579, 588 (2001) (granting

deference to agency expertise on technical matters).      This court "may not

second-guess those judgments of an administrative agency which fall squarely

within the agency's expertise." In re Stream Encroachment Permit, Permit No.

0200-04-0002.1 FHA, 402 N.J. Super. 587, 597 (App. Div. 2008).

      "In order to reverse an agency's judgment, an appellate court must find the

agency's decision to be 'arbitrary, capricious, or unreasonable, or . . . not

supported by substantial credible evidence in the record as a whole.'" In re

Stallworth, 208 N.J. 182, 194 (2011) (quoting Henry v. Rahway State Prison, 81

N.J. 571, 579-80 (1980)).

      In 1987, the Legislature found "children have the highest average medical

costs among the population as a whole[,]" and as a result, some families are

"push[ed] . . . into bankruptcy and others toward seeking inferior medical care."

N.J.S.A. 26:2-148(c), (b). In response, the Legislature enacted the Catastrophic

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                                       5
Illness in Children Relief Fund Act (the Act), which created a non-lapsing,

revolving fund earmarked "to provide assistance to children and their famil ies

whose medical expenses [related to a catastrophic illness] extend beyond the

families' available resources." N.J.S.A. 26:2-148(e); N.J.S.A. 26:2-151.

        Under the Act, a "catastrophic illness" is defined as "any illness or

condition the medical expenses of which are not covered by any other State or

federal program or any insurance contract and exceed 10% of the first $100,000

of annual income of a family plus 15% of the excess income over $100,000."

N.J.S.A. 26:2-149(a).    "The moneys necessary to establish and meet the

purposes of the [Act] are generated by a one dollar annual surcharge per

employee for all employers who are subject to the New Jersey Unemployment

Compensation Law." Lewis, 336 N.J. Super. at 365-66 (citing N.J.S.A. 26:2-

157).

        The Act statutorily creates the Commission to effectuate its purpose.

N.J.S.A. 26:2-151. The Commission is tasked with administering the fund by

establishing procedures to apply for reimbursement, determining eligibility,

calculating the reimbursement amount, and processing the fund awards.

N.J.S.A. 26:2-154(a) to (c).

                                                                       A-5660-18T3
                                       6
      A family seeking reimbursement must apply each year, listing costs

already incurred from the prior twelve-month time period. N.J.A.C. 10:155-1.4;

N.J.A.C. 10:155-1.5(d); N.J.A.C. 10:155-1.13; N.J.A.C. 10:155-1.12(a)(2)

(mandating the Commission must meet and determine eligibility). Even after

the Commission deems a recipient "eligible, . . . disbursements on behalf of a

child shall be limited by the monies available[,]" giving the Commission

discretion on whether to approve the award requested. N.J.A.C. 10:155-1.3(b);

N.J.A.C. 10:155-1.7 (establishing caps per child). Further, the award is subject

to the rules and regulations adopted by the Commission. N.J.S.A. 26:2-154(i);

N.J.S.A. 26:2-156.

      N.J.A.C. 10:155-1.14 provides a non-exhaustive list of eligible health

services which the Commission may fund. N.J.A.C. 10:155-1.14(a)(14) allows

reimbursement for "[e]xperimental medical treatment/experimental drugs in

connection with an FDA-approved clinical trial, which are provided by licensed

health care providers."   The regulation further notes applications for these

treatments "may require additional review[.]" N.J.A.C. 10:155-1.14(a)(14).

      As stated, HBOT has not been approved by the FDA as a treatment for

cerebral palsy or Lyme disease. Susan's HBOT treatments were not part of a

clinical trial. Because HBOT treatment is not on the non-exhaustive list of

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                                       7
eligible health services in N.J.A.C. 10:155-1.14, it was well within the

Commission's discretion to deny the 2016 HBOT costs.

      Plaintiffs contend that because the Commission approved reimbursement

for HBOT costs in 2015, it was bound to approve them in later years. We

disagree. The Commission has admitted it erred in approving reimbursement

for Susan's 2015 HBOT treatment. As we have stated, the Commission was

within its wide discretion to deem the costs ineligible in 2015. But it did not.

      That error, however, did not obligate the Commission to reimburse the

HBOT costs in future years.       Nor were there any promises made by the

Commission on which plaintiffs could rely for future reimbursement. The award

letter sent by the Commission to plaintiffs in 2016 for the 2015 expenses stated

that the award was for expenses incurred in that calendar year. Reimbursement

was made for qualifying expenses from the prior year. There were no promises

for reimbursement of any future costs.      There were no misrepresentations.

Moreover, plaintiffs were familiar with the process as demonstrated by their

annual applications and they knew each application was assessed on its merits

each year.

      Because the Commission's decision was not arbitrary, capricious, or

unreasonable, we affirm.

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                                        8
Affirmed.

                A-5660-18T3
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