Blue Cross & Blue Shield of Georgia, Inc. v. Shirley

699 S.E.2d 616, 305 Ga. App. 434, 2010 Fulton County D. Rep. 2676, 2010 Ga. App. LEXIS 706
CourtCourt of Appeals of Georgia
DecidedJuly 15, 2010
DocketA10A0326
StatusPublished
Cited by10 cases

This text of 699 S.E.2d 616 (Blue Cross & Blue Shield of Georgia, Inc. v. Shirley) is published on Counsel Stack Legal Research, covering Court of Appeals of Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Blue Cross & Blue Shield of Georgia, Inc. v. Shirley, 699 S.E.2d 616, 305 Ga. App. 434, 2010 Fulton County D. Rep. 2676, 2010 Ga. App. LEXIS 706 (Ga. Ct. App. 2010).

Opinions

MlKELL, Judge.

A Gwinnett County jury awarded Melanie Suzanne Shirley $52,136.30 in damages in an action she brought against Blue Cross and Blue Shield of Georgia, Inc. (“Blue Cross”), her insurer, for failure to pay a hospital bill. Blue Cross appeals from the judgment entered on the jury verdict, and the denial of its motion for judgment notwithstanding the verdict (“j.n.o.v.”), or in the alternative, for a new trial.

1. Blue Cross argues that the trial court erred in denying its motion for j.n.o.v., or in the alternative, for a new trial on Shirley’s [435]*435breach of contract claim. We find no error in the trial court’s denial of Blue Cross’s motion for j.n.o.v. on this issue, but we conclude that a new trial is required for reasons stated below.

The record here shows that at some time prior to June 2006, Shirley purchased an Individual Hospital/Surgical Contract (the “Contract”) from Blue Cross. The first paragraph of the Contract provides as follows:

This Contract is a LIMITED POLICY designed to offer you catastrophic coverage. The intent of this Contract is to provide benefits for basic inpatient services and outpatient surgical care when medically necessary. Strict limitations apply to other outpatient services. For example, this Contract does NOT cover outpatient medical care including physician office visits, prescription or over-the-counter drugs, nervous and mental care, maternity conditions, physical therapy, durable medical equipment and many other services. Exclusions are explained more fully in the Contract.

Section 3.3 (1) in Article 3 of the Contract, which is entitled “Hospital Inpatient Services,” essentially reiterates the introductory paragraph of the Contract, providing as follows:

This individual direct pay policy is designed to offer you catastrophic coverage. It pays for covered Hospital inpatient care and surgery and selected outpatient services related to inpatient admissions. Strict limitations apply to covered services. For example, this Contract does not cover outpatient medical care including Physician office visits, prescription drugs, nervous and mental care, maternity care, physical therapy, durable medical equipment and many other services. Exclusions are explained more fully in Article 9.

Section 9.1 (1) of Article 9 of the Contract lists “outpatient medical care including Physician office visits” as an item for which the insured will not receive benefits. Article 11, entitled “Conditions Under Which Benefits Shall Be Rendered,” defines “hospital inpatient benefits” in Section 11.1 as follows:

These benefits are available only if you are admitted as a bed patient to a Hospital on the order of a licensed Physician. You must be under the care of this Physician. The Physician must be a member of the staff of, or acceptable to, the Hospital where you are a patient. The service which you [436]*436get at a Hospital is subject to all the rules and regulations of the Hospital which you or your Physician selects. Such rules also control Admission policies.

At 5:48 p.m. on June 5, 2006, Shirley sought treatment at North Fulton Regional Hospital’s emergency room for chest pain. According to the hospital’s “Standard Chest Pain Admission Orders,” which includes a section entitled “Status,” offering the physician the option to check either “inpatient” or “observation,” Shirley was admitted for observation. Almost 23 hours later, Shirley was released. Patricia A. Barton, the hospital’s director of business services, testified that the “Standard Chest Pain Admission Orders” is a standard set order used by the hospital and that it is standard for the hospital to determine what information to submit in its billing form from the physician’s order; that the universal billing form sent electronically to Blue Cross for Shirley’s treatment specified Code 131, which means outpatient discharge, and is determined from the physician’s order; that the hospital’s billing system electronically codes the billing forms based on the data entered by the registration personnel, who can select inpatient admission, outpatient admission, or observation admission; and that the hospital considers “observation” as outpatient services. Blue Cross denied the claim for services submitted on Shirley’s behalf.

After receiving a request for payment from Shirley’s counsel, Sharon Moss, a senior legal specialist at Blue Cross, sent a letter to Shirley explaining that the bill was not paid because the claim was billed as outpatient care as Shirley was admitted to an observation room rather than an acute care room or unit for inpatient care and that the Contract did not pay for outpatient care. Moss testified that there was no room and board charge on Shirley’s bill; that Blue Cross requires precertification for emergency and hospital admissions but no precertification was required because Shirley was admitted for observation; that Blue Cross received a fax from the hospital on June 6, which indicated that Shirley was admitted for observation; that the hospital called Blue Cross to begin a precertification but that it was voided due to the fact that Shirley was placed in observation; and that the Contract does not include a definition for inpatient or outpatient but that observation means outpatient in the insurance industry.

In the instant case, Shirley presented no evidence other than her testimony to substantiate her claim that she was admitted as an inpatient at the hospital. Instead, she points us to the use of the word “admit” in the medical records, arguing that evidence of her admission and inpatient status was “overwhelming and uncontra-dicted” as shown in Blue Cross’s records, the hospital records, and [437]*437the standard dictionary definition of inpatient. As further support for her position, Shirley relies on her testimony that her room contained a hospital bed, medical equipment, and a bathroom, and that she was provided meals, nursing care, and various procedures and tests.

This appeal is governed by our holding in Michna v. Blue Cross and Blue Shield of Ga.,1 in which we interpreted provisions of the same catastrophic coverage policy at issue here under a similar factual scenario and concluded that the policy did not cover the patient’s medical bills where the patient was not charged for a room and his stay was less than 24 hours.2 As we held in Michna,3

[¡Insurance in Georgia is a matter of contract and the parties to the contract of insurance are bound by its plain and unambiguous terms. Whether a contract is ambiguous, however, is a question of law for the court. Thus, construction of contracts involves three steps. At least initially, construction is a matter of law for the court. First, the trial court must decide whether the language is clear and unambiguous. If it is, the court simply enforces the contract according to its clear terms; the contract alone is looked to for its meaning. Next, if the contract is ambiguous in some respect, the court must apply the rules of contract construction to resolve the ambiguity. Finally, if the ambiguity remains after applying the rules of construction, the issue of what the ambiguous language means and what the parties intended must be resolved by a jury. It is the function of the court to construe the contract as written and not to make a new contract for the parties. . . .

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Blue Cross & Blue Shield of Georgia, Inc. v. Shirley
699 S.E.2d 616 (Court of Appeals of Georgia, 2010)

Cite This Page — Counsel Stack

Bluebook (online)
699 S.E.2d 616, 305 Ga. App. 434, 2010 Fulton County D. Rep. 2676, 2010 Ga. App. LEXIS 706, Counsel Stack Legal Research, https://law.counselstack.com/opinion/blue-cross-blue-shield-of-georgia-inc-v-shirley-gactapp-2010.