Title: Edith C. Deck, Appellant vs. Delmar Teasley, Respondent.
Citation: N/A
Docket Number: SC90628
State: Missouri
Issuer: Missouri Supreme Court
Date: October 26, 2010

SUPREME COURT OF MISSOURI 
en banc 
 
 
EDITH C. DECK,  
 
 
) 
 
 
 
 
 
 
) 
Appellant, 
 
 
 
) 
 
 
 
 
 
 
) 
 
 
 
 
 
 
) 
v. 
 
 
 
 
 
) 
No. SC90628 
 
 
 
 
 
 
) 
DELMAR TEASLEY, 
 
 
) 
 
 
 
 
 
 
) 
Respondent.  
 
 
) 
 
 
 
 
 
 
) 
 
 
 
 
 
 
 
APPEAL FROM THE CIRCUIT COURT OF GREENE COUNTY 
The Honorable Michael J. Cordonnier, Judge 
 
Opinion issued October 26, 2010 
 
Edith Deck appeals a jury verdict entered in her favor and against Delmar Teasley 
in a negligence action arising out of an automobile collision.  On appeal, Ms. Deck 
argues the trial court erred in limiting evidence of the value of the medical treatment she 
received to the amount actually paid for the treatment, rather than the amount she was 
billed.  She argues her evidence, that the value of her medical treatment was the amount 
billed by her health care providers, was sufficient to rebut the presumption in section 
490.7151 that the dollar amount necessary to satisfy the obligation to her health care 
providers constituted the value of her medical treatment.  She also claims that if section 
                                             
 
1 Unless otherwise noted, all statutory references are to RSMo Supp. 2009.  
490.715 permits the trial court to make factual determinations as to damages, the statute 
violates her right to trial by jury guaranteed by the Missouri Constitution.  Ms. Deck 
further claims the trial court erred by excluding expert testimony regarding the costs of 
possible future medical treatment on the basis that such costs were speculative.  Because 
the trial court misapplied the law in finding that Ms. Deck did not rebut the statutory 
presumption and in ruling inadmissible her evidence that the value of the medical 
treatment she received was the amount she was billed by her health care providers, the 
portion of the trial court’s judgment assessing the amount of Ms. Deck’s damages is 
reversed.  Accordingly, the cause is remanded for a new trial on the issue of damages 
only.  In all other respects, the judgment is affirmed.      
Factual and Procedural Background 
In May 2003, Delmar Teasley drove his vehicle into the back of a line of vehicles 
stopped at a traffic signal, causing the vehicle behind Edith Deck to collide with her 
vehicle.  Ms. Deck sustained injuries in the collision and underwent surgery, physical 
therapy and follow-up care.  Ms. Deck was billed $27,991.30 for her treatment.  The 
amount actually paid for the treatment after adjustments was $9,904.28.  Payments were 
made by Medicare, supplemental insurance and Ms. Deck, with most of the expenses 
being paid by Medicare.  
Ms. Deck filed the present suit against Mr. Teasley, alleging that he was negligent 
in causing the collision and her resulting injuries.  In her petition, Ms. Deck sought 
damages for past medical expenses.  Before trial, Mr. Teasley filed a motion to determine 
the value of medical treatment rendered pursuant to section 490.715.5.  The motion 
 
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asserted that the dollar amount necessary to satisfy Ms. Deck’s obligations to her health 
care providers was the amount actually paid to those providers.   
The legislature amended section 490.715.5 in 2005 to limit the evidence litigants 
could introduce regarding the value of medical treatment rendered to an injured party.  
The legislation created a rebuttable presumption that the dollar amount necessary to 
satisfy a plaintiff’s financial obligation to his or her health care provider constituted the 
value of the medical treatment rendered.  Section 490.715.5(1).  The amendment also 
created a non-exclusive list of factors to be considered in determining the value of 
medical treatment rendered.  Section 490.715.5(2)(a)-(c).  In response to Mr. Teasley’s 
motion, Ms. Deck filed suggestions in opposition arguing, inter alia, that the amount 
charged in her medical bills represented the value of her medical treatment.   
At a hearing on the motion, three witnesses testified concerning the value of Ms. 
Deck’s treatment.  The testimony included an offer of proof by Ms. Deck that the amount 
billed by a health care provider is a better indicator of the value of the medical treatment 
rendered than the amount reimbursed by Medicare.  At the conclusion of the offer of 
proof and after hearing the arguments of counsel, the trial court found that the 
presumption in section 490.715 was not rebutted and determined that the value of 
medical treatment rendered to Ms. Deck was the amount actually paid for Ms. Deck’s 
medical treatment, together with any amount she still was obligated to pay.   
At the jury trial of Ms. Deck’s negligence claim, the court precluded Ms. Deck 
from presenting evidence of unpaid medical expenses she was not obligated to pay and 
limited her to presenting evidence of her medical expenses that actually were paid or that 
 
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she still was obligated to pay.  During trial, Ms. Deck made an offer of proof regarding 
the value of her medical expenses, again attempting to rebut the presumption of value 
under section 490.715.   At the conclusion of this offer of proof, the trial court again ruled 
that Ms. Deck could not present evidence to the jury of her medical bills that had not 
been paid by her or on her behalf. 
At the close of all the evidence, the jury rendered a verdict in favor of Ms. Deck 
and assessed damages in the amount of $42,500.  Ms. Deck appeals.  This Court has 
exclusive jurisdiction of her appeal because she challenges the validity of section 
490.715.  MO. CONST. art. V, sec. 3. 
Statutory Presumption Rebutted 
On appeal, Ms. Deck first asserts that the trial court erred in ruling her claim for 
past medical expenses was limited to the amount actually paid for the treatment she 
received.  She claims she rebutted the presumption in section 490.715.5 – that the dollar 
amount necessary to satisfy the financial obligation to her health care providers 
constituted the value of her medical treatment – by presenting evidence that the value of 
her medical treatment was the amount billed rather than the amount paid.  Ms. Deck 
argues that on rebutting the presumption, she was entitled to introduce evidence to the 
jury of her total medical bills. 
The statute at issue in this case, section 490.715, codifies the common law 
collateral source rule and modifies it in certain respects.  The common law collateral 
source rule is an exception to the rule that tort damages are only compensatory.  Smith v. 
Shaw, 159 S.W.3d 830, 832 (Mo. banc 2005).  Specifically, the rule prevents a tortfeasor 
 
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from reducing his or her liability to a plaintiff by proving that payments were made to the 
plaintiff by a collateral source. Id.  Subsection 2 of section 490.715 permits a defendant 
who personally has, or by an insurer or representative, paid all or any part of a plaintiff’s 
special damages to introduce evidence that someone other than the plaintiff paid the 
amount, but the defendant cannot identify any source of the payment.  Section 490.715.2.  
A defendant who elects to introduce such evidence waives the right to a credit against a 
judgment as authorized by section 490.710.  Section 490.715.3.   
Subsection 5 of section 490.715, newly enacted in 2005, governs the admissibility 
of evidence regarding a specific type of damages, the value of medical treatment rendered 
to a party.  It provides that evidence of the dollar amount necessary to satisfy the 
financial obligation to health care providers is admissible at trial and creates the 
rebuttable presumption that such amount represents the value of the medical treatment 
rendered.  On the motion of any party, the court may determine whether other evidence 
of value is admissible at trial and delineates that the other evidence may include, but is 
not limited to:  the medical bills incurred; the amount actually paid for the medical 
treatment; or the amount or estimate of the amount not paid that such party is obligated to 
pay in the event of a recovery.  Finally, subsection 5 provides that, no matter what 
evidence is admissible at trial, that evidence shall not identify any person who paid for 
the medical treatment.  Subsection 5 reads:    
(1) Parties may introduce evidence of the value of the medical treatment 
rendered to a party that was reasonable, necessary, and a proximate result 
of the negligence of any party. 
 
(2) In determining the value of the medical treatment rendered, there shall 
be a rebuttable presumption that the dollar amount necessary to satisfy the 
 
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financial obligation to the health care provider represents the value of the 
medical treatment rendered. Upon motion of any party, the court may 
determine, outside the hearing of the jury, the value of the medical 
treatment rendered based upon additional evidence, including but not 
limited to: 
 
(a) The medical bills incurred by a party; 
 
(b) The amount actually paid for medical treatment rendered to a 
party; 
 
(c) The amount or estimate of the amount of medical bills not paid 
which such party is obligated to pay to any entity in the event of a 
recovery. 
 
Notwithstanding the foregoing, no evidence of collateral sources shall be 
made known to the jury in presenting the evidence of the value of the 
medical treatment rendered. 
 
Section 490.715. 
The rebuttable presumption created by section 490.715.5 is that the dollar amount 
paid to satisfy the financial obligation to the health care providers is the value of the 
medical treatment rendered.  The effect of that presumption is governed by the general 
law of presumptions.  A presumption places the burden of producing substantial evidence 
to rebut the presumed fact on the party against whom the presumption operates.  
Terminal Warehouses of St. Joseph, Inc. v. Reiners, 371 S.W.2d 311, 316 (Mo. 1963).  
When substantial evidence is produced rebutting the presumed fact, the case is decided 
on the basis of the evidence as if no presumption existed.  Duff v. St. Louis Mining & 
Miling Corp., 255 S.W.2d 792, 793-94 (Mo. banc 1953).  In other words, when a 
presumption is rebutted, it disappears from the case and the fact-finder receives the issue 
free from any presumption.  Reiners, 371 S.W.2d at 316.  However, the facts that gave 
rise to the presumption remain in the case and along with the facts to the contrary, are 
 
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considered by the fact-finder like any other evidence.  Id. at 316-17 (citing Michler v. 
Krey Packing Co., 253 S.W.2d 136, 140 (Mo. banc 1952)).   
To decide whether a presumption is rebutted, “[t]he trial judge need only 
determine that the evidence introduced in rebuttal is sufficient to support a finding 
contrary to the presumed fact.”  2 MCCORMICK ON EVIDENCE § 344 (Kenneth S. Broun et 
al. eds., 6th ed. 2006).  In Missouri, the quantum of proof generally required to rebut a 
presumption is “substantial evidence.”  See Reiners, 371 S.W.2d at 316; see also Wills v. 
Townes Cadillac-Oldsmobile, 490 S.W.2d 257, 260 (Mo. 1973).  In the context of 
presumptions, this Court has held that “substantial evidence” is “‘evidence which, if true, 
has probative force upon the issues, i.e., evidence favoring facts which are such that 
reasonable men may differ as to whether it establishes them . . . .’”  Reiners, 371 S.W.2d 
at 317 (internal citations omitted). 
The rebuttable presumption in section 490.715.5 requires the trial court to 
determine if the party seeking to rebut the presumption has presented substantial evidence 
that the value of medical treatment rendered is an amount different from the dollar 
amount necessary to satisfy the financial obligations to health care providers.  If such 
substantial evidence is proffered, the statutory presumption is rebutted.  When the 
presumption is rebutted, the party’s other evidence of value, as well as the amount 
necessary to satisfy the financial obligations, is admitted at trial as if no presumption 
exists.   If the presumption is not rebutted, then the only evidence of the value of medical 
treatment rendered is the dollar amount necessary to satisfy the financial obligation to the 
health care providers. 
 
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In the pretrial hearing on Mr. Teasley’s motion to determine the value of medical 
treatment rendered to Ms. Deck, Christopher Bell, a customer care supervisor for St. 
John’s Health Care System (SJHCS), and Janie Mitchell, a reimbursement specialist for 
St. John’s Physicians and Clinics (SJPC), were called as witnesses.  Mr. Bell testified that 
the amounts billed by SJHCS for the medical services provided to Ms. Deck were 
customary and reasonable.  He further testified that when SJHCS attempts to collect an 
outstanding bill it seeks the full amount of the bill.  Finally, he testified that the amount 
billed by SJHCS is what it considers its services to be worth.  Ms. Mitchell similarly 
testified that the total amount billed by SJPC for health care services provided to Ms. 
Deck was customary, fair and reasonable.  Ms. Mitchell also stated that when SJPC 
attempts to collect an outstanding bill, it seeks the full amount of the bill rather than the 
amount reimbursed by Medicare.  Ms. Mitchell also testified that the face value of its 
medical bills is what SJPC considers its services to be worth.   
Ms. Deck also presented the testimony of Gary Smith, a health care consultant.  
Prior to consulting, he worked as executive vice president at Cox Hospital for 
approximately 25 years and in executive roles for other hospitals and clinics.  Mr. Smith 
testified that the amount reimbursed by Medicare for a patient’s medical bill usually does 
not cover the health care provider’s cost of business.  Because the amount paid by 
Medicare is less than the cost of the medical services, Mr. Smith testified that, in his 
opinion, the amount reimbursed by Medicare does not represent the value of the medical 
services provided by the health care provider.  Mr. Smith further testified that the amount 
reimbursed by Medicare does not take into account the amount of time the health care 
 
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provider spends with a patient, the number of staff members attending a patient or the 
hospital’s costs.  Finally, Mr. Smith stated that the face value of Ms. Deck’s bills were 
fair and reasonable.    
At trial, Ms. Deck made an offer of proof regarding the value of her medical 
expenses, again attempting to rebut the presumption of value under section 490.715.  She 
called as a witness Dr. Shane Bennoch, a physician and former emergency department 
director at Cox Hospital, who testified that the dollar amount necessary to satisfy the 
financial obligation to the health care providers did not represent the value of the services 
provided to Ms. Deck and, specifically, that Medicare does not maintain that its 
reimbursement rates represent the value of medical services.  He further testified that the 
amount billed by a health care provider is a better indicator of the value of the goods and 
services than the amount that Medicare reimburses. 
Ms. Deck’s evidence presented at the pretrial hearing and the offer of proof that 
the amount she was billed is the value of the medical treatment rendered to her is 
substantial evidence that, if true, has probative force upon the issue of the value of the 
medical treatment rendered such that reasonable persons may differ as to whether it 
establishes the value.  Reiners, 371 S.W.2d at 317.  In light of such substantial evidence, 
the trial court misapplied the law in ruling that the statutory presumption in section 
490.715.5 was not rebutted and in precluding Ms. Deck from presenting evidence of the 
amount of the medical bills she incurred to the jury at trial.   
Mr. Teasley argues that allowing Ms. Deck to rebut the presumption under section 
490.715 and present evidence of the unpaid portions of her medical bills to the jury 
 
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would result in her receiving a windfall.  He argues the legislature amended section 
490.715 to prevent such windfalls.  Mr. Teasley’s policy argument overlooks the 
language of section 490.715 creating a “rebuttable presumption that the dollar amount 
necessary to satisfy the financial obligation to the health care provider represents the 
value of the medical treatment rendered.” Section 490.715.5(2) (emphasis added).  The 
legislature’s use of a “rebuttable presumption” is consistent with its recognition that the 
item of damage for which recovery is sought is the value of services rendered, not a 
reimbursement of amounts paid by a collateral source.  Therefore, the legislature 
permitted a party to introduce evidence that a figure other than the amount actually paid 
represented the value of the services rendered in the particular case.2  
The trial court further erred in the present case because the court did not limit its 
role to determining whether the presumption was rebutted by substantial evidence.  
Instead, the trial court weighed the competing evidence presented by both parties 
concerning the value of medical treatment and determined that the value of medical 
treatment rendered to Ms. Deck was the amount actually paid for Ms. Deck’s medical 
 
2 The legislative history of the bill indicates an unsuccessful attempt was made to prohibit 
the introduction of unpaid medical bills.  HB 393, as originally introduced, would have 
amended section 490.715.5 to read:  
Parties may introduce evidence of the amount actually paid for medical treatment 
rendered to a party that was reasonable, necessary, and the proximate result of the 
negligence of any party. No party may introduce evidence of billing for an amount 
in excess of the amount actually paid for said medical treatment for which 
payment was made, and if no payment was made, then a party may only introduce 
evidence of the amount necessary to satisfy the financial obligation remaining to 
the health care provider.   
Section 490.715.5 of HB 393, 93rd Gen. Assemb., 1st Reg. Sess. (Mo. 2005) 
(unenacted).  
 
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treatment, together with any amount she was still obligated to pay.  The language in 
section 490.715.5(2) that “the court may determine . . . the value of the medical treatment 
rendered” could be read, as the trial court did in this case, to indicate that the trial court 
makes the final determination of the value of medical treatment, rather than submitting 
the issue to the jury for adjudication.  However, such an interpretation is not supported by 
a full reading of section 490.715.5 because the creation of the rebuttable presumption 
indicates that, if the presumption is rebutted, the jury would be presented evidence as 
though no presumption existed.  Additionally, the final sentence of section 490.715.5 – 
“[n]otwithstanding the foregoing, no evidence of collateral sources shall be made known 
to the jury in presenting the evidence of the value of the medical treatment rendered” – 
clearly contemplates that evidence regarding the value of medical treatment will be 
presented to the jury. 
Having determined that the trial court erred in excluding Ms. Deck’s evidence of 
the value of her medical treatment, the Court must determine whether that error was 
sufficiently prejudicial such to justify reversal.  An error is prejudicial if it appears from 
the record that the error “materially affected the merits of the action.”  Newton v. Ford 
Motor Co., 282 S.W.3d 825, 831 (Mo. banc 2009) (citing Rule 84.13(b)). 
In the present case, Ms. Deck proffered evidence that the value of the medical 
treatment rendered to her was $27,991.30.  However, due to the trial court’s exclusion of 
that evidence, the jury only was permitted to hear evidence that the value of her medical 
treatment was $9,904.28, the amount that Ms. Deck, Medicaid and supplemental 
insurance actually paid for the treatment after adjustments.  The exclusion of evidence of 
 
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the additional $18,087.02 in potential damages the jury should have been allowed to 
consider materially affected the merits of the action.  See Accomac Realty Co. v. City of 
St. Louis, 152 S.W.2d 100, 103 (Mo. 1941).  Accordingly, the trial court’s exclusion of 
Ms. Deck’s evidence of the value of medical treatment was prejudicial.  Ms. Deck is 
entitled to a new trial on the issue of damages.   
Expert Testimony Regarding the Cost of Future Medical Treatment 
In her final point, Ms. Deck claims the trial court erred in excluding Dr. 
Bennoch’s testimony regarding the costs of her possible future medical treatment.  
Specifically, Ms. Deck asserts that “[t]he trial court erred in excluding expert testimony 
pertaining to appellant’s possible future medical condition and treatment because such 
evidence is clearly admissible under Missouri law, in that it assists the trier of fact in 
evaluating the nature and extent of appellant’s injuries.”  Because the case is remanded, 
the Court need not decide whether the trial court’s exclusion of Dr. Bennoch’s testimony 
constituted reversible error.  Nevertheless, because the issue may arise on remand, it will 
be discussed briefly.  
The facts that give rise to this point revolve around Dr. Bennoch’s testimony 
regarding Ms. Deck’s possible need for surgery on her injured shoulder.  Specifically, Dr. 
Bennoch testified he would recommend a repeat MRI of Ms. Deck’s shoulder; if the MRI 
showed further deterioration, then a more extensive arthroscopic surgery would be 
required.  When Dr. Bennoch was questioned about the cost of such surgery, Mr. 
Teasley’s attorney objected on the basis that the question called for speculation.  In 
response, Ms. Deck’s attorney argued that future medical treatment conditioned on the 
 
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outcome of care is admissible.  Ultimately, the trial court sustained Mr. Teasley’s 
objection and disallowed evidence of the cost of Ms. Deck’s possible future surgery as 
speculative because Dr. Bennoch did not testify to a reasonable degree of medical 
certainty that surgery would be needed. 
In an offer of proof, Dr. Bennoch estimated that future surgery would cost 
between $15,000 and $20,000 and that physical therapy would cost several thousand 
additional dollars.  On cross-examination, Dr. Bennoch confirmed his earlier testimony 
that Ms. Deck’s need for future medical treatment was dependent on the results of a 
future MRI; therefore, surgery was only a possibility and future treatment was 
speculative.  At the end of the offer of proof, Ms. Deck again sought admission of Dr. 
Bennoch’s testimony regarding the cost of her future care, which the trial court denied.  
Because of the passage of time since trial, the circumstances surrounding Ms. 
Deck’s need for future medical treatment may have evolved.  For example, Ms. Deck’s 
condition may have changed or she may have had intermittent MRI scans, which could 
alter Dr. Bennoch’s testimony regarding the possibility of future treatment.  In the event 
Ms. Deck offers the same testimony from Dr. Bennoch on remand, the trial court’s 
decision to admit or deny such evidence should be informed by this Court’s decision in 
Swartz v. Gale Webb Transp. Co., 215 S.W.3d 127 (Mo. banc 2007). 
 
Swartz involved the testimony of two physicians regarding the possibility of a 
plaintiff’s need for future surgery.  Id. at 129.  While each physician testified the plaintiff 
had an increased risk of surgery, neither could testify to a reasonable degree of medical 
certainty that surgery would be needed.  Id. at 130.  In fact, one of the physicians testified 
 
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that the need for future surgery was “speculation.”  Id.  Nevertheless, the Court held the 
testimony of both physicians, which included an estimate of the cost of the future 
surgery, was admissible for the purpose of establishing the nature and extent of the 
plaintiff’s present injuries.  Id. at 133.   
In reaching its holding, the Court distinguished between present injuries and future 
consequences.  The Court noted that a plaintiff only is entitled to recover for an injury not 
yet occurring if the injury is reasonably certain to occur in the future.  Id. at 130.  
However, the Court noted that expert testimony regarding a plaintiff’s increased risk of 
future consequences is admissible to aid the jury in assessing the extent and value of the 
plaintiff’s present injuries “even if those future consequences are not reasonably certain 
to occur.”  Id. at 131.  The Court noted that other Missouri cases3 have admitted expert 
testimony regarding the possibility of future surgery and the potential costs of such 
treatment, despite the fact that such treatment was not reasonably certain to occur.  Id. 
On remand, the trial court should consider the effect of Swartz and the cases cited 
therein to determine the admissibility of evidence regarding Ms. Deck’s possible future 
medical treatment.    
Conclusion 
 
Because Ms. Deck presented substantial evidence that her total medical bills 
represented the value of her medical treatment, she rebutted the presumption under 
 
3 Of particular significance is the Court’s discussion of Breeding v. Dodson Trailer 
Repair, Inc., 679 S.W.2d 281, 283-84 (Mo. banc 1984) (testimony regarding cost of 
possible future surgery was admissible despite fact that expert testified that surgery was 
conditioned on failure of other treatment and was not reasonably certain). 
 
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section 490.715 that the dollar amount necessary to satisfy the obligation to her health 
care providers constituted the value of her medical treatment.  Therefore, Ms. Deck 
should have been allowed to present evidence of the total amount of her medical bills to 
the jury.  The trial court misapplied the law by refusing to admit evidence of the amount 
of Ms. Deck’s medical bills, and Ms. Deck was prejudiced by the trial court’s error.  
Accordingly, the portion of the judgment of the trial court awarding Ms. Deck damages is 
reversed and the case is remanded for a new trial on the issue of damages only.  In all 
other respects, the judgment is affirmed. 
 
 
 
 
 
 
 
 
 
_________________________________  
 
 
 
 
 
 
 
   PATRICIA BRECKENRIDGE, JUDGE 
 
 
All concur.