Medical Center Health Plan v. Brick

• Decision Date: 14 December 1990
• Docket Number: No. 89-2934,89-2934
• Citation: 572 So.2d 548
• Parties: 15 Fla. L. Weekly D3038 MEDICAL CENTER HEALTH PLAN, Appellants, v. Ricky BRICK, Appellee.
• Court: Florida District Court of Appeals

Page 548

572 So.2d 548

15 Fla. L. Weekly D3038

MEDICAL CENTER HEALTH PLAN, Appellants, v. Ricky BRICK, Appellee.

No. 89-2934.

District Court of Appeal of Florida First District.

Dec. 14, 1990.

James M. Wilson, of Harrell, Wiltshire, Swearingen, Wilson & Harrell, P.A., Pensacola, for appellants.

Walter A. Steigleman, Law Offices of Walter A. Steigleman, P.A., Fort Walton, for appellee.

PER CURIAM.

Appellant Medical Center Health Plan (Plan), an HMO, challenges the trial court's interpretation of its agreement with appellee Brick as requiring the Plan to pay unilaterally incurred and uncovered medical expenses. The Plan contends that medical services incurred by Brick fall outside the four corners of their HMO agreement. We affirm in part, reverse in part, and remand.

In 1986, Brick's employer offered its employees the option of obtaining medical care through an HMO, the Plan, or through a regular group health indemnity policy. Brick opted for the Plan and admitted at hearing that: (1) he participated in an orientation at which he was expressly informed that the Plan was an HMO, not an insurance company, which would pay medical expenses if (a) a participating physician provided treatment, (b) a "primary care physician" (PCP) authorized treatment, or (c) "emergency" treatment was provided; (2) that he received a copy of the parties' Group Health Services Agreement (agreement) containing these restrictions at an orientation; and (3) that he read a question and answer booklet and other materials which stated in pertinent part:

Except for emergencies, you will see your [Plan] physician for all medical needs. Appointments will be made through his office, and he will arrange for any other consultations or treatments you may need.

In February 1987, Brick sustained neck injuries in an automobile accident. He received emergency medical care for which the Plan paid. He sought follow-up care from Dr. Thigpen whose bills were also paid because Dr. Thigpen was the PCP. Dr. Thigpen referred Brick to a neurologist, Dr. Miller, whose bills were paid because he was an authorized "referral physician". At this point, it appears that Brick thought that he had fully complied with the dictates of the agreement.

Conflicting testimony indicates that Brick thereafter unilaterally sought unauthorized chiropractic care from Dr. Fulford. PIP paid most of the medical bills associated with that chiropractic treatment, the Plan did not pay the balance, nor has Brick sought such payment from the Plan. Because of Brick's worsening condition, Dr. Fulford referred him to Dr. Witkind, a neurosurgeon and non-participating physician. Dr. Witkind treated Brick at Humana Hospital, a non-participant facility. The Plan disputes the medical bills Brick incurred for treatment by Witkind at Humana.

Dr. Witkind first examined Brick in April 1987, and performed a CT scan, a myelogram and a post-myelogram CT scan which revealed that he needed surgery to remove a disk from his neck. Brick was admitted to Humana Hospital six days later and Dr. Witkind performed an anterior diskectomy and fusion. Brick incurred bills of over $5,000 with Humana Hospital and over $3,000 with Dr. Witkind, of which Brick personally paid $1,200. A choking incident at home aggravated his neck in May, and rather than reporting to a local participant hospital, Brick reported to the Humana Hospital emergency room 45 miles away. The Plan also disputes the charges stemming from this second admission, based upon Brick's "self-referral--Primary physician not aware of illness or admission" and because Dr. Hodnette stated that a rule violation occurred in by-passing the nearest emergency room. On cross-examination, the doctor admitted it was an unwritten rule not stated in the agreement but arising from his own interpretation of an "emergency". On redirect, Dr. Hodnette testified that whether Brick stopped at the nearest hospital or not, if it's an emergency it's covered just for the emergency.

A third incident occurred in which Brick had a choking seizure and he was hospitalized again at Humana. The Plan did not contest the initial emergency admission at a local hospital, because it met the definition of an "emergency" but contested the participant doctor's referral from that hospital to Dr. Witkind. Brick incurred expenses of $2,016.74 for the third admission. The Plan denied payment for this admission because of "self-referral" and because it was related to some "emotional problem" not considered by Dr. Hodnette to be part of the emergency.

Testimony adduced at hearing in February 1989, indicated that: (1) had Dr. Witkind been a participating physician, he would have been paid a lesser fee than usual for the particular type of operation performed; (2) except in emergencies, nonparticipant physicians and hospitals may not treat plan members without prior approval; (3) Mrs. Brick presented her membership card and listed the Plan as secondary coverage to Humana Hospital admissions; (4) neither Dr. Witkind or Humana contacted the Plan; (5) Mrs. Brick testified that, prior to the third incident, an approved doctor sent them to Dr. Witkind; (6) subsequent to incurring the disputed medical bills, the Bricks met with a Plan administrator, Dr. Hodnette, to discuss the controverted bills; (7) after they were informed that the bills would not be paid Mrs. Brick became very upset and Dr. Hodnette allegedly represented that all disputed bills would be paid if Brick switched to a participant physician.

Dr. Hodnette testified to the contrary that he had no authority to make the commitment alleged by the Bricks and had never told them the bills would be paid. He told them only that the emergency care incurred in the third incident would be paid, that he would accumulate all information for Board consideration, and that future bills incurred would only be paid if Brick switched to the Plan's neurosurgeon, Dr. Raymon. After Mr. Brick apprised him of his condition, Dr. Raymon initially refused to take him because he felt Brick could only receive safe care if it was rendered by the same doctor and he referred Brick back to Dr. Witkind. However, following a call to Dr. Raymon made by Dr. Hodnette, Dr. Raymon agreed to treat Brick who has had another operation and has returned to work.

Brick disclosed that he knew his PCP or personal physician was Dr. Thigpen. Thus, he knew that, under the clear and unambiguous terms of the agreement, except in cases of emergencies, he had to see Dr. Thigpen before incurring any medical services and that he could only receive payment of associated expenses from another doctor after first obtaining a referral from Dr. Thigpen. However, Brick's testimony at hearing provides some insight into his misconstruction of the terms of his agreement:

The way I understood the plan was once you were referred by your primary physician, it was all covered then. I did not understand...