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Miami Valley Hospital v. Community Insurance Co.

August 7, 2006

MIAMI VALLEY HOSPITAL, PLAINTIFF,
v.
COMMUNITY INSURANCE COMPANY, DBA ANTHEM BLUE CROSS & BLUE SHIELD, THOMAS E. GRIFFITH, AND TONYA GRIFFITH, DEFENDANTS.



The opinion of the court was delivered by: Judge Thomas M. Rose

DECISION AND ENTRY REJECTING-IN-PART REPORT AND Recommendation OF UNITED STATES CHIEF MAGISTRATE JUDGE MERZ, (DOC. 22), SUSTAINING-IN-PART PLAINTIFFS' OBJECTIONS TO CHIEF MAGISTRATE'S REPORT AND Recommendation, (DOC. 24), AND GRANTING PLAINTIFF'S MOTION TO REMAND. (DOC. 7).

Pending before the Court are Plaintiff's Objections to the Report and Recommendation of Chief Magistrate Judge Michael M. Merz. Doc. 22. The Report and Recommendation, Doc. 20, concludes that Plaintiff's Motion to Remand, doc. 7, should be denied. As required by 28 U.S.C. § 636(b) and Federal Rule of Civil Procedure 72(b), the Court has made a de novo review of the record in this case. Upon said review, the Court finds that Plaintiff's objections, doc. 24, to the Report and Recommendation, doc. 22, are well taken and they will be sustained. Accordingly, the Court will grant Plaintiff's Motion to Remand. Doc. 7.

I. Background

Because the instant case is before the Court on a motion to remand to state court due lack of subject matter jurisdiction, the Court will draw its understanding of the case from the allegations made in the Amended Complaint:*fn1

2. Between January 24, 2005 and January 25, 2005, Plaintiff provided to Patient, on an emergency basis, medically necessary hospital services in the amount of $23,455.39.

3. At the time of admission, Patient executed the contract attached hereto as Exhibit "A." The contract provides that Patient will pay Plaintiff for all services provided by Plaintiff. The contract also assigned to Plaintiff payment of all insurance benefits to which Patient was entitled under any insurance policy.

4. Shortly after Patient's admission, Plaintiff requested from Anthem authorization to provide Patient medically necessary hospital services. In response to Plaintiff's request, Anthem affirmatively authorized Plaintiff to provide Patient such services. In reasonable reliance on Anthem's authorization, Plaintiff provided Patient with such hospital services.

5. On or about January 31, 2005, Plaintiff electronically submitted to Anthem the bill for the services provided to Patient. That billing expressly notified Anthem that Patient had assigned to Plaintiff all rights to payment of insurance benefits. Pursuant to R.C. § 3901.386,*fn2 Anthem is under a statutory duty to honor the assignment executed by Patient.

6. Upon information and belief, on or about February 14, 2005, Anthem issued a check in the amount of $3,869.97 directly to Patient in violation of R.C. §§ 3901.385*fn3 and 3901.386. At no time did Anthem provide Plaintiff with written notice of its denial of the balance of Plaintiff's claim.

7. Patient has failed to remit to Plaintiff any of the monies paid to him by Anthem.

8. There remains due and owing to Plaintiff the sum of $23,455.39 for the services provided to Patient.

COUNT I (Violations of O.R.C. §§ 3901.385 and 3901.386)

9. Anthem owes Plaintiff the sum of $3,869.97 by virtue of the assignment of benefits executed by Patient.

COUNT II (Promissory Estoppel)

10. Plaintiff realleges and incorporates herein by reference the allegations of Paragraphs 1 through 9 above as if fully rewritten.

11. At no time did Anthem withdraw its authorization for Plaintiff to provide hospital services to Patient.

12. At no time did Anthem request that Patient be transferred to another hospital.

13. Because of Anthem's authorization, and Plaintiff's reasonable reliance on that authorization, Anthem is estopped from denying payment of ...


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