Grp. Health Coop. v. Coon
Grp. Health Coop. v. Coon
Opinion
*844 ¶1 Group Health Cooperative (GHO) provided health insurance benefits to Nathaniel (Joel) Coon, who suffered a serious fungal infection and amputation following knee surgery at the Everett Clinic (TEC). The Coon family later settled potential negligence claims against TEC, and GHO initiated this lawsuit seeking reimbursement of its payments from the settlement proceeds. We must decide if genuine issues of material fact preclude summary judgment in favor of GHO regarding whether the settlement constituted full compensation to Coon, and whether GHO suffered prejudice from the Coons' failure to provide notice prior to finalizing the settlement. For the reasons explained below, we hold that summary judgment is inappropriate. We affirm the Court of Appeals and remand for further proceedings consistent with this opinion.
FACTS AND PROCEDURAL HISTORY
¶2 Coon lives in Snohomish, Washington, with his wife and two teenage daughters. In his early 20s, Coon started a residential lawn-care business that has seen steady growth over the years, even during a recession, and now includes an extensive commercial landscaping component. In addition to being heavily involved in the day-to-day operations *141 of the business, Coon and his family have enjoyed a very active lifestyle with hobbies that include traveling, boating, fishing, and hunting. The Coon family's lives changed dramatically in 2012 after Coon developed a rare fungal infection that ultimately led to an above-knee amputation of his right leg.
Initial Injury and Infection
¶3 In January 2012, Coon heard a "pop" in his right knee while playing tug-of-war on ice; he experienced immediate pain and disability. Clerk's Papers (CP) at 153. Coon's initial surgery was performed on March 1, 2012 at TEC's *845 Kemp Surgery Center; Coon tolerated the procedure well and was sent home the same day. Id. at 153-54.
¶4 Coon's recovery seemed normal until March 19, when he returned to TEC complaining of worsening pain and fever. Lab tests revealed an elevated white blood cell count, although an aspiration 1 of Coon's knee showed no organisms on the gram's stain. The next day, Coon was admitted to Providence Regional Medical Center for further evaluation and initiation of antibiotic treatment. On March 26, the fungus Scedosporium prolificans (SP) was isolated from the knee aspiration fluid collected on March 19. SP, a fungus typically found in soil and polluted waters, is extremely rare, aggressive, and resistant to most known and United States Food and Drug Administration-approved antifungal agents.
¶5 After other cultures grew out of the SP, Coon began the difficult process of antifungal therapy. The University of Washington Medical Center (UWMC) analyzed the pathology of Coon's SP infection and confirmed resistance to antifungal agents. Throughout the month of April, physicians "contacted the [Centers for Disease Control], researched the literature, tried multiple antifungal agents, and consulted with nationally recognized [infectious disease] experts." Id. at 155. During these treatment regimens, Coon suffered severe nausea, vomiting, visual and auditory changes, and hallucinations, and developed Stevens-Johnson syndrome. 2 Id. By the beginning of May it was clear that all attempted measures had failed to control the infection.
*846 ¶6 As his condition severely worsened, Coon consulted with orthopedic surgeons from the UWMC Department of Orthopedics, TEC, and Swedish Medical Center. All advised that they were unfamiliar with this type of aggressive fungal infection and lacked the requisite expertise to provide any new treatment plans. Id. at 155-56. As a result, Coon was referred to the Mayo Clinic for treatment. Id. at 156. From August to October, Coon was seen at the Mayo Clinic by leading orthopedic surgeons and infectious disease physicians. They attempted a combination of aggressive surgical procedures and antifungal therapies with no success. Eventually, Coon's leg had to be amputated due to extreme pain and limited function. The amputation was performed at the Mayo Clinic on October 17, 2012.
¶7 After the amputation, Coon returned to Washington for rehabilitation, prosthesis fitting, and physical therapy. Id. at 157. At the initiation of this litigation, Coon was still suffering from "ongoing phantom pain, stump pain, socket pain, low back and hip pain, trouble sleeping, and poor fit of his prosthesis with multiple falls." Id. In addition to the physical effects of the amputation, Coon has been severely limited in his ability to manage his business, and he struggles to return to the active lifestyle he enjoyed with his family.
Litigation and Settlement
¶8 During the period of treatment and recovery, TEC worked cooperatively with the Coons and paid a total of $322,645 for uncompensated medical expenses, travel, and accommodations.
*142 Id. at 160. The Coons retained counsel to investigate any possible legal claims. Id. at 353.
¶9 Counsel for the Coon family went to great lengths to determine the source of the fungal infection, consulting with various experts. One theory, which evolved after discussions with an expert at the Mayo Clinic, was that the spores were potentially tracked into the operating room by a provider and then somehow managed to settle onto the *847 graft tissue prior to insertion. Id. at 145. Another expert called into question the operation of the positive pressure ventilation system in the operating room, hypothesizing that the SP spores could have been transmitted from construction sites near the clinic. Id. at 146. After examining infection prevention standards at TEC, the history of fungal infections at TEC, and the presence of any permitted or unpermitted construction work during the procedure, the source of the SP fungal spores has yet to be determined. TEC rejects the above potential theories of liability and maintains that Coon was the likely carrier of the SP spores due to his "occupation as a landscaper." Id. at 159. Without extensive discovery to pinpoint an exact theory of causation, counsel concluded that the Coons had a res ipsa loquitur case. Id. at 145.
¶10 In addition to investigating potential theories of liability, counsel notified GHO in December 2013 that the Coons were being represented in connection with the injury and amputation. At that time, counsel requested a breakdown of GHO's subrogation lien for benefits provided to Coon. GHO responded that it had provided medical coverage in the amount of $372,634, in accordance with GHO's individual and family plan 2012 medical coverage agreement. Id. at 390-91. GHO asked counsel to " '[p]lease keep us informed regarding settlement negotiations and contact us prior to final settlement to confirm Group Health's subrogation amount.' " Id. at 392 (alteration in original).
¶11 In January 2014, counsel notified GHO that mediation of the Coons' claim against TEC was scheduled for February. GHO advised that Pamela Henley would be the GHO contact for the mediation. GHO maintains that while it was notified when the mediation was postponed until March 2014, it was never consulted during the mediation negotiations that led to the settlement.
¶12 On April 25, 2014, the Coons and TEC signed a settlement agreement for an additional $2 million. Id. at 254-56. In total, the Coons received $2,328,936.86 from TEC
*848 for their negligence claims. Id. After receipt of the settlement, counsel for the Coons advised GHO that his firm would hold back the amount of GHO's lien in its trust account until May 30, 2014 and requested that GHO waive its reimbursement rights. Id. at 392. On May 30, 2014 at 3:39 p.m., Henley responded that GHO would not waive its reimbursement rights but would pay "its equitable apportionment of the collection costs and legal fees/expenses incurred to recover GH[O]'s subrogated interest." Id. Counsel informed Henley on June 2, 2014 that his firm had disbursed the remaining funds to the Coons. Id. at 393.
¶13 In 2016, GHO filed a complaint in Snohomish County Superior Court, seeking a determination of its subrogation rights and a judgment against the Coons for $372,634, the amount of medical expenses paid by GHO. Id. at 495. Both sides filed motions for summary judgment. The superior court granted GHO's motion and held:
Reasonable minds can reach but one conclusion as to the following facts:
a. Parties may decide by agreement what amounts to full compensation for their damages taking into account their chances of success or failure at trial.
....
c. Once a party settles a claim, the party has identified and accepted the amount of settlement as full compensation for the party's damages.
....
g. By settling for less than the available insurance policy limits in consideration of Defendants' evidence of damages versus risk of failure at trial, NATHANIEL COON and LORI COON's agreement to settle constitutes full compensation for their damages as a matter of law.
*143 Id. at 511-12 (Order Granting Pl. GHO's Mot. for Summ. J.). The superior court entered judgment against the Coons in favor of GHO in the amount of $372,634 plus interest. Id. at 513.
*849 ¶14 The superior court separately denied a cross motion for summary judgment by the Coons, concluding that they "breached their duties under their contract" by settling with TEC "without protecting Plaintiff's subrogation interest." Id. at 516. The Coons appealed the superior court's order granting summary judgment to GHO but elected not to appeal the denial of their motion. 3
¶15 The Court of Appeals reversed the order granting summary judgment to GHO, holding that GHO had no valid and enforceable subrogation claim against the Coons.
Grp. Health Coop. v. Coon,
4 Wash. App. 2d 737, 754,
ANALYSIS
¶16 When an appeal arises out of an order granting summary judgment, this court engages in the same inquiry as the trial court.
Johnson v. Farmers Ins. Co. of Wash.,
¶17 Fundamentally, subrogation governs "how, if, and when an insurer may recover monies that it has paid to its insured." Brendan S. Maher & Radha A. Pathak, Understanding and Problematizing Contractual Tort Subrogation, 40 LOY. U. CHI. L.J. 49, 50 (2008). While the idea of subrogation began as an equitable doctrine, modem subrogation rights can be found in common law, contract, or statute. Id. at 59. Wherever they reside, it has long been recognized that such rights are subject to the principle that an insured must be "made whole" for any losses before an insurer may recover its payments:
[W]hile an insurer is entitled to be reimbursed to the extent that its insured recovers payment for the same loss from a [tortfeasor] responsible for the damage, it can recover only the excess which the insured has received from the wrongdoer, remaining after the insured is fully compensated for his loss.
Thiringer v. Am. Motors Ins. Co.,
A. Absent a Litigated Determination of Nonliability, Any Subrogation or Reimbursement Rights Asserted by an Insurer Are Subject to the "Made Whole" Doctrine
¶18 The relevant portion of the Coons' insurance contract states:
*144 If the Injured Person's injuries were caused by a third party giving rise to a claim of legal liability against the third party *851 and/or payment by the third party to the Injured Person and/or a settlement between the third party and the Injured Person, GHO shall have the right to recover GHO's Medical Expenses from any source available to the Injured Person as a result of the events causing the injury, including but not limited to funds available through applicable third party liability coverage and uninsured/underinsured motorist coverage. This right is commonly referred to as "subrogation." GHO shall be subrogated to and may enforce all rights of the Injured Person to the full extent of GHO's Medical Expenses.
GHO's subrogation and reimbursement rights shall be limited to the excess of the amount required to fully compensate the Injured Person for the loss sustained, including general damages.
CP at 93 (emphasis added). From this contract language, GHO argues that it is entitled to full recovery of its payments to Coon because there is no "third-party tortfeasor ... 'responsible in law' for the insured's injury." Pet. for Review at 10. This argument fails for several reasons.
¶19 Initially, as the Court of Appeals recognized, GHO's argument is internally contradictory.
See
Grp. Health Coop.,
4 Wash. App. 2d at 750-51,
¶20 Second, GHO's argument wrongly assumes that an insured may contract for reimbursement without regard to limits on its subrogation rights. Pet. for Review at 8. GHO
*852
cites to
Mahler v. Szucs
for this notion, but the
Mahler
court explicitly recognized that even when such contract language is employed, any right to reimbursement remains subject to
Thiringer's
"made whole" rule.
State Farm had only a right of reimbursement from its insureds from the proceeds of the settlements. More important, State Farm had to await the outcome of the settlement process before attempting any recovery from the tortfeasors' insurers, because, pursuant to Thiringer, State Farm was not entitled to any recovery of its PIP payments until its insured had been made whole.
¶21 Ultimately, GHO's argument for reimbursement without regard to the "made whole" rule rests on equating this case with
Cook v. USAA Casualty Insurance Co.,
¶22 While the Cooks' litigation efforts were under way, USAA sold its subrogation interest to the water heater installer and a general contractor who was managing the Cooks' home construction, for $151,000.
¶23 As the Court of Appeals recognized, there are three distinguishing factors between
Cook
and the present case.
See
Grp. Health Coop.,
4 Wash. App. 2d at 752-53,
¶24 The fact that the Coons' case involves a health insurance policy rather than a liability or casualty policy does not support a different outcome. Admittedly, there was some initial question early in our jurisprudence "about the extent to which insurance law applies" to health insurance contracts.
Brown v. Snohomish County Physicians Corp.,
¶25 This holding was later applied in
British Columbia Ministry of Health v. Homewood,
where the defendant was sued by her health insurer for reimbursement of medical payments made on her behalf.
*855
As in this case, however, Homewood faced substantial challenges in proving liability and, as a result, estimated
*146
that she would recover less than $5 million at trial.
¶26 Applying the "made whole" rule, the superior court erred when it found, "By settling for less than the available insurance policy limits in consideration of Defendants' evidence of damages versus risk of failure at trial, NATHANIEL COON and LORI COON's agreement to settle constitutes full compensation for their damages
as a matter of law
." CP at 512 (Order Granting Pl. GHO's Mot. for Summ. J.) (emphasis added). Settlement for less than the tortfeasor's policy limits does not create a presumption of full compensation.
Liberty Mut. Ins. Co. v. Tripp
,
¶27 In sum, the Coons have a right in contract and at common law to receive full compensation for their losses before GHO may seek reimbursement of its payments for Coon's medical expenses. The Coons' situation is analogous to that of every injured party who makes a calculated decision based on the risks of litigation to accept a settlement. We decline the invitation to upset almost four decades of insurance law in Washington State recognizing the wisdom and fairness of the "made whole" principle. We reverse the superior court order granting summary judgment to GHO and remand for further proceedings to determine, as a question of fact, whether the Coons have been fully compensated for their damages.
B. An Insurer Is Required To Prove That It Was Prejudiced before It Can Assert Any Reimbursement Rights Based on an Insured's Breach of Contract
¶28 Separate from the question of the applicability of the "made whole" rule, we must address GHO's argument that the Coons forfeited their rights under the insurance contract by breaching the contract. In an order denying the Coons' motion for summary judgment, the superior court found that the "Defendants breached their duties under their contract with Plaintiff" by failing to notify GHO prior to acceptance of a settlement. CP at 516 (Order Den. Defs.' Mot. for Summ. J.). GHO contends that, because of this breach, GHO is entitled, per the contract language, to full reimbursement as a matter of law. CP at 402. This is incorrect.
¶29 "It may be a peculiarity of insurance law, or a variant of general contract law, but not every breach discharges performance by the other party."
Pilgrim v. State Farm Fire & Cas. Ins. Co.,
¶30 Throughout the summary judgment proceedings, GHO did not offer any evidence of prejudice, CP at 389-407, but instead maintained that no showing of prejudice was required because the public policy considerations present in
Tripp
were not at issue. Pet. for Review at 19. GHO relies on
Tran
and
Pilgrim
to support its argument, but these cases compel the opposite conclusion.
Tran,
¶31 Here, questions of fact exist regarding whether GHO was prejudiced by the Coons' failure to provide notice prior to finalizing the TEC settlement. By its own admission, GHO was advised by the Coons' attorney that the Coons would be proceeding to mediation with TEC. CP at 405. GHO was also advised when the mediation was postponed.
CONCLUSION
¶32 The superior court wrongly granted GHO's motion for summary judgment and erred when it concluded that acceptance of a settlement under policy limits created a presumption that the Coons were "made whole" as a matter of law. Because the Coons had a contractual and common law right to receive their full measure of damages before reimbursing GHO and they put forth substantial evidence that they were not "made whole," further proceedings are necessary on this issue. Additionally, GHO cannot avoid its reimbursement obligations as a result of the Coons' contract *859 breach unless it proves that it was prejudiced by the Coons' failure to provide notice prior to settling their tort claims against TEC. We affirm the Court of Appeals and remand to the trial court for further proceedings consistent with this opinion.
WE CONCUR:
Fairhurst, C.J.
Johnson, J.
Madsen, J.
Owens, J.
Wiggins, J.
González, J.
Gordon McCloud, J.
Yu, J.
Joint aspiration is a procedure to remove fluid from the space around a joint for diagnostic purposes. Joint Aspiration, Johns Hopkins Med. , https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/joint-aspiration [https://perma.cc/PJQ4-MM65].
"Stevens Johnson syndrome is a rare, serious, sometimes fatal disorder in which a person's skin and mucous membranes react severely to a medication or infection. It often begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters, eventually causing the top layer of the skin to die and shed." CP at 155 n.5.
GHO argues that the Coons' appeal is moot because they did not appeal the superior court's order denying their summary judgment motion. Pet. for Review at 5. The Court of Appeals rejected this argument, recognizing that the determination of breach does not affect the Coons' rights under the contract absent proof of prejudice to GHO.
See
Grp. Health Coop. v. Coon,
4 Wash. App. 2d 737, 748,
Case-law data current through December 31, 2025. Source: CourtListener bulk data.