Court Opinion

ID: 2691067
Source: CourtListenerOpinion
Date Created: 2014-08-01 20:58:10.770934+00
Date Added: 2024-06-11T12:52:55.376223
License: Public Domain

[Cite as King v. ProMedica Health Sys., Inc., 129 Ohio St.3d 596, 2011-Ohio-4200.]

KING, APPELLEE, v. PROMEDICA HEALTH SYSTEM, INC., ET AL., APPELLANTS.
                    [Cite as King v. ProMedica Health Sys., Inc.,
                        129 Ohio St.3d 596, 2011-Ohio-4200.]
Insurance—R.C. 1751.60—Automobile-insurance medical benefits—Coordination
        of multiple health-care-insurance payors.
     (No. 2010-1236—Submitted May 25, 2011—Decided August 30, 2011.)
       APPEAL from the Court of Appeals for Lucas County, No. L-09-1282,
                                    2010-Ohio-2578.
                                 __________________
        MCGEE BROWN, J.
        {¶ 1} Appellants, ProMedica Health System, Inc., and the Toledo
Hospital, appeal from a decision of the Sixth District Court of Appeals finding
that pursuant to R.C. 1751.60(A), appellants were statutorily prohibited from
billing Virginia King’s motor-vehicle insurer, Safeco Insurance Company of
Illinois, for the medical treatment rendered to her at the Toledo Hospital.
        {¶ 2} We are asked to decide whether R.C. 1751.60(A) prohibits a
provider from seeking payment for medical treatment rendered to an insured
injured in an automobile accident from the insured’s automobile-insurance
medical benefits. R.C. 1751.60(A) states that every provider that contracts with a
health-insuring corporation to provide health-care services to an insured shall seek
payment solely from the corporation. Separately, we also are asked to decide
whether R.C. 1751.60(A) conflicts with Ohio’s law regarding the coordination of
insurance benefits. We hold that R.C. 1751.60(A) applies only when a health-
care provider seeks payment from an insured. We also hold, therefore, that R.C.
1751.60(A) does not conflict with Ohio’s law on the coordination of insurance
benefits. The coordination of multiple health-care-insurance payors is covered
                                  SUPREME COURT OF OHIO

under R.C. 3902.11 et seq. and the rules promulgated pursuant to those statutes.
Accordingly, we reverse the judgment of the Sixth District Court of Appeals.
                                         Background
         {¶ 3} Appellee, Virginia King, was injured in an automobile accident on
December 1, 2007, and was treated for her injuries at the Toledo Hospital. King
informed the hospital admitting staff that she was covered by Aetna Health, Inc.
and provided her health-insurance information to them. It is undisputed that
appellants billed King’s automobile insurer, Safeco Insurance Company of
Illinois, for the services rendered.
         {¶ 4} In her complaint, King alleged personal damages and sought a
class-action suit pursuant to Civ.R. 23 on behalf of all enrollees or subscribers1
treated within the ProMedica Health System who were covered by a health-
insuring corporation.        King raised four causes of action: breach of contract,
violation of public policy, violation of various sections of R.C. Chapter 1345 (the
Consumer Sales Practices Act), and conversion. Each of these causes of action is
based on the claim that the appellants violated R.C. 1751.60(A) by billing the
automobile insurer instead of the health-insuring corporation. Appellants filed a
motion to dismiss King’s complaint for failure to state a claim upon which relief
may be granted, pursuant to Civ.R. 12(B)(6).
         {¶ 5} The trial court granted appellants’ motion to dismiss. The court
noted that King had not alleged that appellants sought compensation directly from
her, the insured. The trial court found that King’s claims, which were all based on
a violation of R.C. 1751.60(A), failed.
         {¶ 6} King appealed, and the Sixth District Court of Appeals reversed.
King v. ProMedica Health Sys., Inc., 6th Dist. No. L-09-1282, 2010-Ohio-2578.
The court held that health-care providers that execute preferred-provider

1. For purposes of this opinion, we will refer to an “enrollee” and “subscriber” as an “insured.”

                                                 2
                                January Term, 2011

agreements with health-insuring corporations can bill only the health-insuring
corporation subject to the agreement for covered services furnished to their
insured and cannot bill any other potential payors. Id. at ¶ 13.         Appellants
appealed the decision to this court. We granted discretionary jurisdiction to
review appellants’ second proposition of law. 126 Ohio St.3d 1597, 2010-Ohio-
4928, 935 N.E.2d 44.
                                     Analysis
       {¶ 7} We are asked to determine the applicability of R.C. 1751.60(A).
Appellants argue that the sole purpose of R.C. 1751.60(A) is to protect an insured
patient from being billed for medical services when the health-care provider has
contracted with the patient’s health-insuring corporation to provide services to the
corporation’s insured. Appellants contend that the Sixth District misapplied R.C.
1751.60(A) when that court concluded that the statute prohibited appellants from
seeking compensation from Safeco, which provided medical benefits as King’s
automobile insurer. We agree.
       {¶ 8} R.C. 1751.60(A) states, “Except as provided for in divisions (E)
and (F) of this section, every provider or health care facility that contracts with a
health insuring corporation to provide health care services to the health insuring
corporation’s enrollees or subscribers shall seek compensation for covered
services solely from the health insuring corporation and not, under any
circumstances, from the enrollees or subscribers, except for approved copayments
and deductibles.”
       {¶ 9} By its express terms, R.C. 1751.60(A) governs providers or health-
care facilities, health-insuring corporations, and a health-insuring corporation’s
insured.   The statute is applicable only when there is a contract between a
provider and a health-insuring corporation, and the provider seeks compensation
for services rendered. The legislature expressed its intent that the provider must

                                         3
                             SUPREME COURT OF OHIO

seek compensation solely from the health-insuring corporation and not from the
insured.
        {¶ 10} It is undisputed that appellants never sought compensation from
King. But King argues that her Safeco medical-benefit payments are an asset that
belongs to her and that by seeking medical-benefit payments available under the
automobile policy, appellants essentially sought compensation from her. King’s
argument is unpersuasive. Under R.C. 1751.01(G), “ ‘[c]ompensation’ means
remuneration for the provision of health care services, determined on other than a
fee-for-service or discounted-fee-for-service basis.” Compensation by Safeco did
not equate to compensation by King: by making the payment, Safeco fulfilled its
contractual obligation to King to cover her medical costs in the event of an
accident.      When appellants received payment, they received it from Safeco.
Because King was not asked to make any payment for the services she received,
appellants did not violate R.C. 1751.60(A).
        {¶ 11} King also argues that appellants violated R.C. 1751.60(A) because
they sought compensation from Safeco and not Aetna. King contends that the
statutory language “shall seek compensation for covered services solely from the
health insuring corporation and not, under any circumstances, from the enrollees
or subscribers” means that all providers that contract with a health-insuring
corporation relinquish their ability to seek compensation from any other parties
and can collect payment from only the health-insuring corporation. The Sixth
District agreed, finding that providers that execute preferred-provider agreements
with health-insuring corporations can bill only the health-insuring corporation
subject to the agreement for services furnished to an insured to the exclusion of
any and all other potential payors. The Sixth District’s reasoning relied on its
construction of the word “solely,” defining it to mean “to the exclusion of others.”
2010-Ohio-2578, at ¶ 12. This interpretation, however, cannot be reconciled with
the statute.

                                         4
                                  January Term, 2011

           {¶ 12} R.C. 1751.60(A) has limited application. The statute addresses the
contract between a provider and a health-insuring corporation. No other entities
are mentioned in the statute. The statutory language allowing a provider to
recover “solely from the health insuring corporation and not, under any
circumstances, from the enrollees or subscribers” relates only to this contractual
relationship. Here, the term “solely” does not have the meaning given to it by the
Sixth District. Reading the word in this manner would impermissibly render the
phrase “and not, under any circumstances, from the enrollees or subscribers”
superfluous. Rather, the word “solely” is part of a phrase that defines the context
of the statute; it means, in this context, to the exclusion of a health-insuring
corporation’s insured. This reading gives full meaning to every word of the
statute.     Read in context, the statute’s language allowing a provider to seek
compensation from the health-insuring corporation and not the insured is limited
to the situation in which a health-care services contract is in place between a
provider and a health-insuring corporation.         Therefore, we hold that R.C.
1751.60(A) applies only when a provider seeks payment from a health-insuring
corporation’s insured with which the provider has entered into a contract.
           {¶ 13} King’s argument that appellants were not entitled to seek the
medical-benefit payments is appropriately covered under R.C. 3902.11 et seq. and
the rules promulgated pursuant to those statutes. Ohio’s coordination-of-benefits
laws apply when a provider seeks compensation from multiple insurers who are
obligated to pay for health-care services rendered to an insured. R.C. 1751.60(A)
concerns only a health-care provider’s ability to seek compensation from a health-
insuring corporation’s insured, where the health-insuring corporation has a
contract with the provider, and therefore does not apply to coordination of
benefits and does not conflict with R.C. 3902.11.
           {¶ 14} Appellants did not seek compensation from King. Thus, King fails
to show that appellants violated R.C. 1751.60(A).

                                           5
                                SUPREME COURT OF OHIO

                                     Conclusion
       {¶ 15} Because King failed to show that appellants sought compensation
from her, she failed to establish a violation of R.C. 1751.60(A). Accordingly, we
reverse the court of appeals and reinstate the trial court’s order dismissing King’s
complaint pursuant to Civ.R. 12(B)(6).
                                                                Judgment reversed.
       O’CONNOR, C.J., and LUNDBERG STRATTON, O’DONNELL, LANZINGER,
and CUPP, JJ., concur.
       PFEIFER, J., dissents.
                                 __________________
       PFEIFER, J., dissenting.
       {¶ 16} R.C. 1751.60(A) provides, “[E]very provider or health care facility
that contracts with a health insuring corporation to provide health care services to
the health insuring corporation’s enrollees or subscribers shall seek compensation
for covered services solely from the health insuring corporation and not, under
any circumstances, from the enrollees or subscribers, except for approved
copayments and deductibles.”
       {¶ 17} “Solely” in R.C. 1751.60(A) means solely.          It does not mean
“unless you can get paid closer to your top rate through an injured patient’s
automobile-insurance policy.” Applying the usual meaning to the word “solely”
does not, as the majority states, render the phrase “and not, under any
circumstances, from the enrollees or subscribers” superfluous. This is because of
still another phrase, “except for approved copayments and deductibles.” Read as
a whole, R.C. 1751.60(A) requires providers that have contracted with a health-
insurance corporation to seek payment from only the health-insurance
corporation, except for copayments and deductibles, which may be billed to
enrollees or subscribers.

                                          6
                                 January Term, 2011

           {¶ 18} When a patient’s other insurance is not dissipated through direct
billing by health-care providers, the patient can use that other insurance to pay
copayments, deductibles, or for treatment options excluded from the health-
insurance corporation’s coverage. An automobile-insurance policy that includes
medical coverage is an asset of the patient—when a provider seeks compensation
from that policy, it seeks compensation from the patient in violation of R.C.
1751.60(A).
                                 _________________
             Murray & Murray Co., L.P.A., John T. Murray, Leslie O. Murray, and
Michael J. Stewart; and Mickel & Huffman and John L. Huffman, for appellees.
             Jones Day, Patrick F. McCartan, Marc L. Swartzbaugh, Douglas R.
Cole, and Alexis J. Zouhary; and Marshall & Melhorn, L.L.C., Marshall A.
Bennett Jr., and Jennifer J. Dawson, for appellants.
             Anspach Meeks Ellenberger, L.L.P., Garrick O. White, and Richard F.
Ellenberger; and Barry F. Hudgin, urging reversal for amici curiae Mercy Health
Partners and Catholic Healthcare Partners.
             Bricker & Eckler, L.L.P., Anne Marie Sferra, and Bridget Purdue
Riddell, urging reversal for amici curiae Ohio Hospital Association, Ohio State
Medical Association, Ohio Osteopathic Association, and Ohio Association of
Health Plans.
             Arthur, O’Neil, Mertz, Michel & Brown Co., L.P.A., Daniel R. Michel,
and Jennifer N. Brown, urging affirmance for amicus curiae Ohio Association for
Justice.
                              ______________________

                                          7