Opinion
W.C. No. 4-424-539.
August 24, 2006.
FINAL ORDER
The claimant seeks review of an order of Administrative Law Judge Cain (ALJ) dated February 21, 2006, that determined that the claimant lacked standing to seek an order requiring the respondents to reimburse another carrier for payments in excess of the fee schedule. We affirm.
A hearing was held on the sole issue of the claimant's claim that the respondent insurer should be required to reimburse the claimant's health carrier for payments it made in excess of the fee schedule pending resolution of the compensability of the claim. Based upon a stipulation between the parties, the ALJ entered findings of fact that may be summarized as follows. On May 24, 1999, the claimant sustained an injury to his left foot, the compensability of which was disputed by the respondents. By order dated February 26, 2002, ALJ Felter determined that the claim was compensable and ordered the respondents to pay benefits, including reasonable and necessary medical benefits. Between the date of the claimant's injury and the date of ALJ Felter's order the claimant's health carrier, Aetna U.S. Healthcare (Aetna) paid medical bills for treatment that occurred pending resolution of the issue of compensability. Aetna paid bills in the total amount of $134,793.95. Pursuant to its obligation to provide medical treatment under ALJ Felter's order, the respondent insurer reimbursed Aetna the amounts it would have paid under the fee schedule for the treatment. The total fee scheduled amount was $66,036.88, which the respondent insurer reimbursed Aetna. The ALJ also found that the claimant's attorney, who was asserting the claim for reimbursement in excess of the fee scheduled amounts on behalf of Aetna, did not represent Aetna. The ALJ also found that Aetna had not appeared or intervened, that it had not assigned to the claimant any claim for its potential right to reimbursement, and that it had no contractual or other right to seek reimbursement from the claimant.
Based upon the findings of fact the ALJ concluded that the claimant lacked standing to assert the claim for reimbursement on behalf of Aetna. Accordingly, the ALJ dismissed the claim that the respondent insurer was liable to Aetna for the amounts it paid medical providers in excess of that required by the fee schedule. The claimant appealed and, although he has not filed a brief in support of his petition to review, the petition itself sets forth specific allegations of error. However, we disagree with the claimant's argument that the ALJ erred in concluding that the claimant lacked standing to assert Aetna's claim for reimbursement.
In general, "standing" is a doctrine of justiciability rooted both in constitutional limits on judicial power and in prudential principals of judicial restraint. City of Greenwood Village v. Petitioners for the Proposed City of Centennial, 3 P.3d 427 (Colo. 2000). Nonetheless, although judicial authority is not implicated in an agency proceeding, the requirement that a party have standing to assert a right to relief has also consistently been applied in the workers' compensation context. See American Compensation Insurance Company v. McBride, 107 P.3d 973 (Colo.App. 2004); Carlson v. Industrial Claim Appeals Office, 950 P.2d 653 (Colo.App. 1997); Bradley v. Industrial Claim Appeals Office, 841 P.2d 1071 (Colo.App. 1992); Bell v. Adams County School District No. 14, W.C. No. 4-516-837 (October 11, 2005); Gant v. Etcetra, W.C. No. 4-586-030 (September 17, 2004); Gonzales v. City of Fort Collins, W.C. No. 4-365-220 (August 5, 2004); McLaughlin-Kramer v. Capital Pacific Homes, W.C. No. 4-491-883 (June 20, 2002); Ahlstrom v. Colorado Compensation Insurance Authority, W.C. No. 4-176-876 (January 26, 1998). See also § 8-43-301(2), C.R.S. 2005 (statute that "dissatisfied" party may seek review of order that grants or denies benefits incorporates standing principle). The purpose of the standing requirement is to insure that a legitimate dispute exists, before a forum in a position to provide a remedy to party who has been legally injured. Bradley v. Industrial Claim Appeals Office, supra.
The proper inquiry regarding standing is whether the party has suffered an "injury in fact" to a legally protected interest as contemplated by constitutional or statutory provisions. Carlson v. Industrial Claim Appeals Office, 950 P.2d 663 (Colo.App. 1997). Moreover, the injury in fact must be to a legally protected interest that is concrete and particularized and "actual or imminent," and not merely "conjectural or hypothetical." Lujan v. Defenders of Wildlife, 504 U.S. 555, 112 S.Ct. 2130, 2136 (1992). There also must be a causal connection between the injury and the conduct complained of in that the injury must be "fairly . . . trace[able] to the challenged action of the defendant, and not . . . the results of the independent action of some third party not before the court. . . ." Id. Finally, it must be likely as opposed to merely "speculative" that the injury will be redressed by a favorable decision. Id. A plaintiff who is not among the injured himself but is merely a "concerned bystander," has not shown an injury in fact and has no standing. Koziara v. City of Casselberry, 392 F.2d 1302, 1305 (11th Cir. 2004).
Here, we agree with the ALJ that the claimant lacked standing to assert the rights of Aetna to be reimbursed for amounts paid in excess of the fee schedule. The claimant conceded that he did not represent Aetna, nor did that insurer assign any portion of its claim against the respondent insurer or the medical providers to the claimant. Since, as the ALJ correctly noted, the claimant is not potentially liable to Aetna for any amounts the carrier paid in excess of the fee schedule, the claimant lacks standing to assert Aetna's claim for reimbursement. Further, although we agree with the claimant that economic loss is not the only form of loss that satisfies the "injury in fact" requirement of standing, e.g., Rocky Mountain Animal Defense v. Colorado Division of Wildlife, 100 P.3d 508 (Colo.App. 2004), we disagree that the claimant's generalized interest in "proper handling" of the claim is sufficient to show a potential injury in fact. See Gant v. Etcetra, supra. (claimant lacks standing to seek penalties for defaulting employer under section 8-43-409, C.R.S. 2005). Indeed, the requirement that there be a particularized and specific "injury in fact" is inconsistent with the position that the Act confers on any particular party standing merely to "oversee" the administration of a claim.
We note in connection with the question whether the claimant is able to show an injury in fact, that his petition to review recites that he "directly paid medical providers . . ." and is therefore entitled to reimbursement for those amounts. While recognizing that a claim by a claimant for reimbursement on account of direct payments to medical providers satisfies the standing requirement, we are unable to locate any point in the record at which the claimant proved such direct payments. It is true that the claimant alleged in his Post-hearing Position Statement that the carrier made payments directly to him, at least suggesting that he in turn made direct payments to the providers. However, in our view this establishes no more than that the claimant might have been a conduit through which the payments were made. We do not understand the claimant to be arguing that he is seeking reimbursement of amounts paid in excess of the fee schedule by him or that the payments sought from the respondent insurer are intended to compensate him for money paid personally and for which he is presently out-of-pocket. The claim he asserts remains one on behalf of Aetna, and in our view the mechanism of payment does not confer standing on the claimant to assert the claim on behalf of Aetna.
We also disagree with the claimant's argument that the ALJ misallocated the burden of proof. Contrary to the claimant's argument, the burden is not on the respondents to establish the lack of standing as an affirmative defense. Rather, standing is a jurisdictional requirement that must be shown as a threshold matter. See Wimberly v. Ettenberg, 194 Colo. 163, 570 P.2d 535 (1977). Here, the ALJ did not err in requiring the claimant to show that he suffered an injury in fact in order to establish his standing to assert Aetna's claim.
We have considered the claimant's remaining arguments and they do not persuade us to reach a different result.
IT IS THEREFORE ORDERED that the ALJ's order dated February 21, 2006, is affirmed.
INDUSTRIAL CLAIM APPEALS PANEL
____________________________________ John D. Baird
____________________________________ Curt Kriksciun
Rosendo Rodriguez, Denver, CO, Ted's Plumbing Heating, Denver, CO, American Family Insurance, Schofield, WI, Chris L. Ingold, Esq., Denver, CO, (For Claimant).
Mark H. Dumm, Esq., Denver, CO, (For Respondents).