184 Conn. App. 467
Conn. App. Ct.2018Background
- Boileau (insured under Cigna via employer) received chiropractic care from DeAngelo, a participating provider, beginning August 2011; his plan covered only ten chiropractic visits per calendar year.
- Boileau signed (1) an authorization/financial policy at initial visit agreeing to be responsible for charges not paid by insurance, (2) a letter of protection, and (3) on his 13th visit a verification form showing he had exhausted his ten-visit benefit and acknowledging financial responsibility for visits over the limit.
- DeAngelo provided 29 visits in 2011 and 11 in 2012; 20 visits exceeded Boileau’s benefit. DeAngelo submitted some claims to Cigna; certain claims were not paid due to missing treatment plans.
- Vaccaro (Boileau’s attorney) settled Boileau’s personal-injury case for $75,000 and tendered $6059 claimed by DeAngelo; DeAngelo rejected the payment and claimed a larger balance. Vaccaro interpleaded the disputed funds.
- At trial the court awarded DeAngelo $5780 of the contested funds; Boileau cross-appealed arguing (a) DeAngelo breached the provider services agreement by failing to obtain Member Billing Acknowledgment forms for services after benefits were exhausted, and (b) the authorization form is illegal/unenforceable (violating statutes on balance billing, usury/interest, and attorney’s fees).
Issues
| Issue | Plaintiff's Argument (Boileau) | Defendant's Argument (DeAngelo) | Held |
|---|---|---|---|
| Whether §2.03.12(b) of the provider agreement required DeAngelo to obtain a Member Billing Acknowledgment at each post‑benefit visit so he cannot bill for those visits | §2.03.12(b) required an acknowledgment for any self‑pay “Non‑Covered Services”; after benefits were exhausted each additional visit required the form, so DeAngelo breached and cannot collect | DeAngelo complied with §2.03.12(d) by providing written verification of exhausted benefits; §2.03.12(b) applies only to services that are inherently non‑covered (not to visits that exceed a plan’s numeric limit) | Held for DeAngelo: §2.03.12(b) applies to "Non‑Covered Services," not visits exceeding plan limits; verification satisfied the notice requirement and DeAngelo may bill for visits beyond the benefit limit |
| Whether the authorization/financial policy is illegal under Conn. Gen. Stat. §20‑7f(b) (balance‑billing prohibition) | The form makes Boileau responsible for “all professional services submitted” and for charges not paid by insurance, which negates §20‑7f(b) and permits prohibited balance billing | The provision can be read to permit billing only for copays, deductibles, and charges not paid because benefits were exhausted or services genuinely non‑covered; Boileau did not identify any actual balance‑billing charge | Held for DeAngelo: provision is reasonably susceptible to a lawful construction; Boileau failed to show the form’s inherent purpose was unlawful or that any billed charge was balance billing |
| Whether the authorization violates usury statute §36a‑573 by providing 18% interest | The form imposes 18% in interest/finance charge on unpaid balances, contrary to usury limits | Interest clause is a late fee on unpaid bills, not a loan; usury applies to loans, and Boileau did not show a loan existed | Boileau abandoned/us did not brief this adequately; court rejects review on this ground |
| Whether attorney‑fee clause violates §42‑150aa(b) (limits on contingency fees) | The form permits attorney’s fees in excess of statutory limits, rendering it unenforceable | Clause does not make the contract void; Boileau failed to brief or analyze applicability | Abandoned/inadequately briefed; court declines to review |
Key Cases Cited
- State v. Donald, 325 Conn. 346 (review standard when trial court’s legal analysis is unclear)
- Meeker v. Mahon, 167 Conn. App. 627 (plenary review of unambiguous contract language)
- Welch v. Stonybrook Gardens Cooperative, Inc., 158 Conn. App. 185 (contract interpretation principles)
- South End Plaza Assn., Inc. v. Cote, 52 Conn. App. 374 (avoidance of absurd contractual results)
- Carriage House I–Enfield Assn., Inc. v. Johnston, 160 Conn. App. 226 (contracts contrary to public policy; scope of review)
- Dougan v. Dougan, 301 Conn. 361 (caution in applying public‑policy voidness)
- Marlborough v. AFSCME, 309 Conn. 790 (prefer interpretation that preserves validity of contract)
- Gianetti v. Rutkin, 142 Conn. App. 641 (statutory scheme addressing balance billing under §20‑7f)
- Stelco Indus., Inc. v. Zander, 3 Conn. App. 306 (usury statute construed as applying to loans, not ordinary sales/credit)