GUADALUPE FERREIRO v. STATE OF NEW JERSEY, et al.

 

NOT FOR PUBLICATION WITHOUT THE

APPROVAL OF THE APPELLATE DIVISION

SUPERIOR COURT OF NEW JERSEY

APPELLATE DIVISION

DOCKET NO. A-3746-04T1
3746-04T1

GUADALUPE FERREIRO,

Appellant,

v.

STATE OF NEW JERSEY, DEPARTMENT OF

THE TREASURY, DIVISION OF PENSION

AND BENEFITS, STATE HEALTH BENEFITS

COMMISSION, HORIZON BLUE CROSS BLUE

SHIELD OF NJ,

Respondent.

_____________________________________

 

Argued May 8, 2006 - Decided June 6, 2006

Before Judges Cuff and Lintner.

On appeal from a Final Administrative Determination of the State Health Benefits Commission.

William G. Sanchez argued the cause for appellant (Andril & Espinosa, attorneys;

Mr. Sanchez, on the brief).

Christine R. Lucarelli, Deputy Attorney General, argued the cause for the State Health Benefits Commission (Zulima V. Farber, Attorney General, attorney; Patrick DeAlmeida, Assistant Attorney General, of counsel; Linda Bilec, Deputy Attorney General, on the brief).

PER CURIAM

Appellant, Guadalupe Ferreiro, appeals from a Final Administrative Determination of the State Health Benefits Commission (Commission) denying her claim for continued Horizon Blue Cross Blue Shield of New Jersey (HBCBS) health benefits for services rendered by Aaron Lederer, a psychoanalyst. The relevant facts are substantially undisputed. Ferreiro is a licensed clinical social worker who is a member of the Traditional Plan, one of several health care plans offered to State employees. According to Ferreiro, before she began treatment with Lederer for depression in December 2000, she received telephonic authorization from HBCBS.

On July 25, 2003, HBCBS wrote to Ferreiro, explaining that Lederer did not meet the State Health Benefits Program's (Program) definition of eligible provider, and giving the following as the Program's definition of "Doctor":

A physician or surgeon licensed to practice medicine. The term also includes certified acupuncturists, dentists, podiatrists, psychologists, psychiatrists, licensed clinical social workers, nurse midwives, certified nurse practitioners, clinical nurse specialists, optometrists, audiometrists and chiropractors licensed and working within the scope of their practice.

HBCBS's July 25 letter also explained that because Ferreiro had received payments from it in error, it would not seek reimbursement for those payments previously made and would allow Ferreiro an additional thirty days to receive reimbursement for services rendered, after which time she would "no longer be considered eligible for benefits under [her] Traditional Plan."

In May 2004, after reviewing a submission on Ferreiro's behalf from Dr. Karp, HBCBS advised Ferreiro that she was eligible for the mental health services rendered by Dr. Karp, but reiterated that its "earlier decision regarding the eligibility of Aaron Lederer . . . remains unchanged [because] [s]ervices rendered by this type of provider are not eligible under the Traditional Plan."

On April 30, 2004, Ferreiro filed an Administrative Appeal. On November 10, 2004, the Commission denied the appeal, concluding, "under the Traditional Plan, Aaron Lederer, NCPsyA (NAAP) Transactional analyst and psychoanalyst is considered an ineligible provider." On December 22, 2004, Ferreiro requested that the matter be presented to the Office of Administrative Law (OAL) for a hearing. On February 14, 2005, the Commission denied Ferreiro's request, determining "that no issue of material fact exists" and that the Traditional Plan Member Handbook (Handbook) provides, "Charges Not Covered by the Plan" include "[s]ervices and supplies prescribed or provided by an ineligible provider."

On appeal, Ferreiro asserts that HBCBS is equitably estopped from denying further payment because it initially authorized treatment upon which she relied in getting treatment from a trusted professional. Based on the record before us, we find no support for appellant's claim that HBCBS was equitably estopped from terminating reimbursement for services rendered by Lederer. "'Estoppel is an equitable doctrine, founded in the fundamental duty of fair dealing imposed by law, that prohibits a party from repudiating a previously taken position when another party has relied on that position to his [or her] detriment.'" State v. Kouvatas, 292 N.J. Super. 417, 425 (App. Div. 1996) (quoting Hous. Auth. of Atlantic City v. State, 188 N.J. Super. 145, 149 (Ch. Div. 1983), aff'd, 193 N.J. Super. 176 (App. Div. 1984)); accord Casamasino v. City of Jersey City, 158 N.J. 333, 354 (1999). "[O]ne may, by voluntary conduct, be precluded from taking a course of action that would work injustice and wrong to one who with good reason and in good faith has relied upon such conduct." Summer Cottagers' Ass'n of Cape May v. City of Cape May, 19 N.J 493, 503-04 (1955). "The doing or forbearing to do an act induced by the conduct of another may work an estoppel to avoid wrong or injury ensuing from reasonable reliance upon such conduct." Id. at 504. Equitable estoppel is "'rarely invoked against a governmental entity.'" Middletown Twp. Policemen's Benevolent Ass'n Local No. 124 v. Twp. of Middletown, 162 N.J. 361, 367 (2000) (quoting Wood v. Borough of Wildwood Crest, 319 N.J. Super. 650, 656 (App. Div. 1999)); accord County of Morris v. Fauver, 153 N.J. 80, 104 (1998). The doctrine, however, will be applied in the appropriate circumstances unless the application would "'prejudice essential governmental functions.'" Wood, supra, 319 N.J. Super. at 656 (quoting Vogt v. Borough of Belmar, 14 N.J. 195, 205 (1954)).

Ferreiro argues that that she received a predetermined telephonic approval to treat with Lederer. The Handbook, however, specifically provides "predetermination for any service may be obtained in writing" and "[t]elephone contact . . . about coverage does not constitute a predetermination of benefits." Moreover, "[a] predetermination is valid for one year from the date of issue." Ferreiro conceded in her December 22, 2004, letter requesting a transfer to the OAL and in her appellate brief that she understood that psychoanalysts are not service providers under the Plan and that is why she made the telephone call before beginning treatment. Under these circumstances, Ferreiro could not establish reasonable and justifiable reliance.

Equally unpersuasive is Ferreiro's contention that HBCBS is equitably estopped because it mistakenly made payment over an approximate three-year period before discovering its mistake. Simply stated, the record does not present any compelling circumstances upon which to apply equitable estoppel against a governmental agency. Twp. of Fairfield v. Likanchuk's, Inc., 274 N.J. Super. 320, 331 (App. Div. 1994). Indeed, when HBCBS discovered its mistake, it provided Ferreiro with an additional thirty days of treatment and did not seek reimbursement for the payments mistakenly made.

Finally, Ferreiro's assertion that the Commission's decision was arbitrary, capricious, and unreasonable simply lacks merit. Our independent review of the record leads us to conclude that, in this case, the record is sufficient to support the Commission's decision. Clowes v. Terminix Int'l, Inc., 109 N.J. 575, 587 (1988); see also R. 2:11-3(e)(1)(D).

Affirmed.

 

The Handbook provided in respondent's brief is dated January 2005.

(continued)

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A-3746-04T1

June 6, 2006