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Watts v. Promina Gwinnett Health System2/15/2000
MC-017C
Maggie Watts was taken by ambulance to the emergency room of Gwinnett Medical Center ("Gwinnett") after sustaining injuries in a vehicular collision. She was treated and released. The total bill for services rendered was $786.10. Ms. Watts had health insurance coverage through Kaiser Permanente Insurance Co. ("Kaiser"). Kaiser and Promina Health System, Inc., on behalf of its participating hospitals, including Gwinnett, have entered into an "Agreement for Hospital Services" ("Agreement"), which requires Gwinnett to charge a flat fee of $216.00 to Kaiser's insureds for " ny treatment(s) performed in the emergency room that does not result in an admission or any outpatient surgery." Gwinnett billed Kaiser $786.10; Kaiser paid $166, and Ms. Watts made a co-payment of $50, leaving a balance of $570.10. Gwinnett also filed a hospital lien in the Superior Court of Gwinnett County in the amount of $786.10. Ms. Watts later sued the tortfeasor and settled that action for $15,000.00. Kaiser asserted a subrogation claim for $539.00. Ms. Watts paid the hospital's lien in full and settled Kaiser's subrogation claim for $400.00. Gwinnett refunded $50.00 to Ms. Watts and $166.00 to Kaiser. Kaiser thus recovered a total of $566.00.
Ms. Watts then filed suit against Kaiser and Gwinnett. The allegations against Gwinnett include breach of contract for charging fees in excess of the flat fee set out in the Agreement and failing to pay attorney fees under OCGA § 15-19-14 (b); breach of good faith and fair dealing; violation of the Georgia Racketeer Influenced and Corrupt Organizations Act (RICO); conversion; fraudulent concealment; money had and received; and unjust enrichment. The claims were based on Gwinnett's recovery of $570.10 more than the flat fee in the Agreement. At the heart of this dispute is Article C, Compensation , Section C-1, which states in relevant part:
No Charges to Members: Participating Hospitals will look solely to [Kaiser] for compensation for Hospital Services rendered to Members under this Agreement. . . . Participating Hospitals agree that in no event . . . shall Participating Hospitals bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against any Member for Hospital Services provided pursuant to this Agreement.
Gwinnett answered and counterclaimed for declaratory judgment, asserting affirmative defenses of waiver, estoppel, preemption pursuant to 29 USC § 1001 et seq., and accord and satisfaction. In its counterclaim, Gwinnett sought a declaration that the Agreement did not prohibit it from filing a lien to recover fees for services rendered to Ms. Watts out of her recovery from the tortfeasor. Gwinnett also alleged the assignment of benefits Ms. Watts executed in the emergency room permitted Gwinnett to recover full payment pursuant to the lien.
The assignment states in relevant part:
I hereby irrevocably assign and transfer to Gwinnett Hospital System and treating Physicians all benefits and payments now due and payable or to become due and payable to me under any insurance policy or policies. . . . I understand and acknowledge that this assignment does not relieve me of my financial responsibility for all hospital charges and treating Physicians charges incurred by me . . ., and I hereby accept such responsibility, including but not limited to payment of those fees and charges not directly reimbursed to the Hospital and treating Physicians by any insurance policy . . .
Summary judgment was granted to Gwinnett on all claims and this appeal followed.
Held:
1. Ms. Watts' first and third enumerations will be consider
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