Key Takeaway
NY court case on healthcare provider's right to recover reasonable value for medical services when insurance claims are improperly processed or denied.
Spanakos v Racanelli, 2021 NY Slip Op 50127(U)(App. Term 2d Dept. 2021)
(1) “Plaintiff, a chiropractor, brought this action to recover, among other things, the balance allegedly due him for healthcare services rendered to defendant. At a nonjury trial, plaintiff proffered evidence that he had submitted bills to defendant’s health plan requesting payment, which bills set forth a total charge of $ 1,756.81, which sum includes a co-payment of $ 480 due from defendant. Defendant presented evidence that plaintiff had failed to provide information necessary for the health plan to process plaintiff’s claim, but implicitly conceded that defendant was responsible for paying the $ 480 co-payment. After the trial, the Civil Court awarded plaintiff the principal sum of $ 480. [*2] Plaintiff appeals on the ground of inadequacy.”
(2) “It is well settled that a healthcare provider is entitled to recover for professional services rendered by him or her under an implied agreement by the patient to pay the reasonable value of the services (see Taranto v Abohwo, 45 Misc 3d 130, 3 N.Y.S.3d 287, 2014 NY Slip Op 51578 ; Brookhaven Mem. Hosp. Med. Ctr. v Lukashevskiy, 43 Misc 3d 128, 990 N.Y.S.2d 436, 2011 NY Slip Op 52557 ; Brottman v Crane, 11 Misc 3d 129, 815 N.Y.S.2d 493, 2006 NY Slip Op 50299 ). The performance and acceptance of such services give rise to the inference of an implied contract to pay for the reasonable value of the services (see Moors v Hall, 143 AD2d 336, 338, 532 N.Y.S.2d 412 ; Brookhaven Mem. Hosp. Med. Ctr. v Lukashevskiy, 43 Misc 3d 128, 990 N.Y.S.2d 436, 2011 NY Slip Op 52557; Long Is. Jewish Med. Ctr. v Budhu, 20 Misc 3d 131, 867 N.Y.S.2d 17, 2008 NY Slip Op 51436 ; Brottman v Crane, 11 Misc 3d 129, 815 N.Y.S.2d 493, 2006 NY Slip Op 50299).”
(3) “The terms of an agreement, if any, by plaintiff to seek recovery of his fees from defendant’s [*3] health plan is not part of the record. Assuming, without deciding, that plaintiff’s right to recover payment from defendant was not affected by plaintiff’s failure, if any, to properly pursue payment from defendant’s health plan, plaintiff, in any event, did not establish the reasonable value of the services he rendered, which proof is part of plaintiff’s prima facie case (see Castro v East End Plastic, Reconstructive & Hand Surgery, P.C., 47 AD3d 608, 610, 850 N.Y.S.2d 483 ). The sole proof submitted by plaintiff as to the reasonableness of the charges appearing on his bills was the bills themselves (see id.). Consequently, plaintiff failed to establish that the award in his favor was inadequate.”
