Opinion ID: 4188371
Heading Depth: 2
Heading Rank: 3

Heading: Jackson’s Claims Against PRI and MDB

Text: We review de novo a district court’s decision to grant a motion to dismiss for failure to state a claim under Fed. R. Civ. P. 12(b)(6). Lambert v. Harman, 517 F.3d 433, 438-39 (6th Cir. 2008). In reviewing the grant of such a motion, we construe the complaint in the light most favorable to the plaintiff and accept all factual allegations as true. Id. at 439. “To survive a motion to dismiss, a complaint must contain sufficient factual matter, accepted as true, to ‘state a claim to relief that is plausible on its face.’” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009) (quoting Bell Atl. Corp. v. Twombly, 550 U.S. 544, 570 (2007)). Jackson contends that PRI and MDB are subject to Ohio Rev. Code § 1751.60. As previously noted, in order for PRI and MDB to be bound by the requirements of Ohio Rev. Code § 1751.60, they must be a “provider” or a “health care facility” that “contracts with a health insuring corporation.” There is no dispute that PRI and MDB are both healthcare providers and have contracts with Jackson’s insurance company, United Healthcare. The plain language of the statute prohibits PRI and MDB from seeking compensation from the enrollees or subscribers. In this case, the enrollee or subscriber would be Jackson who has insurance coverage through United Healthcare. PRI and MDB rely on two state court decisions in support of their claim that they should not be held liable, but neither is applicable under the facts of this case. In King v. ProMedica Health System Inc., the Supreme Court of Ohio addressed the applicability of Ohio Rev. Code § 1751.60. 955 N.E.2d 348 (Ohio 2011). Similar to Jackson, the plaintiff in King was injured in No. 16-4171 Jackson v. Professional Radiology, et al. Page 6 an automobile accident. Id. at 349. The plaintiff informed the hospital where she was treated that she was covered by health insurance, but instead of billing the health insurance company the hospital billed the plaintiff’s automobile insurance. Id. The plaintiff brought a class action suit and claimed various state causes of action. Id. at 349-50. Each cause of action was based on the claim that the defendants violated Ohio Rev. Code § 1751.60 by billing the automobile insurer instead of the plaintiffs’ health insurance company. Id. at 350. The Ohio Supreme Court held that Ohio Rev. Code § 1751.60 does not prohibit a provider from seeking compensation for medical treatment rendered to the plaintiff as a result of an automobile accident from the insured’s automobile-insurance company. Id. The court in King explained that “the word ‘solely’ [in Ohio Rev. Code § 1751.60] is part of a phrase that defines the context of the statute; it means, in this context, to the exclusion of a health-insuring corporation’s insured,” and does not extend to any other parties. Id. at 351. Thus, the Ohio Supreme Court ultimately held that “Ohio Rev. Code 1751.60(A) applies only when a provider seeks payment from a health-insuring corporation’s insured with which the provider has entered into a contract.” Id. This type of action is prohibited by the plain language of Ohio Rev. Code § 1751.60(A). The Ohio Court of Appeals’ decision in Hayberg v. Robinson Memorial Hospital Foundation, 995 N.E.2d 888 (Ohio Ct. App. 2013), further analyzed King for the application of Ohio Rev. Code 1751.60(A) to automobile insurance. Similar to the plaintiff in King, the plaintiff in Hayberg was injured in an automobile accident and the hospital where she was treated sought payment from the plaintiff’s husband’s health insurance. Id. at 889. Under the contract the hospital had with the husband’s health insurance company, the hospital could only bill the health insurance company for a reduced amount, which the health insurance company paid. Id. The hospital later billed and received full payment for the plaintiff’s treatment from her husband’s automobile insurance. Id. Thereafter, the hospital reimbursed the husband’s health insurance company for the amount it paid. Id. The plaintiff filed a negligence lawsuit against her husband and the automobile insurance settled for the policy limits. Id. at 890. Because the automobile insurance already paid for the plaintiff’s medical treatment and bills, her final payment from the automobile company was reduced by the amount paid for the medical treatment and bills. Id. The plaintiff thereafter No. 16-4171 Jackson v. Professional Radiology, et al. Page 7 brought a class action suit against the hospital alleging a violation of Ohio Rev. Code § 1751.60(A). Id. The plaintiff claimed that the hospital violated Ohio Rev. Code § 1751.60(A) because the hospital took the full amount of the medical bills from the husband’s automobile insurance, as opposed to the reduced amount that the hospital was required under contract to take from the health insurance company. Id. at 891-92. Therefore, the plaintiff argued, the hospital reduced the amount she would have received from the automobile insurance settlement, which was tantamount to taking payments directly from the plaintiff. Id. The Ohio Court of Appeals, relying on the King decision, disagreed with the plaintiff and found that the hospital’s collection efforts were legal under Ohio Rev. Code § 1751.60(A), finding that Ohio Rev. Code § 1751.60(A) “has no application to an automobile insurer in any respect. In other words, Ohio Rev. Code [§] 1751.60(A) is not controlling as to the amount which a hospital can seek to recover[] from an insurer other than the health insurer.” Id. at 893. However, this case is distinguishable from both King and Hayberg. Neither of those two cases had a hospital directly billing an insured, as was the case for Jackson. PRI and MDB contend that Ohio Rev. Code § 1751.60(A) merely prohibits the healthcare provider from billing the patient for the difference between the amount it contractually agreed to accept from the health insuring corporation and the full amount of the services provided (i.e. balance billing). However, neither case stands for that proposition. In fact, both cases only deal with billing third party automobile insurance companies. In this case, PRI and MDB directly billed Jackson for the amount of her medical treatment rather than an automobile insurer. Although Jackson may have received a settlement from an automobile insurer, the plain language of Ohio Rev. Code § 1751.60(A) directly prohibits this type of direct billing. Instead, PRI and MDB could have sought payment from either United Healthcare, under the reduced rate through the contract with the hospital, or from the third party automobile insurance company, which allegedly provided Jackson torts proceeds, for the full sum of medical bills. Nothing in Ohio Rev. Code § 1751.60(A) would allow PRI and MDB to seek payment directly from Jackson. No. 16-4171 Jackson v. Professional Radiology, et al. Page 8 In reviewing the grant of a motion to dismiss for failure to state a claim, we construe the complaint in the light most favorable to the plaintiff and accept all factual allegations as true. If it is true, as Jackson alleges, that PRI and MDB sought payment directly from her for medical benefits, and did not attempt to collect from her health insurance company, United Healthcare, or a third party automobile insurance company, this is a direct violation of Ohio Rev. Code § 1751.60(A), and PRI and MDB’s motion to dismiss should not have been granted.