Justia Contracts Opinion Summaries

The issue this case presented for the Pennsylvania Supreme Court’s review centered on review of a Commonwealth Court order Court interpreting a provision of a consent decree, negotiated by the Office of Attorney General of Pennsylvania ("OAG") and approved by the Commonwealth Court, between Appellant UPMC, a nonprofit health care corporation, and Appellee Highmark, a nonprofit medical insurance corporation, which established the obligations of both parties with respect to certain health care plans serving vulnerable populations. Specifically, the Court considered whether the Commonwealth Court erroneously interpreted this "vulnerable populations" provision as creating a contractual obligation for UPMC to treat all participants in Highmark’s "Medicare Advantage Plans" (for which Highmark and UPMC currently have provider contracts which UPMC has indicated it will terminate) as "in-network" for purposes of determining the rates it is permitted to charge these individuals for physician, hospital, and other medical services during the duration of the consent decree. After careful review, the Supreme Court affirmed the Commonwealth Court’s finding that the "vulnerable populations" clause of the consent decree required UPMC to "be in a contract" with Highmark for the duration of the consent decree, and, thus, that UPMC physicians, hospitals, and other services shall be treated as "in-network" for participants in Highmark Medicare Advantage plans which were subject to provider contracts between Highmark and UPMC set to be terminated by UPMC on December 31, 2015. The Court also affirmed the portion of the Commonwealth Court’s order requiring judicial approval for any further changes in business relationships between these parties which were governed by the consent decree, but quashed as not yet ripe for review the portion of the order which directed the OAG to file a request for supplemental relief to effectuate compliance with the consent decree. View "Pennsylvania v. UPMC" on Justia Law

Todd Kiser initiated this action by filing a form complaint against Noel Kiser and Marie McDowell alleging that Noel and Marie owed him a sum of money arising out of an asserted agreement among them regarding their father’s nursing care and cremation costs. The small claims court entered judgment in favor of Todd. Noel and Marie appealed the judgment to the district court. The district court dismissed the appeal, reasoning that the brief filed by Noel and Marie had been untimely filed. The Supreme Court reversed, holding that the district court erred in dismissing the appeal on the basis of the briefing deadline imposed in the inapplicable Municipal Court Appellate Rules. Remanded to the district court for reinstatement of Noel and Marie’s appeal and for further proceedings. View "Kiser v. Kiser" on Justia Law

In 2011, 74-year-old Garnell Wilcoxon lived alone. He suffered a stroke, awoke on the floor of his bedroom covered in sweat, feeling sore and with no memory of how he got there. Wilcoxon was admitted to the Troy Regional Medical Center for analysis and treatment for approximately one year before he died. Following Wilcoxon's death, Brenda McFarland, one of Wilcoxon's daughters, filed a complaint as the personal representative for Wilcoxon's estate, asserting claims for : (1) medical malpractice; (2) negligence; (3) breach of contract; (4) negligent hiring, training, supervision, and retention; and (5) loss of consortium. In its answer, Troy Health asserted, in part, that McFarland's claims were barred from being litigated in a court of law "by virtue of an arbitration agreement entered into between plaintiff and defendant." Troy Health then moved to compel arbitration, asserting that forms signed by one of Wilcoxon's other daughters, acting as his attorney-in-fact, contained a valid and enforceable arbitration clause. McFarland argued that "Wilcoxon did not have the mental capacity to enter into the contract with [Troy Health,] and he did not have the mental capacity to give legal authority to enter into contracts on his behalf with" relatives who initially helped admit him to Troy Health facilities when he first fell ill. According to McFarland, "[t]he medical records document that Wilcoxon was habitually and/or permanently incompetent." Therefore, McFarland argued, both a 2011 arbitration agreement and a 2012 arbitration agreement were invalid. The circuit court denied Troy Health's motion to compel arbitration. The Supreme Court reversed, finding that McFarland failed to prove that Wilcoxon was mentally incompetent when he executed a 2012 durable power of attorney naming his other daughter as his attorney-in-fact, and also failed to demonstrate that Wilcoxon was "permanently incompetent" before that date, and because there was no other issue concerning the validity of the 2012 arbitration agreement. View "Troy Health and Rehabilitation Center v. McFarland" on Justia Law

Prentice Delon Hyler sought health care services from Action Chiropractic Clinic, LLC (Plaintiff) after she was injured in an automobile accident. Hyler executed an “Assignment of Rights” to Plaintiff for medical benefits payable to Hyler by Erie Insurance Exchange. Erie was the automobile liability insurance provider for the opposing driver involved in the accident. Erie and Hyler entered into a settlement agreement providing that Erie would pay Hyler $8,510 for claims relating to the accident. Plaintiff sued both Erie and Hyler seeking to recover the $5,010 it was owed from Hyler. The trial court granted Erie’s motion for summary judgment, concluding that the Assignment of Rights was not a valid assignment. The Supreme Court affirmed, holding that the assignment in this case was ineffective. View "Action Chiropractic Clinic, LLC v. Hyler" on Justia Law

Allstate Insurance Company petitioned for review of a court of appeals' judgment that reversed the dismissal of a breach of assignment claim brought by Medical Lien Management (MLM). The district court effectively construed MLM's Lien and Security Agreement with a motor vehicle accident victim (upon which the underlying complaint was premised), as failing to assign the victim's right to the proceeds of his personal injury lawsuit against Allstate's insured. The court of appeals found a valid assignment to MLM all rights to the future proceeds from the personal injury claim in an amount equal to the costs of medical services paid for by MLM, as well as a sufficient allegation in the complaint of an enforceable obligation by Allstate to pay the assigned sums to MLM. The Supreme Court reversed, finding that the court of appeals erred in finding the purported assignment in this case. View "Allstate Insurance Co. v. Medical Lien Management, Inc." on Justia Law

The underlying lawsuit in this case, "Retailers’ Credit Association of Grass Valley, Inc. v. Leonard," was filed by real party in interest Retailers’ Credit Association of Grass Valley, Inc., and alleged petitioner Kathleen Leonard breached a contract by failing to pay $2,340.41 for medical services provided by additional real party in interest, Dignity Health, which was doing business as Sierra Nevada Memorial Hospital. Retailers’ Credit Association was the local collection agency providing collection services for Sierra Nevada Memorial Hospital. Leonard filed a pro. per. cross-complaint against Retailers’ Credit Association, alleging a violation of the Health Insurance Portability and Accountability Act of 1996 by negligent disclosure of private medical information (i.e. “date of medical visits, medical record number, [and] account numbers”). On the front page of her cross-complaint, Leonard checked the box on the form that stated, “ACTION IS A LIMITED CIVIL CASE ($25,000 or less).” In the complaint itself, Leonard checked the box requesting “compensatory damages” for “limited civil cases.” She also requested injunctive relief in the form of a court order requiring Retailers’ Credit Association to remove the allegedly private information from its complaint. Leonard later filed a pro. per. motion to amend her cross-complaint. In the caption of the motion, she stated the amendment was to “NAME SIERRA NEVADA MEMORIAL HOSPITAL AS A CROSS-DEFENDANT and TO REMOVE THIS CASE TO A COURT OF GENERAL JURISDICTION.” The memorandum of points and authorities alleged that the documents attached to the complaint contained her medical record number and were not necessary for the prosecution of the collection claim and at the very least could have been redacted to protect her privacy. When she reviewed the complaint, she “noticed the attachment to the complaint contained [her] medical records and medical record number” and that the complaint with the attachment had been filed publically at the courthouse. The trial court denied Leonard’s motion to amend the cross-complaint and “[t]ransfer to [u]nlimited [j]urisdiction” without prejudice. Leonard “failed to attach the proposed [a]mended [c]ross-[c]omplaint to the motion” and as a result, the court was “unable to determine what the proposed changes include.” The court was “unable to determine if an additional [c]ross-[d]efendant [wa]s sought to be named or if damages sought exceed $25,000. Thus, th[e] Court [w]as unable to determine if [Leonard] [wa]s entitled to the relief sought.” This case involves how a limited civil case (here a cross-complaint) gets reclassified as an unlimited civil case. After review, the Court of Appeal held that where Leonard filed, through counsel, an amended cross-complaint that added a cross-defendant and added causes of action that increased the amount in controversy to over $25,000 and tried twice to pay the court clerk the reclassification fee, the trial court was required to reclassify the case. Here, the trial court refused to reclassify the case and went on to deny Leonard’s later-filed motion for reclassification, a motion that was unnecessary because the trial court should have already reclassified the case (and in any event, the motion was the inappropriate vehicle by which to change the classification here). The Court therefore granted Leonard’s petition and issued a peremptory writ of mandate directing the trial court to reclassify the case upon Leonard paying the reclassification fee. View "Leonard v. Super. Ct." on Justia Law

Home Orthopedics Corp. was a medical equipment supplier based in Puerto Rico. Raul Rodriguez, the president of another home medical supplier in Puerto Rico, attempted to collect a consulting fee Home Orthopedics agreed to pay him. Home Orthopedics refused to continue paying the fee when it discovered that the contract upon which it was based was fraudulent. Soon companies in the health insurance field started terminating their contracts with Home Orthopedics. Home Orthopedics filed an amended complaint seeking relief against numerous defendants - some of whom worked with Rodriguez and others of whom worked for the companies that terminated their contacts with Home Orthopedics - for violating, among other laws, the Racketeer Influenced and Corrupt Organizations Act (RICO). Specifically, Home Orthopedics alleged that Defendants conspired to help Rodriguez strong-arm more money from Home Orthopedics. The district court dismissed Home Orthopedics’ claims. The First Circuit affirmed, holding (1) Home Orthopedics failed to sufficiently allege a “pattern of racketeering activity” necessary to sustain its RICO claim; and (2) the district court did not err in denying Home Orthopedics’ motion to conduct limited discovery and then to amend its complaint for a second time. View "Home Orthopedics Corp. v. Rodriguez" on Justia Law

Medical provider North Cypress Medical Center Operating Co., Ltd. and North Cypress Medical Center Operating Co. GP, LLC (collectively, “North Cypress” or “the hospital”) sued Cigna Healthcare, Connecticut General Life Insurance Company, and Cigna Healthcare of Texas, Inc. (collectively, “Cigna”) for breach of healthcare plans administered or insured by Cigna. North Cypress argued that Cigna failed to comply with plan terms and underpaid for covered services. Cigna counter-claimed, arguing that it paid more than was owed; that North Cypress as an out-of-network provider did not charge the patients for coinsurance, but billed Cigna as if it had. The district court dismissed North Cypress’s ERISA claims for want of standing and Cigna’s ERISA claims as time barred. Finally, the district court granted summary judgment against North Cypress’s breach of contract claims, concluding there was no breach. North Cypress appealed and Cigna cross-appealed. The Eleventh Circuit, after review, affirmed in part, reversed in part, and remanded for further proceedings. In holding that North Cypress had standing to bring ERISA claims, the Court removed the grounds for the district court’s preemption ruling. The parties did not brief the issue of whether the "Discount Agreement" claims would survive un-preempted. Accordingly, the Court vacated the grant of summary judgment and remanded so that the district court could consider the question of preemption in light of our ruling on standing. The Court affirmed the remainder of the district court’s judgment. View "North Cypress Medical Center, et al v. Cigna Health" on Justia Law

Sarun, uninsured when he received emergency services from a hospital owned by Dignity Health, signed an agreement to pay the "full charges, unless other discounts apply.” The agreement explained uninsured patients might qualify for government aid or financial assistance from Dignity. After receiving an invoice for $23,487.90, which reflected a $7,871 “uninsured discount,” and without applying for any other discount or financial assistance, Sarun filed a putative class action, asserting unfair or deceptive business practices (Business and Professions Code 17200) and violation of the Consumers Legal Remedies Act (Civ. Code, 1750). The complaint alleged that: Dignity failed to disclose uninsured patients would be required to pay several times more than others receiving the same services, the charges on the invoice were not readily discernable from the agreement, and the charges exceeded the reasonable value of the services. The trial court dismissed, finding that Sarun had not adequately alleged “actual injury.” The court of appeal reversed. Dignity’s argument Sarun was required to apply for financial assistance to allege injury in fact would be akin to requiring Sarun to mitigate damages as a precondition to suit. Mitigation might diminish recovery, butt does not diminish the party’s interest in proving entitlement to recovery. View "Sarun v. Dignity Health" on Justia Law

The Louisiana Supreme Court granted this writ application to determine whether a plaintiff had a private right of action for damages against a health care provider under the Health Care and Consumer Billing and Disclosure Protection Act. Plaintiff Yana Anderson alleged that she was injured in an automobile accident caused by a third party. She received medical treatment at an Ochsner facility. Anderson was insured by UnitedHealthcare. Pursuant to her insurance contract, Anderson paid premiums to UnitedHealthcare in exchange for discounted health care rates. These reduced rates were available pursuant to a member provider agreement, wherein UnitedHealthcare contracted with Ochsner to secure discounted charges for its insureds. Anderson presented proof of insurance to Ochsner in order for her claims to be submitted to UnitedHealthcare for payment on the agreed upon reduced rate. However, Ochsner refused to file a claim with her insurer. Instead, Ochsner sent a letter to Anderson’s attorney, asserting a medical lien for the full amount of undiscounted charges on any tort recovery Anderson received for the underlying automobile accident. Anderson filed a putative class action against Ochsner, seeking, among other things, damages arising from Ochsner’s billing practices. Upon review of the matter, the Supreme Court found the legislature intended to allow a private right of action under the statute. Additionally, the Court found an express right of action was available under La. R.S. 22:1874(B) based on the assertion of a medical lien. View "Anderson v. Ochsner Health System" on Justia Law