CREDIT BUREAU SYSTEMS, INC. v. Carter
2011 Mo. App. LEXIS 195
| Mo. Ct. App. | 2011Background
- CBS, as assignee for Auburn Surgery Center, sued Brenda and Michael Carter for the balance of $27,100.30 for procedures performed on Brenda Carter in late 2005 and early 2006.
- Auburn was an out-of-network provider for Blue Cross Blue Shield; Auburn used a courtesy process where it would submit claims and treat the patient as if in-network, with patient responsible for deductible and co-pay.
- Brenda signed a form instructing her to forward insurance checks to Auburn and indicating the balance would be applied to Auburn's account; the form also stated attorney fees if collection became necessary.
- Brenda cashed insurance checks she received, did not forward them to Auburn, and Auburn pursued collection beginning in 2006, with CBS eventually assigned the account in July 2006.
- The trial court entered judgment for CBS for the full billed amount plus interest and awarded Brenda attorney’s fees; on appeal, the court partially reversed and remanded.
- On appeal, the court held Carter not estopped from full collection but reversed the amount awarded, remanding for calculation per out-of-network benefits.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether CBS is estopped from collecting the full billed amount | Carter claims CBS is estopped due to Dr. Park's representations that Auburn was in-network. | Carter asserts reliance on misrepresentations by Auburn/Dr. Park prejudiced her. | Not estopped; no agency fraud established; evidence contradicts Carter's testimony. |
| Whether the full billed amount was properly awarded despite out-of-network status | CBS argues it is entitled to the full amount billed. | Carter contends the charges are excessive and not supported by insurance terms. | Full amount not supported; remand to calculate due per out-of-network benefits. |
| What amounts defendants owe under out-of-network benefits and applicable insurance terms | Defendants owe the balance not covered by out-of-network benefits. | Defendants should only pay the deductible and co-pay, not the full charges. | Defendants liable only for the portion not covered by out-of-network benefits; remand for calculation. |
Key Cases Cited
- Murphy v. Carron, 536 S.W.2d 30 (Mo. banc 1976) (standard of review for trial court judgments)
- Supplemental Medical Services v. Medi Plex Health Care, 293 S.W.3d 128 (Mo.App. E.D.2009) (appellate review framework for judgments)
- Gibson v. Adams, 946 S.W.2d 796 (Mo.App. E.D.1997) (creditor assumed risk with signed contracts)
- SE Co-Op Service Co. v. Hampton, 263 S.W.3d 689 (Mo.App. S.D.2008) (credibility and weighing of witness testimony on appeal)