What Health Insurance Companies Write Binds Even In Spite of Interpretation Difficulties

An Eighth Circuit Court of Appeals case demonstrates the importance – even to health care services providers – of carefully scrutinizing contractual provisions in contracts with health insurance companies. In spite of some contractual interpretation difficulties, the Eighth Circuit has found that the contractual language binds. It favored the insurance companies, even on a motion for summary judgment. The case is 32^nd Street Surgery Center (“32^nd Street”) v. Right Choice Managed Care (“insurer”), No. 15-1727. https://www.courtlistener.com/opinion/3197844/32nd-street-surgery-center-v-right-choice-managed-care/

In this case, the health care provider 32^nd Street contracted with the insurer to become a network provider, which ensures increased patient volume as well as marketing and promotion by the insurer. In exchange for these benefits, a network provider generally agrees to receive discounted reimbursement rates. The disputed contract stipulated that a network provider is one “designated to participate in one or more [of insurer’s] Networks.” Another contractual stipulation stated, in much legalese, that if 32^nd Street’s participation was limited to a certain plan, which it was, it would only receive the discounted in-network reimbursement rates for services in relation to other plans of which it was not a member. In other words, even though 32nd Street had contracted for only one certain “stick” in the insurance provider’s overall bundle, the entire lower insurance bundle pricing applied to 32^nd Street.

This is boiled down from many gobbledygook contractual stipulations that, to me, seemed to indicate at least some reasonable factual doubt and thus at a minimum not to be suitable for summary judgment. But the court found the contract provisions sufficiently clear for that standard. Claims of unjust enrichment and quantum meruit were also rejected because they sound in quasi-contract whereas Missouri law does not allow such remedies when an express contract exists.

In today’s health insurance company apparent strong-arming tactics and power grabs, this case again demonstrates the importance of making sure that one has read and truly understands all the contractual provisions in the health care context. However, that is, as this case and others demonstrate, difficult enough to do for corporations with, presumably, sufficient assistance of counsel. But where does such law and precedent leave private individuals encountering similar problems? Not in a good place. This area is ripe for abuse by the stronger contractual party, which in this context always seems to be the health care insurance company. Arguments of good faith and fair dealing are, as this case demonstrates, largely or entirely ignored. The court did in this case. Good luck to future patients encountering problems of this nature. Further regulations truly seem to be in order in the health care field.