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Insurance Company Must Proffer Expert Testimony or Other Competent Evidence to Prove the Fair and Reasonable Value of Medical Services

Brethren Mutual Insurance Co. v. Suchoza
Case No. 1787 (Maryland Court of Special Appeals)
by Joel M. Celso, Summer Associate
Semmes, Bowen & Semmes (www.semmes.com)

Defendant/Appellant, Brethren Mutual Insurance Co. (“Brethren”), appealed a jury verdict in the Circuit Court for Baltimore City, as to claims that Brethren failed to pay benefits under an uninsured motorist (“UM”) policy between Brethren and the Plaintiff/Appellee Suchoza’s employer, Matrix Mechanical, Inc. (“Matrix”). One of the issues on appeal was whether the circuit court erred when it refused to admit testimony of the payment of Suchoza’s workers’ compensation carrier and the acceptance thereof as full payment by his health care providers. The intermediate appellate court determined that the trial court did not err on the issue, and affirmed.

Suchoza was driving a commercial van within the scope of his employment as a Service Technician with Matrix on May 29, 2007. While stopped at a traffic light in Prince George’s County Maryland, Suchoza’s vehicle was struck in the rear by a pickup, as part of a chain reaction collision that began when the pickup truck was struck from behind by a Dodge Caravan. The driver of the Dodge Caravan was an uninsured motorist. As a result of the accident, Suchoza sustained injuries to his neck and left shoulder, requiring a cervical discectomy and fusion. Suchoza then filed a worker’s compensation claim.

Matrix maintained a UM policy with Brethren. The insurance policy contained a provision limiting Brethren’s liability in the event that an employee recovered worker’s compensation benefits stemming from the same accident for which UM benefits were sought. Suchoza filed a claim with Brethren under its UM policy, which Brethren denied. Suchoza then filed a complaint in circuit court alleging that Brethren’s denial constituted a breach of contract. As of the trial date, Suchoza had received $179,206 in workers’ compensation benefits, including $69,496 in medical expenses and $109,710 in lost wages.

At trial, Suchoza introduced evidence of his medical bills totaling $129,876, which he incurred as a result of the accident. Brethren tried to introduce evidence of the value of the medical services given to Suchoza by proffering evidence of the actual payments made by Suchoza’s workers’ compensation carrier and accepted as full payment by the health care providers. The circuit court refused admission of the evidence. The jury returned a verdict for Suchoza in the amount of $535,876, which the judge remitted to $356,669, reflecting the set-off for Suchoza’s previously received workers’ compensation benefits. Brethren appealed.

On appeal, Brethren argued that the trial court abused its discretion by excluding the amounts excepted as full payment by Suchoza’s health care providers. In writing for the Court of Special Appeals, Judge Woodward began by stating that the determinative issue governing the admissibility of Brethren’s proffered evidence was whether it was evidence of the fair and reasonable value of the medical expenses incurred by Suchoza as a result of the accident. The Court recognized that Brethren’s purpose in having the evidence admitted was to show the jury that the fair and reasonable value of the medical services rendered to Suchoza was the amounts paid and accepted by healthcare providers, not the amounts stated in the medical bills.

In relying on Maryland case law, the Court held that evidence of the payment of Suchoza’s medical bills would not establish the reasonable value of the services for which the bills were rendered, and therefore were irrelevant in determining reasonableness. To be admissible, Brethren had to adduce expert testimony or other competent testimony that the amount of such payment was the fair and reasonable value of the medical services given to Suchoza. Brethren had not done so in trial court. Further, the Court stated that it was not necessarily probative of the reasonable value of the medical services that the medical provider accepted payment of the lesser amount on a bill. Therefore, the Court affirmed the circuit court’s decision.