### IN THE COURT OF APP EALS OF TENNESS EE AT NAS HVILLE A ssi gne d on Br ie fs Jun e 5, 200 7
BRI DGET T HI LL, ET AL 

### . v. NH C H EAL THC AR E/NA SHV ILLE, LLC, ET AL 

### . Appeal from the Circuit Court for D avidson County No. 03C2808 Walte r Kurtz , Judge

No. M2005- 01818-COA-R 3-CV - Filed April 30, 2008

The a dminist rators of

the estate of a w oman who died af t er being transported by ambulanc e fr om a nursing home t o a h o s p ital filed a wr ongful death suit which named the nursing home and the ambulanceserviceas def

endants. The nursing home responded wit h a motion to compel arbitration, citing a provision in the admissions agree ment which the dece dent had signed, requiring both parties to submitany disputes to a rbitration and to w aive their rights to jury trial. The trial court found the arbitration c lause to be unconsciona ble and denied the motion. The nur sing home then filed a dir ect app e a l to thi s c ou rt

pu rs ua nt t o T e nn . Co de An n. § 2 9- 5- 31 9. W e a ff irm. Tenn. R. App . P. 3 Appeal as of Right; Judgment of the Cir cuit Court Affir med
P A T R I C I A J. C O TTR ELL , J. delivere d the opinion of the court. F R ANK G. C LE MENT , J R ., J. filed a concur ring opinion. W I L L I AM B. C A IN , J., not participating.
John B. Curtis , Jr., Bruce D. Gill, C h at t an o oga, Te nnessee , for the a ppellants, NHC Hea lthcare/Nashville, LLC; and National He althcar e Corp. Joseph K. Dughman, James W. Tiller, Na s hville, Tennesse e, for the appe llees, Bridget Hill, and Janec e Wilson, as c o-administratrice s of the estate of Bar bara Hill, decea sed.
OP IN ION
I. A C ON TRA C T B E T W E E N A P AT I E NT AND A N URS I NG H O ME
Barbar a Hill was a

sixty year- old woman who suff ere d fr o m a number of se rious medical conditio n s i n cl u d i n g co n g es t i v e h ea rtfa i l u re , ch ro n i c o b s tru ct i v e p u l m o n ary disea se, coronary a rtery disease and hyperte nsion. She developed pneumonia and was admitted to the hospital. Upon her
rele ase f rom the hospital on May 28, 2003, she was ref err ed to the def

endant nur sing home, operated by defe ndant NHC He althcar e/Nashville, LLC (he reina fter “ NHC”) f or further tre atment.T he r ecor d s ho w s t he A A A an no un ced t hat aft er Januar y 1, 200 3, i t w ou l d no l on ger acc ept heal t h car e c as es 1 i n v o l v i n g i n d i v i d u al p at i en t s w i t h o u t a p o st -dis p u t e ag reem en t t o arbit rat e. T h e A H L A an n o u n ced t h at aft er J an u ary 1 , 2 0 0 4 , it “

. . . w ill o n ly a d m in ister c o n su m e r h e a lth c a re liab ili ty c la im s if a n a g re e m e n t to a rb itra te w a s e n te re d in to i n w r i t i ng af

t er t he al l eged i nj ury occurr ed. ”

A t t h e h eari n g o n t h e m o t i o n t o co m p el arbit rat i o n , t h e p l ai n t i ff s’ at t o rney ass ert ed t h at t h e l an g u a g e in 2 ques t i on on hi s c opy of t he cont r ac t w as not i n bol d t ype. The t r i al c our t ’ s or der obs er ved t hat “ [ w ] hi l e t he w ai ver of ju ry trial is se t o u t i n w h a t ap p e a rs to b e a slig h tly b la c k e r ty p e c o lo r, it is c e rta in ly n o t em p h a siz e d , n o r w a s it o ra lly
ex p l ai n e d

. ” O u r exam i n at i o n of t h e co n t ract co n fi rm s t h e t ri al co u rt ’s ob ser v at i o n s as t o t h e ap p earan ce o f t h e j u ry w ai ver l angu age. -2- At NHC, Ms. Hill was given an “Admission and F inancial Cont rac t” t o sign. Section H of the thirteen pa ge docume nt was titled “Dispute Resolution Procedur e. ” Un der its provisions, the patient or he r re prese ntative was a llowed to submit any dispute with the nursing home to mediation. In the e vent that mediation fa iled or the patient chose not to use that method of r esol ution, the aggrie ved party’s only avenueof re course was binding arbitration, to be administered by either the Americ an Ar

bitration Association (AAA ) or the A merican Hea lth Lawye rs Association (A HLA). 1
A sentence in somewhat bolder letters tha n the re st of section H stated that “[b]y a gree ing to arbitration of a ll disput es, b oth parties ar e waiving a jury trial for a ll contrac t, tort, statutory, regulatory or other

claims.” At the bottom of the section was a box with bold letters containing the 2 words, “I am in total agreem en t wi th the arbitration procedur es desc ribed a bove in Section H, including the use whe re a pplicable of t h e AA A Def ined ‘Consumer- Related Disputes.’ T he provisions of this S ection H ha ve bee n revie wed with me prior to my signature below.”
The box re fer ence d above and the contra ct itself wer e signed by Barbar a Hill, as well as by her daughter , Janec e Wilson on May 29, 2003. The nursing home repr esentative John Ho u m es sig ne d th e c on tr a c t onthefo llo wi ng day. Ms. Hi ll’ s br oth e r La rry J or da n a dd e d h is s ign a tur e to b oth the box and the c ontrac t on June 4, 2003. Mr. Jordan serve d as Ms. Hill’s attorney in fa ct under a power of attorne y and a dur able powe r of attorney for healthca re. H oweve r, the pa

rties ac knowledge that Ms. Hill was competent at the time the contra ct was execute d, so the additional signatures of Ms. W ils on a ndMr . J or da n h a ve no le ga l si gn if ic a nc e in this app e a l.
Barbar a Hill was de pendent on the c ontinuous administ ration of oxyge n when she was admitted to the nursing home, and pr esumably wa s rec eiving oxygen at the tim e s he signed the contra ct. On June 4, 2003, she was rele ased from NHC and went home to her f amily where she wa s to rec eive home health care service s. Howeve r, t he following day she was a dmitted to the hospit al once a gain, with complaints of shortness of br eath and pain in her f eet and back.

Ms. Hill was discharge d from the hospital on June 12, 2003, and w as subseque ntly readmitted to th e n u rs i n g h ome. Her treatment plan require d further continuous administration of oxygen twenty- four hours a day. Ms. Hill deve loped additional hea lth complications at the nursingT h e issu e s c u rr e n tly b e fo re th is c o u rt d o n o t in v o lv e M e d ic O n e
. A c c o rd in g ly , w h e n w e m a k e re fe re n c e to 3

“ th e d e fe n d a n t” in th is o p in io n , w e m e a n N H C H e a lth c a re o n ly

. -3- home, and on the morning of June 21, 2003, NHC c alled for the def endant Medic One ambulance serviceto transport her

to the emer gency r oom. When the Medic One emer gency me dical tec hnician ar rived at the nursing home, an NH C nurse disconne cted Ms. Hill’s oxygen. The EMT did not bring any oxygen to Ms. Hill’s r oom. A s he tra nsported her

from the third floor of the nursing home t o the ambulance, she asked f or oxygen, and then began gasping for bre ath. Oncein the ambulance , the EMT began administering oxygen to Ms. Hill, but her c ondition worsened, and the EMT began Cardiopulmonary R esuscitation. She arrived at the e merge ncy room whe re doc tors continued CPR, but wit hout succe s s. Ms. Hill was pr on ou nc e d d e a d at 11 :45 a .m.
II

. L EGA L P ROCE E DI NGS
Barbar a Hill’s childre n filed a wrongful death complaint on October 8, 2003, naming NHC a ndMe dic On e a s d e fe nd a nts

. Th e y c la ime d th a t a lth ou gh NH C’ s e mpl oy e e s k ne w that Ms . H ill 3 was oxyge n depende nt, they disconnec ted her oxygen while she was still in her room, and they fa iled to re-c onnect it despite their a war eness that the Medic One EMT did not have oxyge n to give her. They fur ther c laimed that the NHC staf f knew that the patient began having difficulty bre athing as sh e wa s b e ing tr a ns po rt e d to the a mbu la nc e wh ile sti ll on the ir pr e mis e s. Th e y c on te nd e d th a t bo th defe ndants wer e negligent in failing to ensure that t h e patient had a continuing supply of oxygen, and that as a result of that negligence“Barba ra H ill died a slow, painful, and a gonizing death that was unne cessa

ry.”
O n N o v e mb e r

1 9 , 2 0 0 3 , N H C f

i l e d a m o t i o n t o c o m p e l ar

b i tr a t i o n a n d s t a y p r o c e e din gs , acc ompanied by a me morandum of law and a copy of the Admission and Financial Contract. The parties agree d to postpone argume nt on the m otion until the completion of certain dis covery. After sever al depositions were taken, the de fendant rene wed its motion to com p el arbitration. The trial court c onducted a

hearing on the motion on June 23, 2005. At the conclusion of the hea ring, the trial court took the case under advisement. On J uly 1, 2005, the court issued a memora ndum and orde r denying the def

endant’ s motion. In its order, the court discussed in de tail the fac ts behind the exec ution of the Admission and Fin a nc ia l Co ntr a c t, anddis cus sed two re c e nt o pin ion s b y th is c ou rt wh ic h in vo lve d s imi lar f a c ts: Howell v. NHC Healthcare- Fort Sanders, Inc., 109 S.W.3d 731 (Tenn. Ct. App. 2002) and Ra ite ri v. NHC Healthcare

/Knoxville, Inc., No . E 20 0 3

- 0 0 0 6 8- CO A- R9- CV , 2 00 3 W L 2 30 94 41 3 ( Te nn . Ct

. App. Dec . 30, 2003)(no Te nn R. App. P. 1 1 application filed) . In both those ca ses, we f ound the arbitration clauses at issue we re une nforc eable beca use they we re unc onscionable. ThecourtT en n
. C o d e A n n
. § 2 9 -5-3 1 9 al l o w s a p art y t o fi l e a d i rect ap p eal t o t h e C o u rt of A p p eal s o f a t ri al co u rt ’s 4

or der de nyi ng a n a ppl i ca t i on t o c om pel a r bi t r at i on or gr ant i ng a n a ppl i ca t i on t o s t ay ar bi t r at i on, w i t hout i m pl i ca t i ng t he
r equi r em ent of

a fi nal or der i n t he ca s e as i s s et out i n Tenn. R. A pp. P. 3. -4- re a so ne d th a t th e sim ila

ri tie s be tw e e n tho se c a se s a nd the on e be fo re it c omp e lle d th e sa me re su lt. This appea l followed. 4
III
. S TANDA RD OF R EVIEW
When r uling on the appea l of a denial of a mot ion to compel arbitration, we must follow the standard of

revie w that applies to be nch trials. Spann v. Ame rican Expre ss Travel Related Serv ices Co. , 22 4 S.W .3 d 69 8, 70 6- 07 (T e nn . Ct . A pp . 2 00 6) ; Cabany v. Mayfield Rehabilitation and Special Car e Ce nte r, M2006-00594-COA- R3-CV, 2007 WL 3445550 at *3 (Tenn. Ct. App. N ov. 15, 2007) (p e tit ionto r e he ar d e nie d N ov . 2 7, 20 07 ); H u b e rt v
. T

u r n b e r r y H o m e s, LLC , No. M2 00 5- 00 95 5- CO A- R3- CV , 2 00 6 W L 2 84 34 49 , at *2 (T e nn Ct. Ap p. Oc t. 4, 20 06 ) ( no Te nn . R. App. P. 11 application filed). Under that standard, r eview of

the trial court's findings of fac t are “de novo upon the re co rd of the trial court, a ccompanied by a pr esumption of the cor rec tness of the finding unless the preponde ranc e of the evidenc e is otherwise .” Te nn. R. App. P. 13(d).
If the trial court ha s not made a spe cific f inding of fac t on a particular matter , we r eview the rec ord to determine wher e the preponde ranc e of the e vidence lies without employing a presumption of cor rec tness. Ga nz e v oo rt v . R us se ll , 9 49 S.W .2 d 2 93 , 296 (T e nn . 1 99 7) ; Ha rd c as tle v . H

ar ris , 170 S.W.3d 67, 78-79 (Te nn. Ct. App. 2004). Questions of law are likewise revie wed de novo without a p r e s u mp ti o n o f c o rr ectne ss. Johnson v. J ohnson , 3 7 S. W .3 d 8 92 , 8 94 (T e nn . 2 00 1) ; Nutt v. Cha mp ion In t'

l Co rp ., 980 S.W.2d 365, 367 (Tenn. 1998) ; Union Carbide Corp. v. Huddleston, 854 S.W .2 d 8 7, 91 (T e nn . 1 99 3) ; Hicks v . Cox , 978 S.W.2d 544, 547 (Tenn. Ct. App. 1998).
IV. I SSU ES P R ESENTED The issue in this appea l is whether the t rial court err ed in denying NHC's motion to compel arbitration. On appea l, in asserting that the trial court did e rr, NHC makes seve ral a rguments: (1) that the trial court should have applied the Federa l A rbitration Act (“ FAA”), w hich has a “potential pre- emptive ef

fec t on contrary state law;” (2) that the trial here in mist akenly r elied on two ca ses from the Ea stern Section of this court, and the rea soning of those case s was c ontrary to f eder al law be c aus e thec ou rt

app lie d a hei gh te ne d s c ru tin y to thearb itr a tio n c laus e ; ( 3) that a n a rb itr a tio n c laus e in a contra ct for m ed i ca l s ervic es is not unconscionable wher e it does not attempt to limi t the provider’ s liabilit y; (4) that ar b i t ra t i o n i tself is not oppressive, so agr eeme nts to arbitrate a re not unconsciona

ble; (5) t h at , co n sidering the fa cts of this case , the agr eeme nt here in is not unconsciona

ble and should be enfor ced; and (6) that the agreeme nt is enfor cea ble, despite the r efusa l of the a rbitration bodies re fer ence d in the agre ement to conduc t the arbitration.
The plaintiffs addre ss the issues raised by NHC, arguing that the FAA d o es n o t p re clude relianc e on the e arlier

opinions fr om this court; that the trial court had sufficie nt gr ounds in la w and evidenc e to hold that the agr eeme nt was unenf orce able; that ther e wa s a suffic ient s h o wi ng thatFor s om e w eeks , t he new er opi ni on appear ed at 200 7 W L 4 87 79 15

. H ow ever , t he s ub s t i t ut i on has now been 5

m ade , a nd t he newer opi ni on a ppea r s , a s t he onl y opi ni on, a t 2007 W L 3284669. The onl y di f f er enc es f r om t he ori gi nal l y-fi l ed op i ni on i s an addi t i on t o foot no t e 4 , n ot rel evant h er ei n, an d a c hang e i n t he pl ace m ent of t he f oo t no t es a t t h e e n d a fte r th e o rd e r o n p e tit io n to re h e a r.

W hi l e t he exa ct r el at i ons hi p bet w ee n t he cor por at e defenda nt i n O wens an d t h e co rpo rat e d efen d an t be fore 6

us i s unc l ea r , t he s i m i l ar i t i es be t w ee n t hei r na m es a nd t h e co n t ract s t hey us ed ar e obvi ous l y not t he pr oduct s of
c o in c id e n c e a lo n e . W e a lso n o te th a t t h e sa m e in d iv id u a ls a re a tto rn e y s o f re c o rd fo r th e d e fe n d a n ts in b o th c a se s. -5- arbitration would have bee n cost prohibitive fo r t h e plaintiffs; and that the ref usal of AAAand AHLA to a

rbitrate this type of dispute ma de agr eeme nt unenforc eable . The plaintiffs also argue that the ar bitration agre ement is not enfor cea ble bec ause it violates Medic are and Medic aid law.
Ou r co urts h a ve re c e ntl y c on sid e re d th e e nf or c e abil ity of

a n a gr e e me nt t o a

rb itr a te dis pu te s, which nec essarily includes a wa iver of the right t o a jury trial, in nursing home admission agre ements. While those c ases involved se vera l fac tual scena rios and raised various issues, many of the iss ues raised in this case wer e also raised in other ca ses, and most wer e re cently re solved by the Tenne ssee Supre me Court.
On Novembe r 8, 2007, the Te nnessee Supreme Court i ssued an opinion in the case of Owens v. National Health Corporat ion et al , No

. M2005-01272-SC-R11-CV, 2007 WL 3284669 (T enn. Nov. 8, 2007). Following the filing of a petition to rehea r by NHC, the Court, by o rd er entere d Fe br ua ry 7, 20 08 , g rante d inpa rt a ndde nie d i n part th e pe tit ionto r e he ar andfi le d a su bs titute opinion that modified footnote 4 of its ear lier opinion. Id. , at * 12. We will, of course , ref er to the substitut ed opinion. 5
V. T HE H OL DI NGS I N O WEN S
A ce ntral issue in Owens was whether a durable power of attorne y for he althcar e authorized an attorne y-in-fa ct to bind a nursing home resident to ar bitration and to waive her right to trial by jury. Al tho ug h that que sti on is n ot at is su e in the pr e se nt c a se , th e Sup re me Cou rt ’s pr on ou nc e me nts in Owens on oth e r i ssu e s r e latin g to thee nf or c e abil ity of

thearb itr a tio n a gr e e men t in clu ded in nursing home admission agre ements ar e dire ctly on point with the issues in t his case.
The Owens case involved allegations of m al p ra ctice a gainst a nursing home, a nd an Ad mis sio n a ndFin a nc ia l Co ntr a c t w itha n a rb itr a tio n c laus e wh os e qu ote d p ortio ns areide nti c a l to thela ng ua ge in the c on tr a c t befo re us
. W ithre ga rdto a rg ume nts pr op ou nd e d b y th e pa rt ie s in 6 O we ns th at are als o r a ise d inthec a se be fo reus , w e wi ll d isc us s mo refu lly be low theSup re me Court’s treatment of the issue of the application of fe dera l or state law. T he Court’s rulings on other issues common to both Owens and the c ase be fore us can be dealt with more summarily.
Fir st, the Cou rt , fol low ing auth ority fr om oth e r state s, he ld that th e arb itr a tio n a gr e e me nt i n thenu rs ing ho me c on tr a c t di d n ot v iol a te e ither fe de ra l law o r r e gu latio n g ov e rn ing theMe dic a id program because re quiring the patient to agre e to ar bitrate doe s not c onstitut e an additional fee or other c onsideration as a

prec ondition for admission. Owens , 2007 WL 3284669, at *9-10. The-6-

Cou rt a lso re je c te d th e plaint if

f’ s ar gu me nt that pre -d isp ute arb itr a tio n ag re e me nts in n ur sin g h ome contra cts areper se invalid as contra ry to public policy. Id ., at *10-11.
The c ontrac t in Owens included the sa me lang u ag e as the contra ct her ein stating that arbitrations of disputes would be done by the Ame rica n Arbitrat i on Association or the A merican Hea lth Lawyer s Association. Since neither of t hose organizations any longer conducts a

rbitrations of health car e claims in which the agr eeme nt to arbitrate pr e-dates the dispute, the plaintiff in Owens a sse rt e d th a t th e c on tr a c t w a s u ne nf or c e able . T he plaint if

f i n th is c a se make s thesa me arg ume nt. In Owens , the S upreme Court reje cted that argume nt on the basis t hat Tenne ssee Code A nnotated § 29-5-304 pr ovides that when an agre ed-upon a rbitrator is unavailable, the cour t may appoint an arbitrator. Id ., at *8. The Court also reje cted the plaintiff’s claim that the spec ification of the two arb itr a tio n o rg a niz a tio ns wa s a mate ri a l te rm

of the c on tr a c t r e qu iring failu reof thec on tr a c t if

tho se organiz ations are unavailable

. Id

. This court is, of cour se, bound by t he holdi ngs of the Te nnessee Supreme Court in Owens

. Consequently, we must reje ct the same argume nts put forth here in.
VI
. F E DE RAL OR S TATE L A W
NHC contends that the Fede ral Ar bitration Act gov er n s t h e arbitration provision at issue beca use of the inter sta t e n at u re of commerc e conduc ted by NHC. It further a rgues that the FAA prohibits state law treatment of agre ements to arbitrate that is unequal to or more burdensome than treatment of other types of contra cts. Acc ording to NHC, the two case s relied on by the trial court place d additional conditions on, or applied a he ightened scr utiny to, arbitration agre ements that ar e not placed on othe r contra cts. The plaintiffs he rein a

rgue that the FAA and the Tenne ssee Ar bitration Act ar e similar in the rele vant provisions, and the trial court found there was not much di ffe renc e in the application of the tw o s tatut e s. Ina ny e ve nt, bo th f e de ra l a ndstatela w a llow cou rt s to app ly s tate la w d e fe ns e s to contra ct enforce ment of arbitration provisions and to decline to enfor ce suc h a provision “upon suc h grounds as e xist at law or inequity for the revoc ation of any contra ct.” Tenn. Code Ann. § 29- 5-302; Do c tor ’s As so c ., Inc. v. Casa ro tto , 5 17 U. S. 6 81 , 6 87 (1 99 6) (h old ing that ge ne ra lly app lic able c on tr a c t de fe ns e s, inc lud ing un c on sc ion abil ity , may be app lie d to inv a lid a te arb itr a tio n a gr e e me nts wi tho ut c on tr a ve nin g th e FAA ). Th e tria l c ou rt he re in ba se d it s d e c isi on on thege ne ra lly app lic able contra ct de f

e n s e of unc onscionability. Consequently, the unequal state la w ar gument under the FAA does not apply. We find no err or in the trial court’s consideration of th e d ef ense of unconsciona

bility.
A lt h ough the def

endant in the Owens case mad e th e sam e F AA-b ased argu men t, the Sup re me Court did not resolv e t h e i s s ue, finding it unnece ssary in light of the contra ct’s choic e of la w provision. Owens , 2007 WL 3284669, at *4-5. That provision s tated “[t]his agre ement for binding arbitration shall be governed by and int erpr eted in acc ordanc e with t he laws of the State wher e the Center is license d.” The Owens court, re lying on Volt Info Scis., Inc. v . Bd

. o f T r s
. o f Leland Sta nfo rd J un ior Un iv ., 489 U.S. 468, 109 S. C t. 1248 (1989), held that pa rties to an ar

bitration a gr e e me nt a

refr e e to c ho os e to h a ve the ir a gr e e me nt g ov e rn e d by a pa rt ic ula r s tate ’s arb itr a tio n a c t.S u b se q u e n t ca se s h a v e a lso b e e n re m a n d e d fo r d e v e lo p m e n t o f th e fa c tu a l re c o rd

. See , e
. g. , Rai nes v. Nat i onal 7 H eal t h Cor

por at i on , N o
. M 2 0 0 6 -12 8 0 -C O A -R 3 -C V , 2 0 0 7 W L 4 3 2 2 0 6 3 , at * 7 -8 ( T en n
. C t

. A p p
. D ec. 6, 20 0 7 ). I n Cabany , t h i s co u rt rem an d ed fo r co n si d era t i o n o f t h e q u esti o n o f w h eth er th e p o w er o f att o rn ey w as e ffec t i v e, b u t also
n o te d th a t t h e trial c o u rt c o u ld a lso a d d re ss o n re m a n d th e iss u e o f w h e th e r th e a g re e m e n t w a s a “ c o n tra c t o f a d h e sio n .” 2007 W L 3445550, a t n. 19. -7- Acc ordingly, the Court held that the case was governe d by the Tenne ssee Unif orm Arbitration Act and not the FAA. Owens , 2007 WL 3284669, at *4-5.
The contract in the present case contains i dentical language to the choice of law provision in Owens , q uo te d a

bo ve , a nd th e defe nd a nt d oe s n ot d isp utethat it is l ic e ns e d to do bu sin e ss i n Tenne ssee. Ac cordingly, we hold that the Tenne ssee Ar bitration Act is to be applied he rein.
The holdi ngs in the Owens opinion resolve all the issues in this case exce pt one: the question of unconsc ionability.
VII. U N C ON SCI ON A BI LI TY
Like its fede ral c ounterpa rt, Tenne ssee’ s version of the U niform Arbitration Act states that “a pr ovision in a w ritten contra ct to submitto arbitration any c ontroversy the rea fter a rising betwee n thepa rt ie s is va lid , e nf

or c e ablea nd ir

re vo c able sa ve up on su c h gro un ds a s exi st at la w o r i n e qu ity for the r evocation of any contra ct.” Te nn. Code Ann. § 29-5- 302(a) . Consequently, when de te rm ini ng wh e the r the re is a va lid a gr e e me nt to a rb itr a te , c ou rt s a

pp ly g e ne ra lly app lic ablestate law governing the for m at i o n of a c ontrac t. Taylor v. Butler , 142 S.W.3d 277, 284 (Tenn. 2004)

. Ap pli c ablegr ou nd s f

or re fu sin g to e nf

or c e a c on tr a c t may in c lud e thede fe ns e s o f l a c he s, e sto pp e l, waiver , fraud, duress a nd unconsciona bility. Sp an n v . A me ric an Ex pre ss , 224 S

. W. 3 d 698, 711 (Tenn. Ct. App. 2006).
The defense of unconsc ionability was raised in Owens , but ha d been prete rmitted in the trial court by its ruling that the attorney- in-fac t did not have authority to bind t he patient to ar bitration. Consequently, the fa ctual re cord on appea l was too limit ed to allow the Supreme Court to resolve the issue of unc onscionability, which requir es an intense ly f act- driven inquiry. Owens , 2007 WL 32 84 66 9, a t *1 1. No ne the le ss, the Cou rt re c og niz e d the via bil ity of un c on sc ion abil ity a s a de fe ns e 7 to an agre ement to a

rbitrate within a nursing home service s contra ct and restated t h e w ell-known princ ipl e s:
A contra ct may be unc onscionable i f t h e p rovi sions are so one -sided that the contra cting party is denied an opportunity for a me aningful choic e. Haun v. King , 6 9 0 S. W

. 2 d 8 6 9 , 8 7 2 ( T e n n
. Ct

. A p p
. 1 9 84) (quoting Brenner v . Litt le Red Sc h. House, Ltd. , 302 N.C. 207, 274 S.E.2d 206, 210 (N.C. 1981)). In makin g that determination, a court must consider a ll the f acts and cir cumstance s of a pa rticular case
. Id

. T h e scant fa ctual re cord in this case does not disclose the c ircumstance s under w hich Danie l signed the arbitration agree ment on b eh al f of King, including wheth er t h e arbitration agree ment was off ere d on a “ta

ke it or lea ve it basis.” Buraczynsk i , 9 19 S.W .2 d at 32 0; se e ge neral ly Howellv . NH C H e althc are -F

ortI f a voi d or une n forceab l e agr ee m ent t o a r bi t r at e, i ncor por at ed i nt o a l ar ger a gr ee m ent , i s c ol l at er al t o t he 8

c o n tra c tu a l m a tter s o r n o t p a rt o f th e su b sta n c e o f th e lar g e r a g re e m e n t, it is se v e ra b le

. Tay l or , 1 4 2 S

. W

. 3 d a t 2 8 7

. An
a rb itra tio n a g re e m e n t d e a lin g o n ly w ith re m e d ie s, w h ic h is g e n e ra lly a ll th e y d e a l w ith , i s se v e ra b le

. Id. -8- S a n d ers, Inc. , 1 0 9 S. W

. 3 d 7 3 1 ( T e n n
. Ct

. A p p
. 2 0 0 3 ) ( r e v ie w in g th e tria l c ourt’s findings of fac t and holdi ng that an ar bitration provision in a nursing-home contr act was unc onscionable and there fore unenfor cea ble).
Owens , 2007 WL 3284669, at * 11.
Ar bit ratio n a gr e e me nts be tw e e n med ic a l pro vid e rs a nd patie nts areno t per se vo id a s a ga ins t public policy. Buraczynsk i v. Eyring, 919 S.W.2d 314 (Tenn. 1996) . Howeve r,

. . . in g e ne ra l, c ou rt s a

rere luc ta nt t o e nf

or c e arb itr atio n a gr e e me nts be tw e e n p a tie nts and hea lth care p ro v i d ers when the agr eeme nts are hidde n within other types of contra cts and do not af

ford the patients an opportunity to q u es t ion the terms or purpose of

the agr eemen t

. T h i s is so particularly whe n the agr eeme nts require the patient to choose be tween f oreve r wa iving the right to a trial by jury or for egoing nece ssary medic al treatment, and when the a gree ments give the hea lth care provider an unequa l advantagein the arbitration process itself.
Bu ra c zy ns k i, 919 S.W.2d at 321. The que stion of whether

a contr act pr ovision, including a provision agre eing to arbitration, 8 is unconscionable, is a

question of law. Taylor , 1 4 2 S. W

. 3 d a t 2 8 4

- 8 5

. H o w e v er, in rea ching a decision on the que stion of unc onscionability of a contr act or provision, a court must consider the circ umstances surr ounding the agre ement and its exe cution, including the setting, the purpose, a nd the eff ect. Taylor , 142 S.W.3d at 285 (quoting R ES TATEMENT (S EC OND ) O F C ONTRACT § 2 08 , c mt. a (1981) ). In the c ase be fore us, the trial court made findings of fac t, w hich we find are supported by the evidenc e. Those f indings and the holdings based there on are set out in the order : The re cord in this case indicates that the de cea sed wa s 60 year s old but that she was under some me ntal and significant physical infirmity and under pr essure of medica l circ umstances to obtain admission at the nursing home. There is no indication here that the re sident was given an explanat i o n o f the terms or the purpose of the arbitration agree ment, nor that any spe cial attention was g i ven by the a dmissions employee to the a

rbitration agr eeme nt. The dec ease d did not read the agre ement, and her daughter testified that the s ocial worker did not discuss medication, ar bitration, or wa iver of jury trial. The pr oof is that the agr eeme nt would not be alter ed by the defe ndant and that the de cea sed had to sign the agree ment as written in order to be admitted. It was “ take it or lea ve it.” The Court is further trouble d by the fa ct that the ar bit ra t i on proce ss can only be a cce ssed, ac cording to the a gree ment, by the posting of m onies by the pl aintiff in exce ss of several thousand dollar s. Furthermore, there is no explanation of how arbitration works, and the a dmissions employee w ho-9-

went over

the c o n t ra ct with Ms. Hill was not even c lear how ar bitration worked. While the waiver of jury trial is set out in what appea rs to be a slightly blacke r type color, it is certainly not emphasize d, nor was it orally explained. Ms. Hill enter ed the nursing home on May 29, 2003 and signed the a gree ment on that date. The re w as no showing of any a ctual bar gaining over the terms. The a g re em en t ca lled for arbitration to be administrated either by the Americ an Arbitrati o n Association (“A AA”) or the Ame rica n Hea lth La wyer ’s Association (“ AHLA” ). Inter estingly, the AAA ha d cea sed to do arbitration of nursing home case s January 1, 2003. The AHLA cea s ed providing t his service January 1, 2004. both organizations were c on c e rn e d a

bo ut the ‘c on tr ov e rs ia l” nat ure of r e qu iring nu rs ing ho me re sid e nts to enter into arbitration agr eeme nts. More specifica lly as re lates to this case, how ever , the AAA ha d cea sed to do arbitration of these claims six m onths prior to Ms. Hill’s entering into t h i s ag re ement. De fendant offer s no explanation as to why the AAA rema ined in the agr eeme nt when the de fendant knew or should have know n that the AAA would no longer provide an arbitrator. Since Ms. H ill is now dec ease d, it is not possible to determine what ef fec t the inclusion of the AAA ha d in any dec ision she made, but the AA A is a highly re specte d organiz ation; its i nclusion in the contrac t mig ht h a ve ha d some e ff

e c t on her wi lli ng ne ss to en te r int o an arb itr a tio n a gr e e me nt. As pointed out, the inclusion of the AAA w as inappropriate as the y had ce ased to do arbitration of these kinds of ca ses ef fec tive January 1, 2003.
The admissions c ontrac t he rein containing the arbitration pr ovision is a contrac t of adhe sion. It was a standard form contra ct draf ted by the nursing home and w as pre sented to the patient on a take -i t or le a ve -i t ba sis . Sh e c le arl y h a d n o b a rg a ini ng po wer, need e d th e c arethenu rs ing ho me offe red , an d wo u l d not have be en admitted if she did not sign. Thus, the contra ct meets the definition of an a dhesion contra ct set out in Buraczynsk i :
Ana dh e sio n c on tr a c t ha s b eende fi ne d a s “ a stand ard iz e d c on tr a c t f

orm of fe re d to consumers of

goods and services on e ssentially a ‘take it or leave it’ basis, without aff ording the consumer a rea listi c opportunity to bargain and under suc h conditions that the consumer

cannot obtain the desired pr oduct or service e xcept by a cquiesc ing to the form of the contra ct.” Professor Hende rson has observed that “the essenc e of a n a dh e sio n c on tr a c t is that the ba rg a ini ng po sit ion a ndle ve ra ge e na bleon e pa rty ‘ to selec t and control risks assumed unde r the c ontrac t.” Court s g en er al ly agre e that “[t]hedistinctive featur e of a contra ct of a d h esi on is that the weaker pa rty has no rea listi c choic e as to its terms.” Buraczynsk i, 919 S.W.2d at 320 (c itations omi tted).
Th e c on c l u s i o n t h a tt h e a d m i s s i o n s c o n tr a c th e r e i n w a s a n a d h e s i o n c o n tr a c td o e s n o t, ho we ve r, e ndtheinq uiry. Con tr a c ts of a dh e sio n are no t fa vo re d a ndmus t bec los e ly s c ru tin iz e d to determine if unconsciona ble or o p p re s sive terms ar e imposed which pr event e nforc ement of the agre ement. Id. at 316. Neve rtheless, such c ontrac ts are e nforc eable unless t h ey ar e found to be “beyond the rea sonable e xpectations of an ordinary person, or oppressive or unconsciona ble.” Id

. at 320. A contr act may befound to be une nforc eable on g ro u n d s o f unconsciona bility where the-10-

“inequa lity of the bargain is so manifest as to shock the judgm ent of a person of common sense , and wher e the terms are so oppr essive that no re asonable person would makethem on the one hand, and no honest and fair person w ould acc ep t t h em on the other.” Tay lor , 142 S.W.3d at 285 (quoting Haun , 6 90 S.W .2 d at 87 2) . “ Inde te rm ini ng wh e the r a c on tract is u nc on sc ion able , a c ou rt mus t c on sid e r a ll the fa c ts andc ir c ums ta nc e s of a p art ic ula r c a se . I f the pr ov isi on s a rethe n v ie we d a s so one-sided that the contracting party is denied any opportunity for a me aningful choic e, the c ontrac t should be found unconsc ionable.” Haun , 690 S.W.2d at 872.
The a rbitration agr eeme nts at issue in Buraczynsk i , betwee n an orthope dic surgeon and two of his patients, we reno t c on ta ine d w ith in a ho sp ita l or c lin ic a dmi ssi on c on tr a c t, b ut w e rese pa rate one-pa ge docume nts which explaine d the meaning of the agr eeme nt to arbitrate and encourage d the patient to discuss the agre ement with the doctor . The stateme nt that “by signing this contra ct you are giving up your right to a jury or court trial” wa s in capital letter red t y p e d i re ct l y above the sig natur e lin e . T he patie nts we regiv e n th e ri gh t to re vo ke thea gr e e me nt s f or a ny re a so n w ith in thirty days of their e xecution. The court found that the terms of the a gree ments did not give the doctor a n unfair a dvantage over the patient, and noted that, “ [t]he a gree ments contain no buried terms.” Buraczynsk i , 919 S.W.2d at 321.
After weighing those fa cts, the court concluded that the arbitration agree ments at issue “c an no t bec on s true d a s u nc on sc ion able , o pp re ssi ve , o r o uts idethere a so na blee xp e c tatio ns of

thepa rt ie s. As such, the a gree ments, though contrac ts of adhesion, a re e nforc ea b l e.” Id. Significant, or eve n “mos t i m p o rtant” to that c onclusion was the Court’s de termination, that “the a gree ments did not changethe doctor’ s duty to use rea sonable c are in treating patients, nor limit liability for breac h of that duty, but merely shifted the disputes to a d i ff er en t forum.” Id . Acc ordingly, the Court determined that the ar

bitration provi s i o n s i n the agr eeme nts at issue could not be construe d to be unconsciona

ble, oppre ssive, or outside the re asonable expec tations of the parties. Id

. As a re su lt, the agr eeme nts were enfor cea ble. Id.
Th e fa c ts o f the c a se be fore us dif fe r s ome wh a t f

ro m th os e su rr ou nd ing thea gr e e me nts in Buraczynsk i. Her ein, t he arbitration clause was not contained in a separ ate one -page document, but was c ontained on page s 11 and 12 of the lengthy a dmissions contra ct. It is not at all clea r that the te xt i nd ic a tin g th e patie nt’ s sur re nd e r of he r ri gh t to a jury tri a l wa s suf fi c ie ntl y d ist inc t f

ro m th e re st of the c ontrac t to alert he r to the fac t that she was giving up suc h an important right. Section 3(a ) of thearb itr a tio n c laus e state d th a t the part ies a gr e e d th a t e ith e r o f the m c ou ld i nit iate a c la im pu rs ua nt to the A AAru le s f or “ re so lut ionof

c on su me r- re late d d isp ute s” bu t th a t “ the rearelim its to the do lla

r amou nts wh ic h c a n b e arb itr a te d pur su a nt to the se ru le s. ” Th e pr ov isi on didno t e xp la in what those limit s wer e. This type of arbitration “consumer- related disputes,” is “ba sed upon written documents.” “All ot her disputes [presumably those e xcee ding the dollar limits of consumer-r elated dis pu te s a nd , p e rh aps , th os e that areno t a me na bleto re so lut ion by re vie w of do c ume nts on ly] sh a ll be arbitrated in a ccor dance with the AAA ‘Commercia l D ispute Resolution Proce dures.’ ” The pr ov i s i o n t h e n r e f

e rr e d t o t h e A A A a n d t h e A H L A w e b s i t e s f o r i n f o r m a t i o n r e g ar d i n g t h os e pr oc e du re s. Th e re is nothin g to indi c a te that th e patie nt s e e kin g a dmi ssi on to the nu rs ing ho me is giv e n a c c e ss t o a

c omp ute r andtheop po rtun it y to r e vie w tho se ru le s, e ve n if thepatie nt c ou ld anticipate w hich type of dispute might arise and, there fore , which set of r ules would apply.A l t ho ug h M s
. H i l l s i gn ed t h e b ox cont ai ni ng t he s t at em ent “[ t ] he provi s i on s of t hi s Sect i on H have been 9

r evi ew ed w i t h m e pr i or t o m y s i gn at ure bel ow , ” t here w as no evi dence t hat w as act ual l y t he cas e. H er daug ht er t es t i fi ed t hat M s
. H i l l di d no t r ead i t and t hat s he ( t he daug ht er ) onl y r ead t he f r on t pages deal i ng w i t h c ost s
. I t i s axi om at i c t hat
a par t y m ay not be a l l ow ed t o de ny a n obl i gat i on a s s um ed under a s i gned cont r ac t by s i m pl y pl ea di ng t hat s he di d not
re a d o r d id n o t u n d e rs ta n d th e c o n tra c t. P yburn v. B i l l H ear d C hevr ol et , 63 S.W

. 3 d 35 1 , 35 9 (T en n
. C t

. A p p
. 20 0 1 ); G iles v . A llsta te In su ra n c e C o ., 87 1 S. W

. 2d 15 4, 15 7 ( T enn. C t

. A pp
. 19 93 )

. N on et hel es s , t he f act s and ci r cum s t ances s ur r oundi ng t he exe cut i on of a n a gr ee m ent a r e r el eva nt t o t he ques t i on of i t s unc ons ci onabi l i t y.

-11- Whil e t h e agreement stated that any “c laim, controver sy, dispute, or disagre ement” not resolved thr ough optional mediation “shall be re solved by binding arbitration,” i t contained no e xp la natio n o f b ind ing arb itr a tio n, no r any la ng ua ge t hat wo ulde nc ou ra ge thepatie nt t o a sk questions about the proc ess. Unlike the a gree ment in Buraczynsk i , thearb itr a tio n p ro vis ionhe re in did not give the patient 30 days or any other period of time w ithin which to w ithdraw consent to the pro v is io n
. A s th e tria l c o u rt f o u n d , M s
. H il l w a s u n d e r “ s o me me n ta l a n d s ig n if ic ant physical infirmity and under pressure of medical circ umstances to obtain a dmission at the nurs i n g h ome.” As the trial court also found, there was no proof that she was given an explanation of the terms or the purpose of

the ar bitration agre ement. The trial court summed up that “f urthermor e, ther e is no e xp la natio n o f h ow arb itr a tio n w or ks , a nd the a dmi ssi on s e mpl oy e e wh o we nt ov e r the c on tr a c t w ith Ms. Hill was not even c lear how ar bitration worked.” 9
Based on the fac tual findings se t out earlier, the trial court he rein re lied on two opinions from this court, Howell v. NHC Healthcare -Fort Sanders, Inc ., 109 S.W.3d 731 (Tenn. Ct. App. 2003), and R a i t er i v. N

HC He a l thcare/Knoxville, I

nc., N o
. E 2 0 0 3

- 0 0 0 6 8

- CO A

- R9

- CV , 2003 WL 23094413 (T e nn . Ct . A pp . D e c . 3 0, 20 03 ) ( no Te nn R. Ap p. P

. 11 applic a tio n f ile d) , q uo tin g p art s o f tho se opinions in i ts final order

. The trial court held that the nursing home’s motion to compel arbitration wa s “ a ga ins t th e stand ard s se t f orth i n H ow e ll andRa iti e ri ” a ndfo un d th e a gr e e me nt t o a rb itr a te to be unenf orce able.
In Howell v. NHC Healthcare- Fo r t Sanders, Inc ., 109 S.W.3d 731, the plaintiff signed a n eleve n page nur sing home admission form on behalf of hi s wife, who had bee n discharge d from the hospital, but was too sick to return home. The ar bitration provision was “buried” on pa ge ten of the agre ement. The proof indicated that if the plainti ff had not signed the contra ct, his wife would not ha ve be e n a dmi tte d. Al tho ug h th e plaint if f c ou ld s ignhis na me , h e wa s u na bleto r e a d o r w ri te , s o a nu rs ing ho me e mpl oy e e e xp la ine d th e c on tr a c t to him

. She te sti fi e d th a t sh e e xp la ine d th e dis pu te resolution proce dure, but she a dmitted that she did not expl ai n t h at b y signing the contrac t the plaintiff was giving up his wife’ s right to a jury trial. The plaintiff te stified that he did not reme mber a ny on e us ing thete rm

arb itr a tio n, that heha d n e ve r h e ardthe te rm , that he did no t kn ow wh a t it wa s, and that it was not expla ined t o him. His daughter, who wa s prese nt at the exe cution of the d o cu m en t testified that she did not remembe r hea ring the words “ arbitration,” “mediation,” or “dispute re solution.”
Raiteri v. NHC Healthcare/Knoxv ille, Inc., 2003 WL 23094413, involved a 75 year old man sig nin g w hat app e ars to h a ve be e n th e sa me Ad mis sio n an d Fina nc ia l Contr a c t as wa s in vo lve d in the Ho we ll case so that his 77 year old wif e could be admitted to the defe ndant nursing home.W e not e t hat t he Tenne s s ee Supr em e Cour t i n B uracz yns ki hel d t hat t he agr ee m ent t o ar bi t r at e and t o w ai ve 10
t r i al by j ur y c oul d not be c ons t r ued a s “u n co n sc i onabl e, oppr es s i ve, or out s i de t he r ea s onabl e expe ct at i ons of t he par t i es
. ” B uracz yns ki , 9 1 9 S .W .2 d a t 3 2 1 . W e d o n o t b e liev e th a t t h e a g re e m e n t t o w a iv e ju ry trial, w h ic h is axi om at i cal l y a par t of an agre em ent t o ar bi t r at e di s pu t es , t r i gg er s a hi gh er burden t o s ho w t he agre em ent i s enf orce abl e. To hol d ot her w i s e w oul d vi ol at e t he FA A be ca us e t he cour t s w oul d be t r ea t i ng a r bi t r at i on a gr ee m ent s di f f er ent l y f r om o th e r ty p e s o f c o n tra c ts. See M el ena v. A nh eus er - B usc h, I nc. , 847 N

. E. 2d 99, 103- 107 ( I l l

. 2006) ( di s cus s i ng t he i s s ue “knowi ng a nd vol unt ar y w ai ver ” of a r i ght , i n t hat c as e a s t at ut or y r i ght , and t he i ncons i s t enc y of t hat s t anda r d w i t h t he FA A ). -12- Unlike M r. Howell, the husband in the Ra ite ri case could re ad, and the defe ndant’s admitting coordinat o r t es t i fi ed that he ha d rea d the agr eeme nt. She also testified that she had e xplained the agre ement to him. The proof also showed that the hus band wa s very upse t and very confuse d afte r he signed the agre ement, that he was crying, a nd that he told his stepdaughter and his son that putti ng his wife in the nursing home wa s his only choice beca use he was physically unable to ta ke ca re of her.
Th is c ou rt he ld in both ca se s tha t the a gr e e me nt wa s une nf or c e able

. W e c ite d th e dif fi c ult circ um s t an ces unde r which the contra cts wer e exe cuted, the la ck of me aningful choic e for the sig natorie s, a ndthe fa c t tha t th e arb itr a tio n p ro vis ion s w e reno t c on ta ine d ina stand -a lon e do c ume nt. In Ho we ll , this court relied upon prior authority that re quired the pa rty seeking to enf orce an arbitration agree ment to show that the parties “ actua lly bargaine d over the arbitration provision or that it was a rea sonable term considering the c ircumstance s.” Ho we ll , 109 S.W.3d at 734. The c ourt also found that since the w aiver of a jury trial must genera lly be both knowing and clea r, evide nce that the patient wa s informed that the agre ement to a rbitrate included a waiver of the right to a jury trial was important. Id

. 10
Ina re c e nt p os t- Owen case , this court held that a disputed ar bitration agre ement in a nur sing home admis sion agre ement was enfor cea ble. In Philpot v. Tennessee Health Manage ment, Inc ., No. M2006-01278-COA- R3-CV, 2007 WL 4340874 ( T en n
. C t . App. Dec . 12, 2007), the patient had been a resident at one nursing home and wished t o change to a differe nt one af ter a brief stay at the ho sp ita l. Th e patie nt’ s so n, wh o a c te d a s h e r atto rn e y- in- fa c t, c la ime d th a t it wa s u rg e nt f

or him to find a fa cility for his mother. The r ecor d showed, howe ver, that the urgency “was due in principal p art to th e p lain ti f

f ’ s d e s ir e to a tt e n d to th is matt e r d u r in g h is lu n c h b r e ak.” P h i lpot , 2007 WL 4340874 at *6.
In Philpot , the plaintiff complaine d that the complex a dmiss i o n s p ac k et he was prese nted inc lud e d many do c ume nts a ndth at he di d not r e a liz e he wa s g ivi ng up theri gh t to a jury tria l. Howeve r, the arbitration agre ement was in a sepa rate two-page document titled in large bold letter s a t th e to p o f th e p a g e “ JUR Y T RI AL WA IV ER AN D D ISP UT E R ESOLU TIO N PROCEDURE .” The jury waive r provision itself was f ound in two separate place s on the document and wa s likewise d i s played in bold ca pital letters in both places, w hile another section titled BINDING ARBITRATION in b oldle tte rs se t ou t th e c ir c ums ta nc e s u nd e r w hic h a rb itr a tio n w ou ld come into play. An e mployee of the nursing home expl ai n ed t h e admissi ons documents to the plaintiff, and t h e p l ai ntiff did not argue that the agr eeme nt was uncle ar or that he wa s not given-13-

additio nal time to rea d the agr eeme nt or to ask questions. Further, it was unc ontroverte d that the plaintiff was f

amiliar with at lea st one other nur sing home in the are a.
Ina no the r p os t- Owen decision, Reagan v . Kindred Healthcare O perating, Inc. , No. M2006- 02191-COA-R3-CV, 2007 W L 4523092 (Te nn. Ct. App. Dec. 20, 2007) (Tenn. R. A p p
. P

. 11 app lic a tio n f

ile d Fe b. 15 , 2 00 8) , th is c ou rt a lso fo un d thearb itr a tio n a gr e e me nt i n a nu rs ing ho me admissions setting was enfo r c e a b le

. Central to this holding was the determination that the arbitration agre ement wa s not a contra ct of a dhesion bec ause it wa s clea rly voluntary, and w as expla ined as vo lun tary , a ndwa s n ot a pr e re qu isi te to a dmi ssi on or se rv ic e s. Con se qu e ntl y, it wa s no t a “ take it or lea ve it” situation, and the patient “wa s not force d to choose be tween f oreve r wa iving the right to a jury trial or f

oregoing ne cessa

ry medica l treatm en t.” Reagan , 2007 WL 4523092, at *15. Furthe r, thearb itr a ti on agre e me nt w a s n ot p art of thea dmi ssi on s c on tr a c t, b ut w a s a se pa rate standalone a gree ment, clea rly marke d, and clearly defining arbitration as including the wa iver of the ri gh ts t o a

tria l ( by a

jury o r a jud ge ) a nd to a n app e a l. Th e patie nt w a s in fo rm e d th a t a ny dis pu te rega rding her c are would be settl ed through arbitration inst ead of in court and that she could re voke her a gree ment within 30 days. Id . The c ourt also found that the agre ement did not change the duties or l i ab i l ities betwee n the parties, but “mere ly shifted disputes to a differ ent forum.” Id . (citing Buraczynsk i , 919 S.W.2d at 316). Again, the f

acts in the c ase be fore us d i ff er fr om those in Philpot

and Reagan in s ome meaningful ways. Some of the fa ctors to be considere d in a determination of unconsciona bility m ay be de sc ri be d a s su bs ta nti ve , w hil e oth e rs aremor e pr oc e du ra l. Th e c on c e pt of un c on sc ion abil ity is gener al l y considere d as including both unfairne ss in contrac t formation (proc edura l unconsciona

bility) and unfairne ss in the term s of the contr act ( substantive unconsciona bility). Willia ms v. Wa l ke r-Thomas Furniture Co. , 350 F.2d 445 (D.C. Cir. 1965); E. Allan Farnsworth, F AR NS W OR TH ON C ONTRACTS § 4.28, at 555-56 (2d e d. 1998). While this court has noted that “[ i]n Tenne ss ee we h av e tende d to lump the two together” w hen def ining unconscionability, Trin ity Indus., Inc . v. Mc Kinnon Bridge Co., Inc. , 77 S.W.3d 159, 171 (Tenn. Ct. App. 2001), we find the two component desc ription helpful in analyzing this ca se. With rega

rd to s u b s t an t ive unconsc ionability, our Supreme Court has dete rmined that an agre ement to ar

bitrate, including one made in the context of t he provision of medic al servic es, is not ge ne ra lly un c on sc ion ablewh e n it s pr ov isi on s d o n ot a lte r l e ga l du tie s o r l imi t li abil iti e s a ndsimply provide a n alternative forum for the re solution of disput es. B u r a czynsk i , 919 S.W.2d at 321. Howeve r, inequa lity in t he provisio n s of such an agre ement, whe re theagre ement is an a dhesion contra ct, may re sult in a finding of uncon s ci o n ab i l ity. Taylor , 142 S.W.3d at 286 (holding unconsciona

ble and une nforc eablean ar bitration provision that allowed the de aler who dra fted the a gr e e me nt t o r e ta in j ud ic ia l r e me die s be yo nd arb itr a tio n wh ile lim iti ng thec us tom e r’ s r e me die s to tho se a va ila

bleun de r the Ar

bit ratio n Ac t)

. Th e qu e sti on is w he the r the arb itr a tio n a gr e e me nt i s unrea sonably favor able to the dr afte r of the c ontrac t. Id

. In the c ase be fore us, the fairness of the a rbitration provisions can b e q u es t i o n ed in two re ga rd s. Th e fi rs t inv olv e s the tw o typ e s of arb itr a tio n de sc ri be d in the a gr e e me nt. It is u nc le ar t o us how a c onsumer/patient would know at signing which type would apply or the conseque nces of the distinction (other than that the “ consumer- related disputes” method involves only presentationA p p a re n tly , cla im s o v e r $ 7 5 ,0 0 0 w e re to b e a rb itra te d u n d e r th e c o m m e rc ia l ru le s, in c lu d in g th e fe e sc h e d u le 11 fo r su c h c la im s . It is c e rta in ly fo re se e a b le th a t cla im s o f n e g lig e n c e in th e p ro v isio n o f m e d ic a l ca re , es p e c ia lly
w r ongful de at h c l ai m s , w oul d e xce ed $75, 000. -14- of do c ume nts ). Be c aus e it i s u nc le ar h ow thedif fe re nt typ e s o f a

rb itr a tio n w ou ld i mp act

a 11 claimant, ther efor e making it difficult for us to determine whe ther the a rbitration provisions favor thenu rs ing ho me , th e la c k of cl ari ty to a pa tie nt as ke d to sign be fo rea dmi ssi on to the fa c ili ty i s a fa c tor that is mor e pr op e rl y c on sid e re d inthepr oc e du ra l un c on sc ion abil ity a na lys is.
Th e second pro visio n r a isi ng thequ e sti on of wh e the r the arb itr a tio n p ro vis ionis unrea sonably favor able to the nursing home i s the one identified by the t rial court. Specifica lly, the tria l c ou rt wa s “ tr ou ble d by the fa c t that the arb itr a tio n pr oc e ss c a n on ly b e a c c e sse d, a c c or din g to the agr eeme nt, by the posting of monies by the plaintiff in e xcess of sever al thousand dollars.” The arb itr a tio n p ro vis ionstate s, in p e rt ine nt p art :
Th e a wa rdof c os ts o f the arb itr a tio n s ha ll b e de te rm ine d b y the a rbi tr ator in acc ordanc e with state law

. The Admini strative F ee and Arbitrator ’s compensation shall by initially advanc ed by the party reque sting arbitration, but shall be allocated on the ratio of final awa

rd to e ach party over the total a war d in the final Arbitration Orde r. In this appea l, NHC argue s that the plaintiff had the bur den of pr oving that the costs of arbitration will likely exce ed the c osts of liti gation, citing Cooper v. MRM Inve stment Co. , 367 F.3d 493 (6th Cir. 2003), and Pyburn v. B ill Heard Chevrolet , 63 S.W.3d 351, 365 (Tenn. Ct. App. 2001), and that the plaintiffs he rein did not meet that burde n. NHC asserts that there is insufficie nt proof in this record to de monstrate the pr ohibitiveness of the init i al co s t s t o acc ess the ar bitration proce dure and that the trial court erre d in relying on the evide nce pr esente d. NHC also argue s that the abil ity of the arb itr a tor to re a llo c a te c os ts a ft e r arb itr a tio n make s theagre eme nt e nf or c e able rega rdless of initial costs to the plaintiffs to acc ess ar bitration.
F e de ra l c ourt s, inc lud ingthe Un ite d St ate s Su pr e me Court , h ave r e c og nize d th at, i n s ome ty pes of c ases, a

n arbitration pr o v i s i o n m ay not be enf orce able if the costs of ar bitration are prohibiti v ely

expensive and there by

preve nt vindication of a pa rty ’s rig hts. See R osenberg v

. Bluecross Blueshield of Tennesse e , 219 S.W .3d 892, 905-909 (Tenn. Ct. App. 2007) (disc ussing the development of the l aw in the federa l courts). Th e re qu ir e me nts fo r e sta bli sh ing un e nf

or c e abil ity we r e t h e p r i m ar y s u b

j e c to f t h e d e v e l o p i n g c a s e l a w
. W h i l e t h o s e c a s e s g e n e r a l l y d e a l tw ith un de rl yin g c la ims ba sed on fe de ra l st a tut e s, be c aus e ou r c ou rt s h a ve re lie d o n s omeof tho se opinions, a brief discussion of the m is helpful.
In Gree n Tree Financial Corp. - Alabama v. R andolph , 531 U.S. 79, 121 S. Ct. 513 (2000), theUn ite d St a te s Sup re me Cou rt re c og niz e d th a t th e c os ts o f a rb itr a tio n c ou ld b e larg e e no ug h to prec lude a c laimant from enf orcing a right i n t h e arbitral forum, making such a n arbitration a gr e e me nt u ne nf

or c e able . 1 21 S. Ct . at 52 2. Ho we ve r, theCou rt he ld that “ wh e n a

pa rty s e e ks to invalidate an arbitration agre ement on the ground that arbitration would be prohibitively expe nsive,T he court al s o a dd r es s ed t he ki nd of pr oo f t hat a par t y op po s i ng ar bi t r at i on s ho ul d be re qu i r ed t o produ ce, 12
sta tin g th a t “r e q u irin g th e p la in tiff to c o m e fo rw a rd w ith c o n c re te e stim a te s o f an ticip a te d o r e x p e c te d a rb itra tio n c o sts a s ks t oo m uc h a t t hi s i ni t i a l s t a ge of t he pr oc e e di ng s
. ” Id

. a t 6 6 0

. Si m i l ar l y, t he eff ec t s or r es ul t s of a c os t

- s hi ft i ng pr ov i si o n if

the c l ai m ant i s s ucc es s ful i s a l s o t oo di f fi cul t t o pr ove at t he s t age w her e t he cl ai m ant s ee ks t o ha ve t he
a rb itra tio n p ro v isio n se t as id e
. Id.

I n t hi s a nal ys i s , t he cour t w oul d c ons i der , not t he fi nanc i al re s our ce s of an i ndi vi dual pl ai nt i f f i n de t ai l , but 13 th e re la tiv e in c o m e o f sim ilar ly situ a te d e m p lo y e e s. Id . at 6 6 5

. -15- that party bear s the burden of showing the likelihood of incurring suc h costs.” Id

. The c ourt found that th e fa c t that ag re e me nt wa s sile nt as to t he c os ts o f a

rb itr atio n w a s n ot s uf

fi c ie nt t o e sta

bli shc os t pr oh ibi tiv e ne ss a

nd tha t the re was no pr oo f that th e c os t of arb itr a tio n o f the c la im at is su e wo uld be any gr eate r than the c ost of litigation. Id. Unless a plaintiff proves that the costs of a rbitration are prohibitively high, “the ‘risk’ that [the plaintiff] w ill be saddled with prohibitive costs is too speculative to justi fy the invalidation of an arbitration agree ment.” Id.
In Morrison v. Circuit Ci ty Stores, Inc ., 31 7 F. 3d64 6 ( 6thCi r. 20 03 ), theSix th C ir c uit e xp la ine d th a t th e Sup re me Cou rt ha d ma de “ c le ar that st a tut ory righ ts .

. . ma y b e su bje c t to mandatory a

rbitration only if the ar

bi t ral for um permits the eff

ective vindication of those rights.” Id. at 658 (c iting Gi lm e r v . I nte rst ate /J oh ns on Lan e Cor

p ., 500 U.S. 20, 28, 111 S.C t. 1647 (1991)). Consequently, a cost provision that ef fec tivel y p revents vindication of a statutory right through arbitration make s the arbitration a gree ment unenfor cea ble. Id. In other w ords, the alternative to a jud ic ia l f or um, i.e. , arbitration, mustbe ac cessible a s well as ef fec tive. Id.
Th e c ou rt a do pte d a

te st f or c os t- pr oh ibi tiv e ne ss that de vi a te d f ro m a stric t c a se -b y- c a se analysis and he ld that “potential litigants must be given an opportunity, prior to arbitration on the merits, to demonstrate that the potential costs of a rbitration ar e enough to de ter them a nd simil arlysituated individuals from seeking to vin d i ca t e t h ei r fe dera l statutory rights in the arbitral for um.” Id. at 663. Essentially, the court determined that any cost provision, including one providing for cost-splitting depending on the result of the arbitration, is unenfor cea ble if it would have a “ chilling eff ect” that deter

red e nforc ement of statutory rights. Id. at 661.
In Morrison , the court a lso reitera ted that a c ourt must evaluate the likely cost of ar bitration re lativ e to the lik e ly c os ts o f l iti gatio n. Th e c ou rt fo un d th a t th e e xp e ns e s o f a rb itr a tio n o f s ome 12
c la ims , d e pe nd ing the typ e a nd a mou nt, ma y “ rang e fr om thr e e to n e arl y f if ty t ime s th e ba sic c os ts of litigation in a judicial, rathe r than a rbitral, for

um.” Id. at 669. Additionally, the court c autioned that courts should weigh the r elative c osts of litigation and arbitration “ in a rea listi c manne r” and that the comparison must be made “f rom the per spective of the potential litigant,” me aning that the court must “consider the decision-making pr ocess of these potential litigants.” Id . at 663-64. 13 Following i ts holdings i n Morrison , in Cooper v. MRM Inve stment Co. , 367 F.3d 493, the Six th Cir c uit he ld that up- fr on t cos ts mus t bec on sid e re d, be c aus e su c h c os ts a rea prima ry fa c tor in a c la imant d e c idi ng wh e the r t o p ur su e arb itr a tio n a nd , th e re fo re , p ro hib iti ve ly h ighup -f ro nt c os ts could serveto deter pote ntial claimants from pursuing their c laims. Id

. a t 51 1. Th us , u p- fr on t c os tsIn fa c t, th e S ix th C irc u it sa id th a t o n ly up fr on t cos t s shou l d be con s i dere d, and no t t he l ow er cos t t hat m ay 14

re su lt fr o m c o st-r e a lig n m e n t af te r a rb itra tio n
. Id. at 511. W e not e t hi s hol di ng i s c ont r adi ct or y t o t he hol di ng i n P yb u rn v. B i l l H ear d C hevr ol et , 63 S. W

. 3d 351, a s w i l l be di s cus s ed m or e ful l y l at er i n t hi s opi ni on.

St ut l eri nvol ved s t at e l aw cl ai m s f or ne gl i gent m i s r epr es ent at i on, br ea ch of c ont r ac t , ne gl i genc e, ne gl i gent 15 h i ri n g , an d u nj u st en ri ch m en t

. T h e co u rt h el d t h ere w as n o b asi s i n t h e FA A o r o t h erw i se for t h e fede ral dis t ri ct co u rt t o pre- em p t state l aw r egar di ng ar bi t r at i on agr eem ent s and, i n fa ct , t hat t he E rie doct r i ne prec l ud ed use of f eder al
c o m m o n law to in v a lid a te a n a rb itra tio n a g re e m e n t w h e re th e u n d e rly in g c la im s w e re b a se d in sta te law

. Id . at 3 4 7

. -16- such as those require d in the agre ements bef ore us should be c onsidered, r egar dless of the potential for later rec oupment. Wher e costs to ac cess the r emedy pr ovided in the agr eeme nt, i.e. , arbitration, 14
are so high as to likely deter pa rties from se eking re dress in t hat forum, an agre ement to waive the right to r edre ss in the c ourts is unenforc eable

. Id . (citing Morrison , 317 F.3d at 664-65). The court aff irmed the trial c ourt’s dete rmination that the up- fr ont costs in the agre ement bef ore it would dete r ma ny e mpl oy e e s f

ro m arb itr a tin g th e ir

c la ims and st ated that it ha d p re dic te d, in Morrison , that “many c ourts would regula rly find ar bitration costs too high” for certain potential litigants t o pursue vindication of their rights, rendering cost or cost-splitting provisions “unenf orce able in many, if not most, cases.” Cooper , 367 F.3d at 512 (citing Morrison , 317 F.3d at 665.) Finally, in Stutler v

. T.K. Contractors, Inc ., 44 8 F.3d 34 3 (6th Cir. 20 06 ), theSix th C ir c uit made it c lear

that its prior opinions in Morrison and Cooper , as we ll as the Supreme Court’s de cision in Randolph , wer e limited to sit uations wherethe underlying claim was base d on fede ral statute, i.e. , wher e fede rally statutorily c reated or protec ted rights w ere at stake. Id

. at 345-46. Thus, the ground for r efusing to enfor ce arbitration clauses bec ause of prohibitive costs was base d upon the conc ept that important rights created or prote cted by fede ral civil rights legislation should not be undermined by agre ements that made vindic at i o n o f t hose rights unlikely due to costs. Id . at 346. Whe re no fede rally protec ted interest is at stake, the enfor cea bility of an ar

bitration agre ement must be dec ided un de r s tate c on tr a c t de fe ns e s. Id

. 15
A re vie w o f the c a se s f

ro m Randolph through Stu tle r confirms that tho se ca ses involved claims based on f

eder al statutory rights such as c ivil rights s tatutes prohibiting employment dis c ri min a tio n. Th a t r e vie w a lso de mon str a te s th at th ef e d e r al c o u r

t s c o n sid e re d c os t pr oh ibi tiv e ne ss in this context as a sepa

rate ground, base d in fede ral statute, fo r re fu sing to enforc e an a rbitration a gr e e me nt, ind e pe nd e nt f

ro m st a te -l a w
- b a s e d

u n c o ns c ion abil ity . T he c a se be fo reus inv olv e s c la ims based in state ne gligence la w, so costs to pursue a rbitration ar e re l ev an t , i f at all, as one of the considerations in t he fa ct-ba sed inquiry as to unconsc ionability.
Tenne ssee courts have issued seve ral opinions since Stutler that de a l, in pa rt , wi th a rg ume nts that an ar bitration agre ement is not enfor cea ble bec ause it is cost prohibitive. Although only one of tho se c a se s sp e c if

ic a lly re c og niz e s th e Six th C ir c uit ’s ho ldi ng that a c ha lle ng e to the e nf

or c e abil ity of an a rbitrati o n agreement, whe n the underlying claim is not based on fede ral statute, must be determined under ge nera lly applicable state law, see Rose nberg v. Blue cross Blueshield of Tenn., Inc

. , 2 1 9 S. W

. 3 d a t 9 0 8

- 9 0 9 , a ll th r e e o f th e m t r e a t the P yb urn v. Bill Heard Chevrole t case as having established the la w of this state regarding c ost-prohibitiveness of ar bitration. Ro se nb e rg , 219 S

. W .3 d at 90 9; Cha

pm an v . H &R Bl oc k

Mo rtg ag e Cor

p
. , No

. E 2 0 0 5 -0 0 0 8 2 -C OA -R 3-CV, 2005 WL-17-

31 59 77 4, a t *8 (Te nn . Ct. App . N ov . 2 8, 20 05 ); Fl an ar y v
. Carl Gr

e go ry Do dg e of J

oh ns on City , LLC , No

. E 2 0 0 4

- 0 0 6 2 0

- CO A

- R3 CV , 2 0 0 5 W L 1 2 7 7 8 5 0 , a t * 4 ( T e n n
. Ct

. A p p
. M a y 3 1 , 2 0 05) (perm. app. denied D ec. 5, 2005)

. We do not disa gree as to Py bu rn ’s re le va nc e , but cann ot c on c lud e that it is c on tr oll ing a s to the i ssues raised in this case . First, Py bu rn ’s ho ldi ng re ga rd ing c os ts o f a

rb itr a tio n w a s e xp lic itl y based upon Gree n Tree Financial Corp.-Alabama v. Randolph , decide d by t h e Un i t ed States Supreme Court in 2000. Consequently, the Py bu rn court c onsidered the prohibitive cost argume nt as a se parate ground for

holding an arbitration agre ement unenf orce able and not as a fa ctor re levant to u nc on sc ion abil ity . A s Stutler later clarifie d, that independe nt ground does not apply whe re the underlying cla im is notbased on a right cre ated or

protec ted by fe dera l statute. Because the Py bu rn court did not exa mine cost provisions of an a rbitration agr eeme nt u s i n g t he standa rds for un c on sc ion abil ity , it s c o n c l u s i o n s o ns u c hpr ov isi on s a reno t de te rm inativ e in an a na lys is u sin g th os e stand ard s. Second, Py bu rn , issued in 2001, was de cided be fore the Sixth C ircuit’s holdings in Morrison and Cooper . Consequently, it did not t ake into conside ration t h e d evelopment in the f eder al law rega rding costs of arbitration as a deter rent to pursuing a claim. There fore , we do not conside r as bin din g, a s th e fi na l st a te me nt o f T e nn e sse e la w o n th e qu e sti on , o r a s d e te rm inativ e to the c a se befor e us, some of the Py bu rn conclusions re garding c osts i n arbitration provisions. We do not disagreethat the party seeking to invalidate an arbitration agre ement on the gr ound that the costs ar e too great has t he burden of proving such costs. Py bu rn , 63 S.W.3d at 363. We a lso do not disagree that the costs of arbitration should be c ompare d to the costs of litigation, Id. , be c aus e a n e nf or c e able a gr e e me nt t o a

rb itr a te su bs titute s th a t fo ru m f or thejud ic ia l f

or um o the rw ise a va ila

bleto a c la imant. Howeve r, we disagreethat a provision that allows costs to be shifted to the draf ter of the a

rbitration agre ement if that pa

rty loses in the arbitration makes the agr eeme nt enforc eable

. Id. Instead, w e believethat up-fr o n t co s t s should be consider ed bec ause the arbitration a gr e e me nt m a y u nr e a so na bly favo r the dr a ft e r of the a gr e e me nt sin c e su c h hig h up -f ro nt c os ts w ill deter the pursuit of cla i m s
. T h i s is particularly true when the up- front costs of a rbitration ar e disproportionately high compar ed to the initial costs of institut ing liti gation. In such c ases, the draf ter of the agre ement st ands t o avoid l itigation, beca use t he other party has a gree d not to pursue it, and to avoid arbitration, because the costs ar e so high a s to pr ohibit many claimants from pursuing a re me dy in that for

um. Th us , w e c on c lud e that a n a gr e e me nt t o a rb itr a te that pl a c e s e xc e ssi ve c os ts on the claimant a s a pre condition to arbitration may be unc onscionable because of the inequality of the bar gain, the oppre ssiveness of the terms, or the one- sided adva ntage to the dr afte r. Consequently, the costs to initiate or pursue arbitration of t he wr ongful death claim in the case befor e us is a fac tor to be consider ed in determining whether the a gree ment to arbitrate is enforc eable

. NHC’s ar gument that the proof in this rec ord is insufficient is base d upon the fa ct that the plaintiffs’ proof rega

rding initial cost relied upon the rules and fee schedules of AAA and AHLA. Since the proof also established that neither of those entities would conduct the type of ar bitrationN H C ’s b rie f a sse rts th a t th e trial c o u rt “ e rr e d in re ly in g u p o n th e P la in tiffs’ e v id e n c e o f c o sts re la te d to 16

a rb itra tio n a s b e in g p ro h ib iti v e ly e x p e n siv e c o n sid e rin g th e u n a v a ilab ili ty o f th e fo ru m s c ited fo r p ro o f.”

A ddi ng t o t he unce r t ai nt y i n t hi s c as e i s t he f ac t t hat no ot her a r bi t r at or or e nt i t y ha s be en i dent i fi ed. 17
-18- inv olv e d h e re in, NH C a sse rt s that c os ts tie d to the m we re no t r e le va nt. W e areun c on vin c e d b y th is 16 argume nt. At the time the admissions agree ment was a cce pted by the patient, NHC intended that thesc he du le s o f A AAor

AH LAwo uldapp ly. As the dr a ft e r of thea gr e e me nt, a ndpr e su ma bly wi th su pe ri or kn ow le dg e a s to t he arb itr a tio n p ro vis ion s, NH C c a nn ot d e ny there le va nc y o f the c os ts identifi ed by it in the agre ement. See M orrison , 317 F.3d at 676-77 (stating that “[b] eca use the employer dr afte d the agr eeme nt, the employer is saddled with the conseque nces of the provision as drafted ”). Further, we agre e with the Morrison court’s discussion of t he type of proof a s to projected costs that a potenti al l itigant can off er at this early stage of

a dispute. Proof of c osts calculate d

17
acc ording to the agre ement that NHC i s t ry i n g to enforc e is rele vant and is suffic ient to raise the issue of cost prohibitiveness, particula rly when the re w as no proof that these c osts were higher than or significantly diffe rent fr om costs of arbitration by other entities. The proof shows that the likely costs to simpl y initiate an ar bitration under the a gree ment are ve ry hig h, pe rh aps re a c hin g $18 ,0 00

. W e , like the tria l cou rt , fin d this tr ou bli ng
. Th e c os t to ini tiate litigation would be cons i d er ably less. The a rbitration agr eeme nt, an adhe sion contrac t, is of a distinct benefit to its drafter , NHC, if i ts cost provisions serve to deter claims. A party who has bee n da ma ge d by th e a c t i o n s o f N H C c a n n o ts e e k

r e d r e s s i n t h e c o u rt s i f

t h e ar b i tr a t i o n a g r e e m e n tis enfor ced, but may, dueto expense that would not a ccompany the initiation of litigation, be prec luded from see king relief in the arbitra l f orum. We do not disa gree that a party who was f ully informed of the potential c osts, having weighed a ll the risks and bene fits, may agre e to ar bitrate disputes, as many businesses havedone. Howe ver, in the situation where the a rbitration agr eeme nt is a contrac t of a dh e sio n a nd the re is no pr oo f that th e c la imant h a d a ny inf ormatio n u po n w hic h to make a fu lly inf orme d c ho ic e , o r that a ny oth e r m e a nin gf ul c ho ic e wa s a va ila

ble , b e ne fi t to the dr a ft e r c a lls int o qu e sti on thee nf

or c e me nt o f the a gr e e me nt.
As to the qu e sti on of

pr oc e du ra l un c on sc ion abil ity , s omeof thec ir c ums ta nce s r e le va nt t o determini n g wh et h er an agr eeme nt is a contrac t of adhe sion are a lso relevant to the question of whether the agr eeme nt was fairly entere d into. In addition, the prominence an d cl arity of the questioned provision should be consider ed. In the case befor e us, the a gree ment to arbitrate and waive the right to judicial determination of a ny dispute was contained within a multi-page a gree ment for a dmission t o the nursing home, unlike ca ses wher e the a rbitration agr eeme nt was a se p ar at e, clea rly identified docume nt. The provision in the case before us did not explain arbitration in any detail, and no suc h explanation was otherwise offe red. Theprovisions are le ss than clea r in sever al pa rt ic ula rs , a ndc e rt a inl y d id n ot p la c e a pat ien t on no tic e that la rg e fe e s mi gh t bere qu ir e d a s a prer equisite to pursuing any cla im against the nursing home.
In this case , the patient wa s discharge d from the hospit al but was not we ll enough to return home, and he r nee d for nursing home service s was immediate. Multipl e serious medica l conditions made h e r o x y g e n
- d e p e n d e n t. M r
. H o u me s te s ti f ie d th a t M s
. H il l w o u ld n o t h a v e a d mi tte d to the-19-

nursing home if she did not sign everywher e the c ontrac t require d. Ms. Hi l l lacke d bargaining power . Neither

Ms. Hill nor her childre n wer e given time af ter a dmission to seek c larification of the arbitration provision, such as determining the amount of up-front c osts, or to later re voke agr eeme nt to the arbitration provision.
As se t ou t e arl ie r, the qu e sti on of un c on sc ion abil ity re qu ir e s c ou rt s to c on sid e r a ll the fa c ts relating to a contrac t’s p u rp o s e an d effect a s well as to the setting in which it was signed. One particula r fa ct may not be the de terminative fa ctor; instead , i t i s t h e overa ll sit uation that must be considere d. Under

all the fa cts and c ircumstance s of this case, w e agr ee w ith the t rial court that the arbitration provision was unconscionable and should not be enf orce d.-20- VI II.
The orde r of the trial court is af firmed. W e re mand this case to the Circuit Court of Davidson County for any further proc eedings ne cessa ry. Tax the cost s o n appeal to the appellants, NH C Hea lthcare/Nashville, LLC and National Healthca re Corp.

____________________________________ PATRICIA J. COTTRELL, JUDGE