Court Opinion

ID: 6527057
Source: CourtListenerOpinion
Date Created: 2022-07-19 19:21:41.891482+00
Date Added: 2024-06-11T15:55:14.404601
License: Public Domain

CATES, Judge
(concurring in part).
All members of the court are unanimous-that the judgment below must be reversed. We divide, however, as to the reasons and as to the scope of the quantum of proof needed for the plaintiff to have made a prima facie case.
I.
Since the statute requires the appellant to designate in its contract certificate the hospitals which honor its plan and since the instant policy fails so to ’ designate, I ■ conclude that the plaintiff was not required to prove the Tennessee hospital was within the elaborate inter plan bank formula. Since the contract was primarily for a flat prepaid hospitalization, albeit aleatory in frequency, Blue Cross had equal, if not superior, means to find out whether the Tennessee hospital was affiliated with the nexus of Blue Cross member hospitals.
Therefore, the charges of such hospital were presumptively within the realm of what Blue Cross knew or should have, by reasonable diligence, known. Being for a flat prepaid service, reasonableness of the hospital charge was beside the point.
II.
As to the charges of the doctors, the mere fact that Blue Cross lists máximums in its policy for prepaid medical accumulations to pay for surgery is not a substitute for proof that the doctors’ bills were reasonable and customary in the vicinity in which performed.
III.
Hence, the'majority hold the trial court was not in error in refusing to require the plaintiff under this evidence to prove reasonableness of the charges of the hospital in Tennessee. Otherwise, we concur with PRICE, P. J.
JOHNSON, J., concurs in this separate opinion.