Court Rules that Treating Physicians May Testify as to Whether their Bills were Fair and Reasonable

Plaintiff Maria Napolitano was in a motor vehicle accident when the vehicle in which she was a passenger was struck in the rear by a truck driven by defendant Tony Hudson and owned by MSS Vending Inc.  As the time of the accident, she was insured under an automobile insurance policy that included a $50,000 limit for personal injury protection (PIP) benefits.  She sought more than $765,000 in medical expenses that exceeded her policy limits.  One of the issues in Napolitano v. MSS Vending Inc., 2019 N.J. Super. Unpub. LEXIS 2278 (App. Div. November 7, 2019) was whether her treating doctors could testify as to whether their medical charges were fair and reasonable or whether the plaintiff was required to provide an opinion of someone with expertise in billing practices or approved insurance rates of payment.

While this case was pending, the Supreme Court decided Haines v. Taft, 237 N.J. 271 2019, which found that uncompensated expenses included medical bills which were between the insured’s PIP policy limit and the $250,000 PIP statutory ceiling.  Additionally, the Napolitano Court noted that the New Jersey statute which was decided in response to the Court’s decision in Haines did not apply to this case.

However, nevertheless, the defense argued that the doctor’s testimony concerning their respective medical bills were inadmissible net opinions and the PIP fee schedule adopted by the Department of Banking and Insurance (“DOBI”) )should be applied to all medical bills and any recovery should be limited to the fee schedule amounts for services provided.

The Appellate Division rejected the defendant’s contention that the DOBI fee schedule contained presumptively reasonable amounts for medical services and that plaintiff’s claim was therefore limited to those amounts.  Because the accident occurred prior to August 1, 2019, under the new statute, the DOBI fee schedules did not apply to claims for medical expenses in excess of those paid under plaintiff’s PIP coverage.

The Court pointed out that all of the plaintiff’s testifying doctors were asked to examine the medical bills and state whether the treatments provided were necessary and the costs associated with those treatments reasonable.  The Appellate Division rejected the defendant’s argument that “whether medical charges reflect a fair and reasonable value of services rendered” requires “the opinion of someone with expertise in billing practices or approved insurance rates of payment.”  The Court noted that it has recognized that health care providers and health agencies themselves define what are usual, reasonable and customary charges for medical services.

In this case, all of the medical experts testified regarding the billings and the basis for the reasonableness of the charges.  The defendant had the opportunity and vigorously challenged the reasonableness of the bills, “both by noting that doctors who were frequently paid less by insurance companies and lack of personable knowledge of the billing procedures of associated providers.”  The Appellate Division concluded that the medical providers were competent witnesses who did not provide net opinions regarding the reasonable costs of the medical treatments and procedures they provided to the plaintiff.            

Hence, the Appellate Division affirmed the trial court’s decision in permitting the treating providers to testify as to whether their treatments provided were necessary and the costs associated with those bills were reasonable and necessary.

Tags: medical bills