SUPERIOR COURT OF NEW JERSEY
APPELLATE DIVISION
A-6365-00T1
LOUIS PACE and DIANE PACE,
his wife,
Plaintiffs-Appellants,
v.
PAUL S. KUCHINSKY, JOHN KUCHINSKY,
Defendants-Respondents,
and
STATE FARM INSURANCE COMPANIES,
JOHN DOES 1 through 5 (gender neutral
fictitious names) and ABC CORPORATION
1 through 5 (fictitious names),
Defendants.
______________________________________
Argued November 27, 2001 - Decided
February 4, 2002
Before Judges Stern, Eichen and Lintner.
On appeal from the Superior Court of New
Jersey, Law Division, Union County, L-1912-
98.
Michael Ventura argued the cause for
appellants (Ventura, Miesowitz, Albano &
Keough, attorneys; Mr. Ventura, of counsel
and on the brief).
Robert F. Cox argued the cause for
respondents (McCreedy and Cox, attorneys; Mr.
Cox, on the brief).
The opinion of the court was delivered by
LINTNER, J.A.D.
On March 26, 1998 plaintiff, Louis Pace, and his wife DianeSee footnote 11
filed a complaint for injuries he allegedly sustained on March
29, 1996, when the vehicle he was operating was struck in the
rear by a vehicle operated by defendant Paul Kuchinsky and owned
by defendant John Kuchinsky. He appeals from an order of the Law
Division determining that the injuries to his lumbar spine were
temporary in nature, and barring damages for lumbar injuries that
accrued after April 16, 1999, as not being causally related to
the March 29 accident. We conclude that the Law Division judge
erred in applying the holding in Habick v. Liberty Mutual Fire
Ins. Co.,
320 N.J. Super. 244, certif. denied,
161 N.J. 149
(1999), to the circumstances of this case, and reverse.
We combine the relevant facts and procedural history.
Plaintiff alleges that he sustained both cervical and lumbar
injuries as a result of the accident. Plaintiffs also named his
insurer, State Farm Insurance Companies (State Farm), as a
defendant alleging that it failed to provide Personal Injury
Protection (PIP) benefits afforded by the policy of insurance
issued to plaintiff. State Farm filed its answer in October
1999. Sometime in January 1999, counsel for State Farm contacted
plaintiff's counsel and advised that State Farm had paid all
plaintiff's medical bills to date and that there was no reason to
continue maintenance of the PIP action. Accordingly, on May 5,
1999, after confirming that there were no medical bills
outstanding, plaintiff's attorney dismissed the claims against
State Farm without prejudice.
After the accident, plaintiff was treated extensively by
several doctors. He received emergency treatment at Overlook
Hospital on the day of the accident and thereafter was treated by
Dr. Julie Kawut, a chiropractor, who saw him for his head, neck
and back complaints approximately ninety-eight times between
April 1, 1996 and January 28, 1998. An MRI, performed on January
20, 1997, revealed cervical disc herniations at the C5-C6 and C6-
C7 levels. On January 31, 1997, he consulted with Dr. Michael
Sanaman, a neurologist, concerning his neck, head and shoulder
complaints. Sanaman reported that the cervical herniations were
a result of the automobile accident. A year later, on January
23, 1998, he was examined by another neurologist, Dr. Nazar
Haidri, who found that plaintiff suffered from:
(1) post-concussion syndrome
(2) post-traumatic headaches, dizziness and
blurring of vision
(3) chronic cervical dorsal and lumbar sprain
(4) symptoms consistent with bilateral
cervical and left lumbar radiculopathy
(5) findings consistent with bilateral carpal
tunnel syndrome and neuropathy at both elbows
(6) meralgia paresthetica left side
Haidri ordered various diagnostic tests, including an MRI of the
lumbar spine and a consult with a neurosurgeon.
On February 4, 1998, Dr. Daniel Schlusselberg reported to
Haidri that the MRI of plaintiff's lumbosacral spine revealed,
among other things, multi-level degenerative disc disease. On
April 13, 1998, Dr. Arthur Gilman, a neurosurgeon, reported to
Haidri that plaintiff's previous MRI studies "demonstrated a
small central disc herniation at C5-C6 without significant
impingement upon the thecal sac or nerve root exit," as well as
"congenital and acquired lumbar stenosis at L3-L4 and L4-L5
levels with "broad based disc bulge[s]" at L3-L4 and L4-L5. In
view of plaintiff's active lifestyle, Dr. Gilman advised that
surgery for plaintiff's lumbar discomfort, while possibly
relieving the symptoms, might worsen his back discomfort. He
further indicated that, if plaintiff's symptoms continued or
worsened, surgery might be reconsidered.
On May 11, 1998, following an examination, neurosurgeon Dr.
John Knightly confirmed the existence of the cervical herniations
and lumbar disc bulges found on the MRI studies and advised that
the chronic pain suffered by plaintiff was of "questionable
etiology." He recommended against surgical intervention and
suggested a physiatrist be consulted. Plaintiff was then seen by
Dr. Peter Won, a physiatrist, who found disc protrusions at C5-C6
and C6-C7, as well as disc protrusions and herniations at
multiple levels of the lumbar spine. He concluded that "the
mechanism of the injury appears to be due to whiplash injury
related to [the] motor vehicle accident," and recommended
stretching and aerobic exercises.
In August 1998, plaintiff came under the care of physiatrist
Dr. Douglas Ashendorf. According to Dr. Ashendorf, at the time
plaintiff came under his care, his office practice required that
plaintiff execute an assignment of benefits as a condition of
treatment. On August 7, 1998, plaintiff executed the assignment
of benefits form, authorizing direct payment of health insurance
benefits to Dr. Ashendorf. Plaintiff commenced a regime of
physical therapy treatments with Dr. Ashendorf. On April 9,
1999, State Farm's claim representative wrote a letter to
plaintiff, copied to plaintiff's counsel, stating the following:
Dear Louis Re: Physiatry
You recently attended an Independent Medical
Examination (IME). Attached is a copy of the
report.
In the doctor's opinion, no further treatment
is necessary as a result of your March 29,
1996 accident. We will be unable to consider
any further expenses after 4/16/99.
This decision has been based upon the
information we have received to date. If you
have any additional information or if your
medical condition should change, please
notify us immediately. (Emphasis added)
Pursuant to the assignment of benefits, Dr. Ashendorf filed
a PIP arbitration claim seeking payment of his outstanding bill
in the amount of $9651.24 from State Farm. On October 1, 1999,
in support of his claim, Ashendorf's counsel submitted several of
the doctor's progress notes and a January 7, 1999 report from Dr.
Steven G. Dorsky, who examined plaintiff at Ashendorf's request
three days earlier and found essentially that plaintiff's primary
complaints of low back pain were secondary to the accident, as
was his additional neck pain. Dorsky concluded that plaintiff
had "obvious spondylolisthesis and should continue with
rehabilitation as well as under your care." Ashendorf also
submitted a report of a CT scan performed on February 2, 1999,
pursuant to a referral by Dr. Dorsky, which showed essentially
L3-L4 bulging of the disc annulus with focal disc protrusion and
degenerative facet joint changes, L4-L5 central protrusion of
disc material with mild degenerative facet joint changes and
ligamentous thickening, and L5-S1 bilateral spondylolysis with
degenerative facet joint changes resulting in bilateral foramina
stenosis.
On October 11, 1999, State Farm's counsel filed its
arbitration submission, which included medical reports from a
neurologist, Dr. Lynne Carmickle, and Dr. Horia Schwartz, a
physiatrist. Framing the issue to be decided, State Farm stated
"at issue is the treatment that State Farm's insured, Louis Pace
received from Dr. Ashendorf on August 7, 1998 thru April 23,
1999." Dr. Carmickle's report dated May 19, 1999 covered present
complaints, past medical history, physical examination,
neurological examination, medical review and radiographs,
impressions and a summary. The summary provided a diagnosis, a
prognosis and, finally, a treatment recommendation. The
treatment recommendation concluded:
No further neurological evaluation or
treatment is needed. The patient has
received maximal benefit from therapy.
As a caveat to her treatment recommendation, Dr. Carmickle stated
the following:
The report submitted here is based on
information supplied to me by the claimant,
the findings of my examination as reported
above and all medical reports sent to my
office. If any additional information is
provided, an addendum may be required.
On the way to reaching her conclusion regarding the necessity of
treatment, Dr. Carmickle also stated the following:
The issue is raised at this time of the
medical necessity for surgery. Neuroimaging
studies of the lumbar spine reveal multi-
level degenerative changes with bilateral
spondylolysis . . .
An issue raised at this time is the question
of whether there is a causal relationship of
the patient's complaints to the motor vehicle
accident.
She then made the following diagnosis and prognosis of
plaintiff's condition based upon her examination and review of
the records and reports:
DIAGNOSIS:
1. CERVICAL MUSCLE SPRAIN RESULTING
DIRECTLY FROM THE MOTOR VEHICLE
ACCIDENT, IF THE PATIENT'S HISTORY IS
CORRECT. THERE ARE NO OBJECTIVE SIGNS
OR SYMPTOMS TO SUGGEST CERVICAL
RADICULOPATHY
2. LUMBAR MUSCLE SPRAIN RESULTING DIRECTLY
FROM THE MOTOR VEHICLE ACCIDENT, IF THE
PATIENT'S HISTORY IS CORRECT. THERE ARE
NO OBJECTIVE SIGNS OR SYMPTOMS TO
SUGGEST CLINICAL LUMBAR RADICULOPATHY AT
PRESENT.
3. MULTI LEVEL DEGENERATIVE CHANGES WITH
DISK BULGE/OSTEOPHYTE RIDGE COMPLEXES,
AS WELL AS MINIMAL SPONDYLOLISTHESIS AT
L5-S1 DEGENERATIVE IN NATURE AND
THEREFORE NOT ESTABLISHED AS BEING
CAUSALLY OR TEMPORALLY RELATED TO THE
MOTOR VEHICLE ACCIDENT.
PROGNOSIS:
Guarded. Given that the patient's subjective
complaints do not match the objective
findings on imaging studies, I would not
consider that there is a role for surgical
intervention in this patient's care. As
indicated, the findings noted in the lumbar
spine are degenerative in nature, and
therefore not established as being causally
related to the MVA.
Dr. Schwartz's report, dated May 27, 1999, likewise
mentioned whether future surgery was required and causally
related. She reported that Dr. Ashendorf's progress reports
indicated that he had discussed alternatives to surgery and
mentioned that Dr. Dorsky was either contemplating or discussing
possible surgery sometime in April 1999. Identifying the
question, Schwartz observed:
I have no indication that [plaintiff] stopped
working after the accident. There is an
implication that he is in construction. How
much degenerative arthritic conditions and
discomfort he had prior to this accident and
what kind of past history he had, I have no
information whatsoever. The fact that he
started to have increasing discomfort by 1998
and he was seen by other physicians, was
tested extensively, was found to have
spondylolisthesis as well as radiculopathy
does not surprise me. The question is
whether or not that condition was causally
related to his accident and relative to that
I do not have enough information.
I believe that Dr. Dorsky is a little bit too
fast in performing surgery. . . . Surgery
without fusion is totally not recommended.
Given the fact that this is a chronic
discomfort for approximately three years, it
is almost a foregone conclusion that it will
fail.
She concluded, after pointing out that most of Dr. Ashendorf's
treatment was afforded in 1998 and early 1999, that a further
period of time should be allowed for conservative treatment
"before anyone jumps to the conclusion" that plaintiff needs
surgery and recommended that plaintiff be given approximately six
months to determine how much benefit is received from the
treatment.
Responding to State Farm's submission, Dr. Ashendorf
submitted a copy of an August 3, 1998 report prepared for State
Farm by Dr. Nathan Zemel of Newark Orthopedic and Neurological
Rehabilitation.See footnote 22 Dr. Zemel diagnosed the following:
1. LUMBOSACRAL SPRAIN/STRAIN.
2. HNP CERVICAL SPINE, PPH.
3. CERVICAL SPRAIN/STRAIN.
If the patient's history is correct then,
there is a causal relationship between the
motor vehicle accident of 3/29/96 and the
patient's injuries. The patient has achieved
maximal medical benefit from the conservative
therapeutic regimen rendered to him. No
further treatment recommendations are
specified at this time. Recovery appears to
be complete but permanency is anticipated .
. . There are no pre-existing conditions
affecting this claimant. Claimant is not
disabled. Physical therapy started will be
palliative for the patient's subjective
complaints, but are not felt to be curative
in nature as his injury is permanent.
In reply, State Farm submitted yet another report from Dr.
Douglas D. Bradley dated September 22, 1999. Dr. Bradley noted
the MRI findings of disc herniations at two cervical levels and
degenerative disc disease at multiple lumbar levels. He opined
that plaintiff sustained cervical and lumbar sprains as a result
of the accident and that the findings of degenerative changes
were not causally related to the accident. He concluded that
there was no need for further therapy or chiropractic treatment
and, because no single pain generator had been identified,
surgery was not indicated.
The PIP arbitration was held on October 12, 1999 and the
arbitrator rendered his award on November 18, 1999, concluding in
part:
Claimant must establish causation by a
preponderance of the credible evidence.
Considering the variations in the
examinations of the physicians who were
consulted by, or who treated [plaintiff], it
is as reasonable to conclude that assignor's
back problem is the result of degenerative
changes as it is to conclude that it was
caused by the accident. Claimant has not
carried the burden of proof. Any medical
expenses incurred by assignor after April 16,
1999, the effective date of [State Farm's]
"cut-off" letter are not [State Farm's]
responsibility.
On January 26, 1999, pursuant to plaintiff's request for
modification and clarification of the award, the Arbitrator
issued a Modified Award providing:
A. Review of the testimony and evidence
produced at the arbitration hearing reveals
that services rendered by claimant to
assignor [on six dates prior to the cutoff
date] were not paid by respondent. I find
that these services were causally related to
the accident, and were reasonable and
necessary. See, Thermographic Diagnostic v.
Allstate,
125 N.J. 491 (1991). The
arbitrator previously concluded, in error,
that all services to April 16, 1998 [sic] had
been paid. The arbitrator found that
services rendered subsequent to April 16,
1999, the date included in respondent's "cut-
off" letter were not respondent's obligation.
It is implicit that the services rendered by
claimant to assignor prior to that date are
payable . . . .
B. In all other respects the Award is
affirmed.
Ultimately, plaintiff was hospitalized and Dr. Knightly
performed lumbar surgery on November 24, 1999, which involved
laminectomies at levels L3-L5 and posterolateral fusion at L3-S1,
which were stabilized with screw fixation. Cervical discectomy
and fusions at C5-C6 and C6-C7 were performed by Dr. Knightly in
March 2000. On March 22, 2000, Dr. Knightly reported that, in
his opinion, although the "degenerative changes present in both
the cervical and lumbar spine . . . predate the patient's
accident, his pain syndrome was certainly after the motor vehicle
accident." Dr. Knightly further opined that the chronic pain
syndrome which developed in both plaintiff's neck and back were
"to a reasonable degree of medical certainty a direct result of
the automobile accident." In a subsequent report, Knightly
concluded that plaintiff would have permanent difficulties with
both his lumbar and cervical spine as a result of the accident.
In a report supplied by plaintiff, dated April 24, 2000, Dr.
Allan Tiedrich, an orthopedist, concurred with Dr. Knightly's
opinion and added that although the degenerative changes to
plaintiff's spine may have been present before the accident, the
accident "clearly aggravated the degenerative changes and caused
the chronic pain syndrome." He reached his conclusion based on
the fact that plaintiff was completely pain free prior to the
accident, without any limitation in activities.
Defendant had plaintiff examined and obtained two medical
reports: one from an orthopedic surgeon, Dr. Michael Bercik, and
the other from neurologist, Dr. Allen Josephs. Dr. Bercik
concluded in his report of February 23, 1999, that plaintiff
sustained a post-cervical sprain and post-lumbosacral sprain as a
result of the accident, had reached the maximal benefit of
treatment and sustained no permanent physical impairment to
either his neck or back. In his report of April 6, 1999, Dr.
Josephs found that plaintiff, "despite multiple abnormalities
seen on his scanning, [had] . . . minimal objective findings on
examination." He reported that, although plaintiff had "multiple
disc bulging and/or herniations," which may contribute to his
present symptomatology, some are clearly pre-existing in nature.
He also found a mild degree of objective neurologic permanence
related to the accident.
In November 1999, defendant moved to dismiss plaintiff's
claim for lumbar injury. The motion sought to preclude plaintiff
from proving that his low back condition and subsequent surgery
were related to the March 29, 1996 accident. After hearing
argument on the motion, the judge scheduled a plenary hearing to
determine the scope of the previous arbitration hearing, stating
to counsel:
I want to know what happened at that
[arbitration] hearing. I want to know why
[plaintiff] went to that hearing, who
notified him of the hearing, when he was
notified of the hearing, was it an attorney
that notified him, was it someone else, who
was the attorney that notified him. After
you find out from the attorney who notified
him, was that attorney present at the
hearing. What was done at the hearing?
On January 5, 2001, a plenary hearing was held to determine
whether plaintiff had received a full and fair hearing before the
arbitrator, as well as the scope of the arbitration. The
testimony revealed that Dr. Ashendorf advised plaintiff that
Ashendorf's attorney had filed the PIP arbitration on Dr.
Ashendorf's behalf to collect the unpaid portion of his bill. On
October 12, 1999, a secretary from Dr. Ashendorf's office
telephoned plaintiff and told plaintiff that twenty-five percent
of the doctor's bill was not paid and the doctor wanted plaintiff
to testify as a witness. Following that phone call, plaintiff
called his attorney and asked if it was all right for him to
attend the arbitration. Counsel responded that "it would be okay
to go." Plaintiff's attorney did not attend the arbitration
hearing.
According to plaintiff, he was never advised "that the
outcome of the arbitration hearing could have had a potential
effect on [his] right to have a trial by jury." Plaintiff met
with Dr. Ashendorf's attorney for the first time on the day of
the arbitration. It was plaintiff's understanding that he was
"appearing at the arbitration as a witness, and not as a party."
Plaintiff testified about the lumbar injury that he contended was
caused by the accident and that he had no prior low back
problems. He also acknowledged that he was not precluded from
introducing evidence regarding his lumbar injury.
Copies of both State Farm's and Ashendorf's arbitration
submissions were presented, as was an affidavit from the attorney
who appeared for State Farm at the arbitration. State Farm's
attorney indicated in his certification that it struck him as
"unusual" that Ashendorf's counsel had actually called plaintiff
and Dr. Ashendorf as witnesses. He also stated the following:
8. After this, the [arbitrator] heard live
testimony from [plaintiff] as well as Dr.
Ashendorf. After counsel for plaintiff
conducted his direct examination, my cross-
examination focused on the two year gap in
treatment as well as plaintiff's MRI films
which revealed degenerative changes in his
low back unrelated to trauma. I questioned
both plaintiff and the doctor with respect to
this issue.
9. After I had completed my cross-
examination, I recall that the [arbitrator]
conducted somewhat lengthy examinations of
both the doctor and plaintiff as well.
At the plenary hearing, Ashendorf's arbitration counsel
testified that the issue of causation was not fully litigated and
was beyond the scope of the PIP arbitration. He indicated that
he had considerable experience and expertise in handling over 250
PIP arbitrations. He responded, "I would say no," when asked:
Based on your experience and involvement in
this matter, in your experience as an
attorney who handles other personal injury
matters, do you believe that the issue of ...
the causal relationship of [plaintiff's]
lower back injury was fully litigated at that
arbitration hearing, as if it was being
submitted to a trial by jury in a personal
injury trial?
Ashendorf's counsel stated that "[o]ne would conclude . . . that
not only myself but State Farm was raising an issue of . . .
maximum medical benefit from treatment rendered by Dr. Ashendorf,
not whether or not Plaintiff's back injury was related to the
accident." He acknowledged that although he was representing Dr.
Ashendorf, Dr. Ashendorf's rights "were derivative of the
assignment." He further acknowledged that it was not his usual
practice to have the medical provider present at an arbitration
hearing, conceding that it was a "rare" occurrence, and that
"[g]enerally on the assignment arbitrations the patients are not
testifying."
Against this backdrop, the motion judge found the following.
The court finds that the facts of this
case are similar to the facts in Habick, and
accordingly, the issues decided by the
arbitrator are binding on the plaintiff in
any subsequent trial.
. . .
Plaintiff argues that he should not be
bound by the decision of the arbitrator
because the PIP arbitration was far more
limited in scope than the issues to be
presented at trial regarding plaintiff's
lumbar injury. The court does not find this
argument persuasive. If the plaintiff makes
this argument because [he] received more
treatment to his lumbar injury subsequent to
the arbitrator's decision, then that argument
fails. Regardless of such treatment, that
information is not relevant to the issues to
be decided at trial as the arbitrator
specifically found that any lumbar injury
treatments rendered after the April 16, 1999
cut-off date were degenerative in nature
rather than causally related to the accident.
If the plaintiff makes that argument because
the lumbar injury is only one portion of the
case . . . that argument similarly fails.
Where part of an entire controversy has been
decided in arbitration and part remains for
trial, the collateral estoppel doctrine is
applicable to eliminate wasteful litigation
of issues in court that have already been
decided in arbitration. See Martin Rush,
Urology Associates, P.A. v. Kuhn, Smith, and
Harris, Inc.,
193 N.J. Super. 389 (App. Div.
1984).
. . .
[The arbitrator] specifically found that any
treatments rendered to the plaintiff
subsequent to the April 16, 1999 cut-off date
were not the responsibility of the defendant
as the need for treatment after that date was
not causally related to the accident. . . .
In our case [as in Habick] the only issue
properly before the arbitrator was whether
the defendant was responsible for treatment
rendered to the plaintiff's lumbar region
subsequent to the cut-off date. As bills
prior to that date were not in issue, neither
party had the opportunity nor the incentive
to argue whether plaintiff's lumbar injuries
which were treated without objection up until
that date were causally related to the
accident. Therefore, neither party is bound
by the arbitrator's finding that treatments
rendered to plaintiff's lumbar region prior
to the April 16, 1999 cut-off date were
causally related to the accident and neither
is collaterally estopped from litigating
medical causation for plaintiff's lumbar
injuries up to that date. Plaintiff is,
however, barred from alleging future pain and
suffering or loss of enjoyment or earning due
to the surgery to the lumbar spine which
occurred after the April 16, 1999 cut-off
date, as that issue was decided in the PIP
arbitration.
We first review the general principles governing the
application of the doctrine of collateral estoppel. Collateral
estoppel may apply if the party asserting the bar demonstrates
that: (1) the issue to be precluded is identical to the issue
decided in the first proceeding; (2) the issue was actually
litigated in the prior action, that is, there was a full and fair
opportunity to litigate the issue in the prior proceeding; (3) a
final judgment on the merits was issued in the prior proceeding;
(4) determination of the issue was essential to the prior
judgment; and (5) the party against whom issue preclusion is
asserted was a party to or in privity with a party to the prior
proceeding. In re Dawson,
136 N.J. 1, 20-21 (1994); Selective
Ins. Co. v. McAllister,
327 N.J. Super. 168, 173-74 (App. Div.
2000); Pivnick v. Beck,
326 N.J. Super. 474, 485 (App. Div.
1999), aff'd,
165 N.J. 670 (2000). Even where these requirements
are met, the doctrine, which has its roots in equity, will not be
applied when it is unfair to do so. Barker v. Brinegar, ___ N.J.
Super. ___ (App. Div. 2002); Kozlowski v. Smith,
193 N.J. Super. 672, 675 (App. Div. 1984); McAllister, supra, 327 N.J. Super. at
174; Pivnick, supra, 326 N.J. Super. at 485-86; In re Tenure
Hearing of Tanelli,
194 N.J. Super. 492, 497 (App. Div.), certif.
denied,
99 N.J. 181 (1984).
The factors favoring issue preclusion include:
"conservation of judicial resources; avoidance of repetitious
litigation; and prevention of waste, harassment, uncertainty and
inconsistency." McAllister, supra, 327 N.J. Super. at 174
(quoting Pivnick, supra, 326 N.J. Super. at 486). Those
disfavoring preclusion include: the party against whom preclusion
is sought could not have obtained review of the prior judgment;
the quality or extent of the procedures in the two actions is
different; it was not foreseeable at the time of the prior action
that the issue would arise in subsequent litigation; and the
precluded party did not have an adequate opportunity to obtain a
full and fair adjudication in the prior action. Id. (citing
Restatement (Second) of Judgments § 28 (1982)).
Applying these general principles, we are constrained to
disagree with the motion judge's reliance on Habick, supra,
320 N.J. Super. 244, because the factual circumstances here are
different than those faced in Habick and militate against issue
preclusion. In Habick the plaintiff, Rosemarie Habick, allegedly
suffered from TMJ and a right knee injury as a result of an
automobile accident with an uninsured driver. Id. at 246. Her
PIP carrier paid for treatment of her TMJ condition and approved
arthroscopic surgery for her knee. Ibid. When her treating
physician later recommended knee replacement surgery in lieu of
the arthroscopic procedure, the carrier refused based upon its
own medical examiner's report. Habick filed for PIP arbitration
seeking coverage for the right knee replacement surgery. She
also sought UM arbitration, which the UM arbitrators adjourned
pending the final outcome of the PIP arbitration. The PIP
arbitrator denied Habick's claim, finding that she had received
minor soft tissue injuries, which did not aggravate either her
pre-existing osteoarthritic knee or her continuing TMJ condition.
Id. at 246-47. Habick then filed a verified complaint in the Law
Division seeking in part to limit the scope of the arbitrator's
decision to reflect that it was without prejudice to her pending
UM claim. Id. at 247.
Applying collateral estoppel to bar relitigation of the
issue of causal relationship respecting the right knee injury in
the UM proceedings, Habick observed that the "key factor is the
opportunity to be heard fully." Id. at 255. Equitable
application of the doctrine of collateral estoppel requires not
only that the party sought to be precluded had a full opportunity
to be heard, but also had an "incentive to make a case." Id. at
255. A party sought to be precluded under the doctrine of
collateral estoppel must have his or her "day in court" on the
specific issue in question. Unless expressly waived, a full and
fair hearing requires representation by the party's own counsel,
thereby insuring presentation of the specific issue to be decided
in the very manner that the party chooses. Kozlowski, supra, 193
N.J. Super. at 675. This is especially so where the party sought
to be precluded was not the identical party in the prior
proceeding. McAndrew v. Mularchuk,
38 N.J. 156, 161 (1962).
Unlike Habick, here the real party in interest in the
preceding arbitration was Dr. Ashendorf, not plaintiff. While
Dr. Ashendorf was the assignee of plaintiff's PIP claim, his
overriding interest was the payment of his outstanding bills for
the specific treatment he rendered, not plaintiff's overall
damage claim or future need for surgery. While Rosemarie Habick
was represented by her own counsel, here plaintiff's counsel was
not present and plaintiff did not have the opportunity to present
the issues in the same way as he might have, had his interest
been fully represented by counsel. In Habick, the issues were
well defined between the parties, both of whom were the same in
each proceeding. Here, by contrast, they were not. Defendant,
who now seeks to take advantage of the determination of the PIP
arbitrator, is confronted with different issues and claims than
those asserted against State Farm, in whose favor the arbitration
decision was rendered. The parties in interest at the PIP
arbitration are not the same parties involved here. It is these
very differences that give rise to the equitable considerations
enumerated in subsection five of § 28 of the Restatement,
disfavoring preclusion.
Initially, when State Farm notified both Dr. Ashendorf and
plaintiff's attorney that it was cutting off treatment, the
letter specifically identified "Physiatry" as the subject matter
under consideration. On October 11, 1999, State Farm's
submission in response to Dr. Ashendorf's PIP claim framed the
issue as "the treatment that State Farm's insured . . . received
from Dr. Ashendorf." Although to a limited extent the medical
reports submitted by State Farm embrace the reporting doctors'
opinions concerning the need for surgery intervention and
causation, the conclusions insofar as they related to the
specific PIP claim made by Dr. Ashendorf dealt expressly with the
lack of need for further treatment and whether plaintiff received
maximal benefit from the therapy he received. When read together
with State Farm's own statement of position, one is led to the
inevitable conclusion that the scope of the arbitration was
limited to whether plaintiff received maximal benefit from the
physical therapy treatment rendered by Dr. Ashendorf for those
injuries causally related to the accident. Simply put, it was
not foreseeable that a decision on Dr. Ashendorf's limited claim
would forever preclude plaintiff from relating surgery, not yet
performed, to his pending third-party claim for pain, suffering
and permanency.
We conclude that the scope of the PIP arbitration between
Dr. Ashendorf and State Farm was limited to the doctor's claims
for payment for treatment provided. It embraced a specific
controversy between Dr. Ashendorf and State Farm, not plaintiff
and defendant. Notwithstanding the opinions reflected in the
various medical reports secured by State Farm concerning the lack
of causal relationship and non-necessity for future surgery, the
scope of the issue as presented, in light of Dr. Ashendorf's
specific claim, neither afforded plaintiff an adequate
opportunity to be heard nor an incentive to demand a full and
fair adjudication concerning his lumbar injuries and whether his
resulting surgery and disability, if any, were casually related
to the accident. We therefore reverse and remand for further
proceedings to permit plaintiff the opportunity to pursue claims
for lumbar injuries and resulting surgery.
Reversed and remanded.
Footnote: 1 1As Louis Pace suffered the injuries for which he seeks
damages, we refer to him as "plaintiff."
Footnote: 2 2State Farm had not submitted Dr. Zemel's report. It is
unknown whether Dr. Zemel's report is the one referred to in
State Farm's notice of April 16, 1999, cutting off Dr.
Ashendorf's treatment.