Court Opinion

ID: 6327266
Source: CourtListenerOpinion
Date Created: 2022-03-28 14:06:57.876261+00
Date Added: 2024-06-11T09:22:22.553783
License: Public Domain

RECORD IMPOUNDED

                                NOT FOR PUBLICATION WITHOUT THE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-0839-20
                                                                   A-1901-20

IN THE MATTER OF E.C.
BY I.C.1 AS PARENT AND
NATURAL GUARDIAN,

          Appellant,

v.

CATASTROPHIC ILLNESS
IN CHILDREN RELIEF
FUND COMMISSION,

          Respondent.

R.Z.,

          Appellant,

v.

CATASTROPHIC ILLNESS
IN CHILDREN RELIEF
FUND COMMISSION,

1
  We use the parties' initials to protect the children's privacy. The matters are
sealed. R. 1:38-11(b)(2).
      Respondent.

            Submitted March 17, 2022 – Decided March 28, 2022

            Before Judges Mawla and Mitterhoff.

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

            Ofeck & Heinze, LLP, attorneys for appellant E.C.
            (Mark F. Heinze, on the briefs).

            Elias L. Schneider, attorney for appellant R.Z.

            Matthew J. Platkin, Acting Attorney General, attorney
            for respondent New Jersey Catastrophic Illness in
            Children Relief Fund Commission (Melissa H. Raksa,
            Assistant Attorney General, of counsel; Francis X.
            Baker, Deputy Attorney General, on the brief in A-
            0839-20; Michael R. Sarno, Deputy Attorney General,
            on the brief in A-1901-20).

PER CURIAM

      In A-0839-20 appellant I.C. on behalf of his daughter E.C. appeals from

an October 13, 2020 final decision by respondent the Catastrophic Illness in

Children Relief Fund Commission (Commission) denying reimbursement for

out-of-network medical expenses. In A-1901-20, appellant R.Z. appeals from a

February 8, 2021 final decision denying reimbursement for her out-of-network

psychological expenses. We consolidate the appeals for purposes of this opinion

and now affirm.

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                                       2
      As a toddler, E.C. fell out of a second story window, suffering a traumatic

brain injury and has quadriplegia, vision and hearing loss, ligamentous laxity of

both feet, among other medical disabilities. She requires extensive medical care,

including feeding therapy and intensive physical therapy.

      I.C. submitted four claims to the Catastrophic Illness in Children Relief

Fund (fund) for reimbursement of therapeutic services rendered by out-of-

network providers to E.C. between November 1, 2015 and October 31, 2019.

E.C. had comprehensive health insurance coverage through New Jersey

FamilyCare when she received the out-of-network treatments. The executive

director of the fund sent a letter to I.C. denying the claims, advising as follows:

            According to a recent policy review by the Commission
            effective for applications received on or after October
            1, 2019, [the fund's] statute and regulations do not
            support payment for ambulatory services received from
            out-of-network providers or facilities, where the use of
            out-of-network provider or facility by a child with
            comprehensive health insurance was not inadvertent,
            urgent, or due to an emergency.

      I.C. appealed from the denials, explaining he took E.C. to in-network

providers for therapy but "she made no gains with that therapy." Once he sought

treatment with out-of-network providers, E.C. "saw immediate and consistent

progress; tremendous gains within the first weeks and continuing throughout the

years." I.C. mailed the reimbursement application by regular mail on Sunday,

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                                        3
September 29, 2019, the same day he learned of the policy. He was not able to

express mail the documents the next day because he was observing Rosh

Hashanah. The Commission received I.C.'s application on October 4, 2019.

      The Commission denied the appeals for the same reasons. It pointed to

an advisory bulletin issued on September 20, 2019, as the legal basis for denial

of the appeals, which we will discuss further below.

      R.Z.    is   a   sixteen-year-old       girl   diagnosed   with   attention-

deficient/hyperactivity disorder (ADHD) inattentive type, generalized anxiety

disorder, oppositional defiant disorder, and developmental and conduct disorder.

She has comprehensive medical coverage through New Jersey FamilyCare. She

began psychotherapy with an out-of-network psychologist on May 28, 2019,

enrolled with the psychologist on October 27, 2019, and saw the psychologist

for thirteen appointments throughout 2019.

      R.Z.'s parents, who are Jewish orthodox, wrote to the fund explaining they

chose the psychologist, who happened to be the first and only one R.Z. saw, by

networking through family and friends. The psychologist was

             well-known in her ability to work with troubled teens
             and was literally the only practitioner that we [could]
             find within a [thirty-to-forty] mile[] radius[] who was
             able to help her while identifying with the specific
             lifestyle needs[] we have. Unfortunately, locally, there
             is no one who was able to meet our needs, with her

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                                          4
            credentials in pediatric psychology, and a lifestyle
            background similar to our own.

                  She is familiar with [R.Z.'s] school system and
            curricula, as well as the peer pressures and complicated
            dynamics which [R.Z.] faces daily, both at home, in her
            community, and in her school.

The psychologist issued a report echoing the parents' representations.

      R.Z.'s parents filed a claim for reimbursement of the psychologist's

expenses on January 29, 2020. They explained they contacted their insurance

to look for in-network providers but received a list of social workers rather than

psychologists or psychiatrists. Based on this information, they did not contact

their insurance to see if it would pay for out-of-network services because they

"simply thought that if they don't even have a provider on their list[,] certainly

they wouldn't pay for someone out[-]of[-]network[.]"

      The fund denied the request for reimbursement. In discussions evaluating

R.Z.'s appeal, the Commission vice-chair noted "[a]nxiety and ADHD are

relatively common conditions in our field so [it is] hard to justify that [R.Z.]

needed a very special specialist and no other existed for [thirty-to-forty] miles

. . . ." She also noted treatment centers close to R.Z.'s home and moved to

uphold the denial of reimbursement. For the same reasons as in E.C.'s case, the

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                                        5
Commission issued written findings denying the appeal and cited the bulletin

explaining its policy.

                                       I.

      The scope of review of an administrative decision is limited. Lewis v.

Catastrophic Illness in Child. Relief Fund Comm'n, 336 N.J. Super. 361, 369

(App. Div. 2001). The court "must defer to an agency's expertise and superior

knowledge of a particular field." Dep't of Child. & Fams., Div. of Youth & Fam.

Servs. v. T.B., 207 N.J. 294, 301 (2011) (quoting Greenwood v. State Police

Training Ctr., 127 N.J. 500, 513 (1992)). We examine:

            (1) whether the agency's action violates express or
            implied legislative policies, that is, did the agency
            follow the law;

            (2) whether the record contains substantial evidence to
            support the findings on which the agency based its
            action; and

            (3) whether in applying the legislative policies to the
            facts, the agency clearly erred in reaching a conclusion
            that could not reasonably have been made on a showing
            of the relevant factors.

            [Allstars Auto Grp., Inc. v. N.J. Motor Vehicle
            Comm'n, 234 N.J. 150, 157 (2018) (quoting In re
            Stallworth, 208 N.J. 182, 194 (2011)).]

      "[T]he legislative grant of authority to an administrative agency must be

liberally construed to enable the agency to accomplish its statutory

                                                                         A-0839-20
                                       6
responsibilities" and "permit the fullest accomplishment of the legislative

intent." Lewis, 336 N.J. Super. at 370. To reverse the exercise of authority by

an agency, we must find the "decision to be 'arbitrary, capricious, or

unreasonable, or [] not supported by substantial credible evidence in the record

as a whole.'" Zimmerman v. Sussex Cnty. Educ. Servs. Comm'n, 237 N.J. 465,

475 (2019) (alteration in original) (quoting Stallworth, 208 N.J. at 194).

                                       II.

      The fund is a non-lapsing, revolving fund with the power to authorize

payments or reimbursement of medical expenses of children with catastrophic

illnesses. N.J.S.A. 26:2-150; N.J.S.A. 26:2-154(a). The fund is governed by its

Commission whose duties are to review and decide applications for financial

assistance and develop policies and procedures for the fund's operation.

N.J.S.A. 26:2-154(b); N.J.S.A. 26:2-156.

      A catastrophic illness is "any illness or condition the medical expenses of

which are not covered by any other State or federal program or any insurance

contract . . . ." N.J.S.A. 26:2-149(a). Qualifying expenses are reimbursed to the

"parent . . . who is legally responsible for the child's medical expenses."

N.J.S.A. 26:2-149(d).

                                                                             A-0839-20
                                        7
       The Commission's regulations state expenses eligible for reimbursement

include those "not covered by any other source, including, but not limited to,

other State or Federal agency programs[ or] insurance contracts . . . ." N.J.A.C.

10:155-1.2. N.J.A.C. 10:155-1.14 contains a non-exhaustive list of eligible

health services, for which families can seek reimbursement, including medical

and psychological services.      Even if an applicant is eligible, payment

disbursements are limited by the available funds and the Commission has

discretion whether to approve an award request.         N.J.A.C. 10:155-1.3(b).

N.J.A.C. 10:155-1.2 "protects the fiscal integrity of the [f]und, thereby

preserving it for the benefit of those truly in need." Lewis, 336 N.J. Super. at

371.

       On September 20, 2019, the Commission issued advisory bulletin 19 -

CICRF-01, regarding "Non-Payment for Out-of-Network Ambulatory Care,"

stating:

            During a recent review of regulations, the Commission
            focused on defined terms and [f]und procedures in light
            of those definitions.

            . . . [T]he Commission determined that existing state
            law and regulation preclude any payment for
            ambulatory services received from out-of-network
            providers or facilities, where the use of out-of-network
            provider or facility by a child with comprehensive
            health coverage was not inadvertent, urgent, or due to

                                                                           A-0839-20
                                       8
            an emergency. The Commission directed the State
            Office of the [f]und to process new applications and
            reconsiderations under this determination, effective for
            applications received on or after October 1, 2019.

                  ....

                   The legislation creating the [f]und anticipated
            families applying to the [f]und for out-of-network care
            for emergent care or serious illness or injury where the
            specific expertise and services of an out-of-network
            facility, provider, or specialist were warranted. The
            legislation did not contemplate the [f]und as a source of
            coverage for all voluntary out-of-network services, or
            as a means to circumvent the provider networks or
            payment policies of established health coverage
            programs, including Medicaid.

                  ....

                  Families that have previously applied to the
            [f]und for costs incurred as a result of ambulatory care
            received from out-of-network providers should
            anticipate that the Commission will determine such
            expenses ineligible if submitted to the [f]und again.

                                      III.

      I.C. argues the bulletin implemented a new, arbitrary policy because it

"den[ied] an already-existing claim when, according to the [f]und, parents and

providers routinely looked to the [f]und for out-of-network costs and the [f]und

willingly paid them." He asserts the Commission's decision lacked proper fact

findings because E.C. tried in-network services but only benefitted from treating

                                                                           A-0839-20
                                       9
with an out-of-network provider. I.C. claims the Commission exclusively relied

on the fact he did not file the claims by the deadline in the bulletin, which itself

was arbitrary, because the bulletin provided insufficient time to submit his

claims. He seeks a remand for a hearing.

      At the outset, we note the record establishes: E.C. received non-emergent

services; had comprehensive health insurance when she obtained the out-of-

network services; and there were in-network providers.          Thus, there is no

material dispute requiring a hearing, and the Commission properly decided the

matter based on the evidence in the record. While we appreciate that E.C.

benefitted from the out-of-network services, this does not mandate the fund pay

for the services.

      We are also unpersuaded the bulletin or the notice it provided for

submission of claims were arbitrary, capricious, or unreasonable.           "To be

reasonable, an agency's choice of action for providing notice does not require

adoption of a perfect practice." In re State & Sch. Emps. Health Benefits

Comm'ns' Implementation of Yucht, 233 N.J. 267, 282 (2018). "[A]gencies

have wide latitude in improvising appropriate procedures to effectuate their

regulatory jurisdiction." Metromedia, Inc. v. Dir., Div. of Tax'n, 97 N.J. 313,

333 (1984). "Deference to an agency decision is particularly appropriate where

                                                                              A-0839-20
                                        10
interpretation of the [a]gency's own regulation is in issue." R.S. v. Div. of Med.

Assistance and Health Servs., 434 N.J. Super. 250, 261 (App. Div. 2014)

(quoting I.L. v. N.J. Dep't of Hum. Servs., Div. of Med. Assistance and Health

Servs., 389 N.J. Super. 354, 364 (App. Div. 2006)).

      The bulletin did not establish a new rule; it maintained that non-emergent

out-of-network expenses incurred when a child had comprehensive health

insurance would not be reimbursable. Even if I.C. filed for reimbursement in a

timely manner, nothing in the Commission's policies and procedures or

governing statutes and regulations created an expectation for reimbursement.

                                       IV.

      Like I.C., R.Z. also asserts the Commission's decision lacks fact findings.

She argues the Commission's conclusion the psychologist was out-of-network

was unsupported by the facts and contrary to the Out-Of-Network Consumer

Protection, Transparency, Cost Containment and Accountability Act, N.J.S.A.

26:2SS-1 to -20. R.Z. argues the facts established she urgently needed treatment

and her condition met the requirements for reimbursement of the out-of-network

urgent care. She asserts the Commission's definition of what constitutes urgent

care is vague and should be construed in her favor. She claims the Commission

                                                                            A-0839-20
                                       11
violated the Americans with Disabilities Act,2 failed to make a reasonable

accommodation, and denied her equal access to the fund's benefits.

       R.Z. also challenges the bulletin's imposition of the filing deadline as

procedurally and substantively arbitrary. She argues the bulletin changed the

fund's definition of expenses not covered by insurance, claiming it previously

meant "that if a service was not covered by a network, one could claim it from

the [f]und. Or, from the provider perspective, if they did not join a network,

they could expect the [f]und to pay." R.Z. asserts that pursuant to the bulletin,

"not covered" now means not from a comparable in-network provider, and

providers must join a network to be paid. She claims the Commission previously

"created a parallel regime" to serve as a direct source of payment for out-of-

network ambulatory services, but the bulletin arbitrarily changed the rules to

require the fund to first determine whether an expense could be covered by

insurance.

       Based on the facts in the record, no further factfinding was necessary

because there is no dispute R.Z. had comprehensive health coverage and

obtained out-of-network care without first searching in network.             The

Commission correctly found resorting to an out-of-network provider was

2
    42 U.S.C. § 12101 to -12213.
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                                      12
inappropriate as a matter of law. N.J.S.A. 26:2SS-3 states a covered person

knowingly, voluntarily, and specifically selects an out-of-network provider

when they choose "services of a specific provider, with full knowledge that the

provider is out-of-network with respect to the covered person's health benefits

plan, under circumstances that indicate that covered person had the opportunity

to be serviced by an in-network provider, but instead selected the out-of-network

provider."

      R.Z.    knowingly     and    voluntarily    selected   out-of-network     care.

Furthermore, her condition was not urgent because, as noted in the bulletin,

urgent care "[a]s defined in N.J.A.C. 11:24-5.3 . . . include[s] . . . out-of-service-

area medical care when medically necessary for urgent or emergency conditions

where the member cannot reasonably access in-network services[.]" R.Z. could

reasonably obtain in-network services.            Furthermore, the Commission

determined R.Z. is independent with all activities of daily living and suffered

from relatively common conditions. These findings are supported by the record,

and we owe them deference.

                                         V.

      In both matters, we conclude the Commission did not depart from the

legislative policies animating the fund. The Commission's decisions were not

                                                                               A-0839-20
                                        13
arbitrary, capricious, or unreasonable and were supported by the substantial

credible evidence in the record.      To the extent we have not addressed an

argument raised on either appeal, it is because it lacks sufficient merit to warrant

discussion in a written opinion. R. 2:11-3(e)(1)(E).

      Affirmed in A-0839-20 and affirmed in A-1901-20.

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