November 12, 2010

TO ALL INTERESTED COMPANIES

Deck v. Teasley, ___ S.W.3d ___ (Mo. Banc 2010) The plaintiff in a bodily injury case was billed by medical providers the amount of $27,991 for treatment. The actual amount paid for the treatment, by Medicare, supplemental insurance and the plaintiff was $9,904.

At trial, the court limited the evidence of medical special damages to $9,904, pursuant to Missouri statute Sec. 490.715. This statute allows the court, in a pretrial hearing, to determine the value of the medical treatment rendered. The statute also states that there is a rebuttable presumption that the dollar amount necessary to satisfy the financial obligation to the health care providers, represents the value of the medical treatment. The presumption can be rebutted by evidence introduced by the plaintiff.

At the trial, the court prevented the plaintiff from presenting evidence of the portion of her medical bills that she was not obligated to pay. The court limited her evidence of medical expenses to those that were actually paid or that the plaintiff was still obligated to pay. In an attempt to rebut the presumption provided by the statute, the plaintiff presented evidence of the amount she was actually billed for the medical services. This evidence was presented to the judge prior to the trial.

On appeal, the Missouri Supreme Court held that the trial court erred because the “presumption” – that the amount paid for the medical treatment represented the value thereof – was rebutted by the plaintiff’s evidence. The plaintiff’s evidence consisted of testimony from a hospital customer care supervisor, a reimbursement specialist for a medical clinic and a physician. This testimony was to the effect that the hospital and clinic considered the amounts billed to be customary and reasonable, rather than the amount paid by Medicare. The physician testified that Medicare does not maintain that its reimbursement rates represent the value of medical services.

Consequently, the Supreme Court held that the evidence presented was sufficient to rebut the presumption. Once rebutted, the presumption disappears and the jury gets to hear all of the evidence as to the value of the medical services. This would include both the evidence of the amount paid to the providers, as well as the amount billed.

The Supreme Court further held that the statute, Sec. 490.715, only allows the court to determine whether the presumption is rebutted and not to weigh the evidence to determine the value of the medical treatment rendered. The court came to this conclusion even though the statute states that, upon motion of any party, the court may determine the value of the medical treatment rendered.

The Supreme Court held that what the statute really means is that the court must determine only if the presumption – [that the amount paid to satisfy the financial obligation of the health care providers represents the value of the medical treatment rendered] – has been rebutted.

Also, the court held that, in determining whether the “presumption” has been rebutted, the trial court must decide whether “substantial evidence” was introduced by the plaintiff which, if true, would indicate that the value of medical treatment is in an amount different from the amount necessary to satisfy the financial obligations of the health care providers. The Supreme Court held that the evidence produced by the plaintiff in this case was sufficient to meet this standard and that the trial court erred in not ruling that the presumption had been rebutted.

Comment: The effect of this holding is to prohibit trial courts from determining the “value” of medical service rendered. Now, the court can only determine whether the “presumption” has been rebutted. If the presumption is rebutted, the plaintiff’s evidence of value, as well as the amount necessary to satisfy the financial obligation to the medical providers is admissible in evidence. To rebut the presumption, the plaintiff was allowed to present evidence from her medical providers to the effect that the amount billed was the reasonable and necessary amount. While this case involved only Medicare payments, the holding will extend to other types of medical reimbursements, including Medicaid, medical insurance and possibly, workers’ compensation payments.

If you would like to have a copy of the actual opinion, please contact us and we will be happy to forward it to you.

                                                                       
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