Title: King v. ProMedica Health Sys., Inc.

State: ohio

Issuer: Ohio Supreme Court

Document:

[Until this opinion appears in the Ohio Official Reports advance sheets, it may be cited as 
King v. ProMedica Health Sys., Inc., Slip Opinion No. 2011-Ohio-4200.] 
 
 
NOTICE 
This slip opinion is subject to formal revision before it is published in 
an advance sheet of the Ohio Official Reports.  Readers are requested 
to promptly notify the Reporter of Decisions, Supreme Court of Ohio, 
65 South Front Street, Columbus, Ohio 43215, of any typographical or 
other formal errors in the opinion, in order that corrections may be 
made before the opinion is published. 
 
SLIP OPINION NO. 2011-OHIO-4200 
KING, APPELLEE, v. PROMEDICA HEALTH SYSTEM, INC., ET AL., APPELLANTS. 
[Until this opinion appears in the Ohio Official Reports advance sheets, it 
may be cited as King v. ProMedica Health Sys., Inc.,  
Slip Opinion No. 2011-Ohio-4200.] 
Insurance — R.C. 1751.60 — Automobile insurance medical benefits — 
Coordination of multiple health-care insurance payors. 
(No. 2010-1236 — Submitted May 25, 2011 — Decided August 30, 2011.) 
APPEAL from the Court of Appeals for Lucas County, No. L-09-1282,  
2010-Ohio-2578. 
__________________ 
MCGEE BROWN, J. 
{¶ 1} Appellants, ProMedica Health System, Inc., and the Toledo 
Hospital, appeal from a decision of the Sixth District Court of Appeals finding 
that pursuant to R.C. 1751.60(A), appellants were statutorily prohibited from 
billing Virginia King’s motor vehicle insurer, Safeco Insurance Company of 
Illinois, for the medical treatment rendered to her at the Toledo Hospital. 
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{¶ 2} We are asked to decide whether R.C. 1751.60(A) prohibits a 
provider from seeking payment for medical treatment rendered to an insured 
injured in an automobile accident from the insured’s automobile insurance 
medical benefits.  R.C. 1751.60(A) states that every provider that contracts with a 
health-insuring corporation to provide health-care services to an insured shall seek 
payment solely from the corporation.  Separately, we also are asked to decide 
whether R.C. 1751.60(A) conflicts with Ohio’s law regarding the coordination of 
insurance benefits.  We hold that R.C. 1751.60(A) applies only when a health-
care provider seeks payment from an insured.  We also hold, therefore, that R.C. 
1751.60(A) does not conflict with Ohio’s law on the coordination of insurance 
benefits.  The coordination of multiple health-care insurance payors is covered 
under R.C. 3902.11 et seq. and the rules promulgated pursuant to those statutes.  
Accordingly, we reverse the judgment of the Sixth District Court of Appeals. 
Background 
{¶ 3} Appellee, Virginia King, was injured in an automobile accident on 
December 1, 2007, and was treated for her injuries at the Toledo Hospital.  King 
informed the hospital admitting staff that she was covered by Aetna Health, Inc. 
and provided her health-insurance information to them.  It is undisputed that 
appellants billed King’s automobile insurer, Safeco Insurance Company of 
Illinois, for the services rendered. 
{¶ 4} In her complaint, King alleged personal damages and sought a 
class-action suit pursuant to Civ.R. 23 on behalf of all enrollees or subscribers1 
treated within the ProMedica Health System who were covered by a health-
insuring corporation.  King raised four causes of action: breach of contract, 
violation of public policy, violation of various sections of R.C. Chapter 1345 (the 
Consumer Sales Practices Act), and conversion.  Each of these causes of action is 
                                                 
1 For purposes of this opinion, we will refer to an “enrollee” and “subscriber” as an “insured.”   
January Term, 2011 
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based on the claim that the appellants violated R.C. 1751.60(A) by billing the 
automobile insurer instead of the health-insuring corporation.  Appellants filed a 
motion to dismiss King’s complaint for failure to state a claim upon which relief 
may be granted, pursuant to Civ.R. 12(B)(6). 
{¶ 5} The trial court granted appellants’ motion to dismiss.  The court 
noted that King had not alleged that appellants sought compensation directly from 
her, the insured.  The trial court found that King’s claims, which were all based on 
a violation of R.C. 1751.60(A), failed. 
{¶ 6} King appealed, and the Sixth District Court of Appeals reversed. 
King v. ProMedica Health Sys., Inc., 6th Dist. No. L-09-1282, 2010-Ohio-2578.  
The court held that health-care providers that execute preferred-provider 
agreements with health-insuring corporations can bill only the health-insuring 
corporation subject to the agreement for covered services furnished to their 
insured and cannot bill any other potential payors. Id. at ¶ 13.  Appellants 
appealed the decision to this court.  We granted discretionary jurisdiction to 
review appellants’ second proposition of law. 126 Ohio St.3d 1597, 2010-Ohio-
4928, 935 N.E.2d 44. 
Analysis 
{¶ 7} We are asked to determine the applicability of R.C. 1751.60(A).  
Appellants argue that the sole purpose of R.C. 1751.60(A) is to protect an insured 
patient from being billed for medical services when the health-care provider has 
contracted with the patient’s health-insuring corporation to provide services to the 
corporation’s insured.  Appellants contend that the Sixth District misapplied R.C. 
1751.60(A) when that court concluded that the statute prohibited appellants from 
seeking compensation from Safeco, which provided medical benefits as King’s 
automobile insurer.  We agree. 
{¶ 8} R.C. 1751.60(A) states, “Except as provided for in divisions (E) 
and (F) of this section, every provider or health-care facility that contracts with a 
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health insuring corporation to provide health-care services to the health insuring 
corporation’s enrollees or subscribers shall seek compensation for covered 
services solely from the health insuring corporation and not, under any 
circumstances, from the enrollees or subscribers, except for approved copayments 
and deductibles.” 
{¶ 9} By its express terms, R.C. 1751.60(A) governs providers or health-
care facilities, health-insuring corporations, and a health-insuring corporation’s 
insured.  The statute is applicable only when there is a contract between a 
provider and a health-insuring corporation, and the provider seeks compensation 
for services rendered.  The legislature expressed its intent that the provider must 
seek compensation solely from the health-insuring corporation and not from the 
insured. 
{¶ 10} It is undisputed that appellants never sought compensation from 
King.  But King argues that her Safeco medical-benefit payments are an asset that 
belongs to her, and that by seeking medical-benefit payments available under the 
automobile policy, appellants essentially sought compensation from her.  King’s 
argument is unpersuasive.  Under R.C. 1751.01(G), “ ‘compensation’ means 
remuneration for the provision of health care services, determined on other than a 
fee-for-service or discounted-fee-for-service basis.”  Compensation by Safeco did 
not equate to compensation by King: by making the payment, Safeco fulfilled its 
contractual obligation to King to cover her medical costs in the event of an 
accident.  When appellants received payment, they received it from Safeco.  
Because King was not asked to make any payment for the services she  received, 
appellants did not violate R.C. 1751.60(A). 
{¶ 11} King also argues that appellants violated R.C. 1751.60(A) because 
they sought compensation from Safeco and not Aetna.  King contends that the 
statutory language, “shall seek compensation for covered services solely from the 
health insuring corporation and not, under any circumstances from the enrollee or 
January Term, 2011 
5 
 
subscribers,” means that all providers that contract with a health-insuring 
corporation relinquish their ability to seek compensation from any other parties 
and can collect payment from only the health-insuring corporation.  The Sixth 
District agreed, finding that providers that execute preferred-provider agreements 
with health-insuring corporations can bill only the health-insuring corporation 
subject to the agreement for services furnished to an insured to the exclusion of 
any and all other potential payors.  The Sixth District’s reasoning relied on its 
construction of the word “solely,” defining it to mean “to the exclusion of others.”  
King v. ProMedica, 2010-Ohio-2578, at ¶ 12.  This interpretation, however, 
cannot be reconciled with the statute. 
{¶ 12} R.C. 1751.60(A) has limited application.  The statute addresses the 
contract between a provider and a health-insuring corporation.  No other entities 
are mentioned in the statute.  The statutory language allowing a provider to 
recover “solely from the health insuring corporation and not, under any 
circumstances, from the enrollees or subscribers” relates only to this contractual 
relationship.  Here, the term “solely” does not have the meaning given to it by the 
Sixth District.  Reading the word in this manner would impermissibly render the 
phrase, “and not, under any circumstances, from the enrollees or subscribers” 
superfluous.  Rather, the word “solely” is part of a phrase that defines the context 
of the statute; it means, in this context, to the exclusion of a health-insuring 
corporation’s insured.  This reading gives full meaning to every word of the 
statute.  Read in context, the statute’s language allowing a provider to seek 
compensation from  the health-insuring corporation and not the insured is limited 
to the situation in which a health-care services contract is in place between a 
provider and a health-insuring corporation.  Therefore, we hold that R.C. 
1751.60(A) applies only when a provider seeks payment from a health-insuring 
corporation’s insured with which the provider has entered into a contract. 
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{¶ 13} King’s argument that appellants were not entitled to seek the 
medical-benefit payments is appropriately covered under R.C. 3902.11 et seq. and 
the rules promulgated pursuant to those statutes.  Ohio’s coordination-of-benefits 
laws apply when a provider seeks compensation from multiple insurers who are 
obligated to pay for health-care services rendered to an insured.  R.C. 1751.60(A) 
concerns only a health-care provider’s ability to seek compensation from a health-
insuring corporation’s insured, where the health-insuring corporation has a 
contract with the provider, and therefore does not apply to coordination of 
benefits and does not conflict with R.C. 3902.11. 
{¶ 14} Appellants did not seek compensation from King.  Thus, King fails 
to show that appellants violated R.C. 1751.60(A). 
Conclusion 
{¶ 15} Because King failed to show that appellants sought compensation 
from her, she failed to establish a violation of R.C. 1751.60(A).  Accordingly, we 
reverse the court of appeals and reinstate the trial court’s order dismissing King’s 
complaint pursuant to Civ.R. 12(B)(6). 
Judgment reversed. 
O’CONNOR, C.J., and LUNDBERG STRATTON, O’DONNELL, LANZINGER, 
and CUPP, JJ., concur. 
PFEIFER, J., dissents. 
__________________ 
PFEIFER, J., dissenting. 
{¶ 16} R.C. 1751.60(A) provides, “[E]very provider or health care facility 
that contracts with a health insuring corporation to provide health care services to 
the health insuring corporation’s enrollees or subscribers shall seek compensation 
for covered services solely from the health insuring corporation and not, under 
any circumstances, from the enrollees or subscribers, except for approved 
copayments and deductibles.” 
January Term, 2011 
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{¶ 17} “Solely” in R.C. 1751.60(A) means solely.  It does not mean 
“unless you can get paid closer to your top rate through an injured patient’s 
automobile-insurance policy.”  Applying the usual meaning to the word “solely” 
does not, as the majority posits, render the phrase “and not, under any 
circumstances, from the enrollees or subscribers” superfluous.  This is because of 
still another phrase, “except for approved copayments and deductibles.”  Read as 
a whole, R.C. 1751.60(A) requires providers that have contracted with a health-
insurance corporation to seek payment from only the health-insurance 
corporation, except for copayments and deductibles, which may be billed to 
enrollees or subscribers. 
{¶ 18} When a patient’s other insurance is not dissipated through direct 
billing by health-care providers, the patient can use that other insurance to pay 
copayments, deductibles, or for treatment options excluded from the health-
insurance corporation’s coverage.  An automobile-insurance policy that includes 
medical coverage is an asset of the patient—when a provider seeks compensation 
from that policy, it seeks compensation from the patient in violation of R.C. 
1751.60(A). 
_________________ 
Murray & Murray Co., L.P.A., John T. Murray, Leslie O. Murray, and 
Michael J. Stewart; and Mickel & Huffman and John L. Huffman, for appellees. 
Jones Day, Patrick F. McCartan, Marc L. Swartzbaugh, Douglas R. 
Cole, and Alexis J. Zouhary; and Marshall & Melhorn, L.L.C., Marshall A. 
Bennett Jr., and Jennifer J. Dawson, for appellants. 
Anspach Meeks Ellenberger, L.L.P., Garrick O. White, and Richard F. 
Ellenberger; and Barry F. Hudgin, urging reversal for amici curiae Mercy Health 
Partners and Catholic Healthcare Partners. 
Bricker and Eckler, L.L.P., Anne Marie Sferra, and Bridget Purdue 
Riddell, urging reversal for amici curiae Ohio Hospital Association, Ohio State 
SUPREME COURT OF OHIO 
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Medical Association, Ohio Osteopathic Association, and Ohio Association of 
Health Plans. 
Arthur, O’Neil, Mertz, Michel & Brown Co., L.P.A., Daniel R. Michel, 
and Jennifer N. Brown, urging affirmance for amicus curiae Ohio Association for 
Justice. 
______________________