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There is an ongoing battle to determine the definition of the phrase, “value of medical treatment rendered”, and what this means in regard to financial compensation for medical bills in Missouri Personal Injury cases. A recent unanimous decision by the Supreme Court at least puts an end to the bills paid being the only measure. Now it appears, both bills paid and amount charged will be submitted to the jury; however, many judges on the circuit level have held the statue unconstitutional and thus only amount charged has been submitted in may cases. This Supreme Court decision did not address the constitutionality of the statute; hopefully that issue will be considered int he future.

In 2003, a Missouri negligent driver rear-ended several cars. One of the Missouri personal injury and car crash victims of that car accident sustained several injuries, causing her to undergo surgery, physical therapy and other medical needs. She filed a Missouri personal injury lawsuit stemming from the car crash claiming the other driver was negligent in causing the collision and her personal injuries. She sought compensation for her medical expenses that totaled $28,000 but after adjustments, Medicare, supplemental insurance etc, only $9,900 was actually paid to the medical providers.

The Missouri car accident and personal injury claimant attempted to admit evidence which showed the full amount of her medical bills. She also had testimony of physicians to prove that her value of medical treatment was the amount billed to her, not the amount that was paid by insurance after adjustments.

The trial court would not allow this testimony on grounds that the presumption in section 490.715.5, in the RSMo Supp. 2005, (which states that the dollar amount, after adjustments, needed to pay the plaintiff’s financial obligation, constitutes the value of the medical treatment rendered), was not rebutted, and therefore the court determined that the value of the injury victim’s medical treatment was what she ended up having to pay – not what was billed.

In Deck v Teasley, The Supreme Court of Missouri reversed a portion of the trial court’s judgment regarding damages, remands the case for a new trial on the issue of damages. This unanimous decision was determined on the grounds that the trial court erred by misapplying the law by stating the statutory presumption was not rebutted, and by ruling that the claim for medical expenses was limited to the amount paid not the amount billed. The key to this is that the rebuttable presumptions requires the trial court to determine if the rebutting party has presented substantial evidence to prove that the value of the medical treatment rendered is a different amount from the amount necessary to satisfy the bill to the medical provider.

It also found that the evidence she was trying to present to the jury, was in fact admissible. By doing this, the jury was only permitted to hear evidence that the value of her treatment totaled $9,900 and was not allowed to consider evidence of the $18,100, which would naturally, affect the merits of the action. This also prevented the jury from considering the possibility of future surgeries and treatments.

Below is an excerpt from a Motion Missouri Personal Injury lawyer Ben Sansone drafted and files with the courts to prevent the insurance company from limiting the evidence to amount paid only.

“A: RSMO. 490.715.1 IS UNCONSTITUTIONAL

3. As this court is likely aware, the provisions of RSMo 490.715.1 regarding the value of medical treatment has been applied differently by Judges and courts throughout Missouri. This is a testament to the degree that the statute is ambiguous, vague, and thus unconstitutional.
4. On August 13, 2009, St Louis Circuit Court Judge Goldman held that the statute is unconstitutionally vague stating “§490.715.4 R.S.Mo. has a vague methodology that clearly and undoubtedly violates the substantive due process provisions of U.S Const.-Amend 14 and MO Const. Art. I, § 10[.]” (emphasis added) See Attached “Judgment” granting a New Trial, Vickery v. Glosemeyer, Case # 08SL-CC00824, St Louis County Division 12.
5. Additionally, RSMo. 490.715 violates both the right of a plaintiff citizen of Missouri to have a jury determine the fact issues in a case of law, and provisions for separation of powers between the judiciary and legislature. As provided in Article I, Sec. 22a, “the right of trial by jury as heretofore enjoyed shall remain inviolate…”
6. Article II, Sec. 1 provides: “The powers of government shall be divided into three distinct departments–the legislative, executive and judicial–each of which shall be confided to a separate magistracy, and no person, or collection of persons, charged with the exercise of powers properly belonging to one of those departments, shall exercise any power properly belonging to either of the others.” The determination of fact is a function of the judiciary, and cannot be usurped by the legislature. Nor can the legislature dictate to the judicial branch how it is to determine facts. The issue at hand is the determination of fact as to the value of medical services.
7. Prior to the Constitution’s enactment, the common law provided for determination of fact issues by a jury, and of law issues by a judge. After adoption of the Constitution, the same system has been followed, and is mandated.
8. Additionally, to interpret RSMo § 490.715 as Defense counsel suggests would violate the Equal Protection Clause of the Missouri Constitution in Article I, Section 2, and the Equal Protection Clause of the 14th Amendment of the United States Constitution because it classifies the value of the medical services rendered according to the status of the Plaintiff in terms of whether that person has health insurance, is uninsured, or is on government aid. There is no legitimate, state interest for said classification and, therefore, it does not pass constitutional scrutiny as required for this type of legislation.
9. Such an application would also violate the due process rights of the Plaintiff under Article I, Section 10, of the Missouri Constitution and under the 14th Amendment of the United States Constitution in that it deprives the Plaintiff’s right to property by conferring a benefit upon the Defendant tortfeasor at the Plaintiff’s expense and allows for a contracted-for and paid-for benefit of the Plaintiff to be taken away without due process. Specifically, Plaintiff has essentially pre-paid for their medical services in that they have been paying premiums for their health insurance for years. To take the benefits of those payments away from Plaintiff and provide them instead to the Defendant is unconstitutional.

B: DEFENDANT’S CLAIM THAT THE MEDICAL VALUE IS EQUAL TO THE AMOUNT PAID BY HEALTH INSURANCE IS ERRONEOUS.

10. The Defendant is claiming that the amount paid by health insurance is the value of the medical treatment incurred by Plaintiff under RSMo 490.715.1. See Defendant’s Motion ¶ 3.

11. In Berra v. Danter, 299 S.W.3d 690 (Mo Ct App. ED 2009), the Defendant argued that the court could only consider the medical bills incurred to the extent of the amount paid by health insurance. However, the Berra court rejected this argument stating “our courts have consistently distinguished amounts “incurred” from amounts ‘paid’” See Berra v. Danter, 299 S.W.3d at 311.
12. To “’Incur’ is [to] ‘become liable or subject to’. It is a synonym of ‘accrue’ […] Accruing or incurring [….] is not the same as paying.” Berra, 299 S.W.3d at 311, quoting Next Day Motor Freight Inc. v. Hirst, 950 S.W.2d 676, 680 (Mo. App. 1997).
13. Moreover, the bills paid is only a rebuttable presumption under RSMo 490.715.2 that can be rebutted when substantial evidence is introduced as the presumption then disappears. As a presumption is not itself evidence. Kellogg v. Murphy, 164 S.W.2d 285 (Mo. 1942); State ex rel. Christian v. Lawry, 405 S.W.2d 729 (Mo. App. 1966). Rather, it simply shifts the burden to the Plaintiff, to introduce some evidence rebutting it. Id.
14. It has long been held by Missouri courts that once contrary evidence is introduced, the presumption disappears. Forbis v. Forbis, 274 S.W.2d 800, 807 (Mo. App. 1955), Offord v. Jenner’s Estate, 189 S.W.2d 173 (Mo. App. 1945), Mercantile Bank v. Vilkins, 712 S.W.2d 1 (Mo. App. 1986); State ex rel.Christian v. Lawry, 405 S.W.2d 729 (Mo. App. 1966).
15. Under RSMo 490.715.5 the court can determine the value of medical treatment “based upon additional evidence, including but not limited to […] [t]he medical bills incurred by a party.” RSMo 490.715.2 (2)(a). “[W]hen substantial evidence is introduced, the presumption disappears[.]” See Berra v Danter, 299 SW3d at 701. Such evidence includes medical billing affidavits and expert testimony.
16. Once the presumption is rebutted by substantial evidence then the fact is determined “as if no presumption had ever been in effect.” Costello v. Miranda, 137 S.W.3d 498 (Mo. App. 2004).

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