Out-of-Network NJ Cardiologist Wins a Case Against Aetna

A recent decision by a New Jersey Appellate Court confirmed an out-of-network provider’s right to collect from an insurance company for emergency services he rendered to patients covered by the insurance company. 

Instead of paying for emergency services on an out-of network basis, argued the out-of-network interventional cardiologist, Aetna turned to the courts. In a lawsuit, the insurer accused the doctor of wrong doing that ranged from insurance and common law fraud to violations of the New Jersey Board of Medical Examiners’ regulations against excessive fees. The doctor counter sued for, among other things, unjust enrichment, in order to obtain payment for services he rendered to patients with a cardiac emergency. He objected to insurer’s claims that his fees were excessive, arguing that he charged the reasonable value of his services given his education and experience.

The jury found for the doctor on his claim for unpaid services and awarded him slightly less than $2 million dollars. Both sides appealed the final judgment.

On appeal, Aetna argued that the cardiologist should only recover the “fair value” of his services and further argued that the trial judge erred in rejecting its request that the jury be instructed on the “fair value” measure of damages. The Appellate Division, however, did not disturb the ruling of the trial court.

The trial court held, for example, that it was not going to define the “‘fair value’ of the doctor’s services, concluding that such a determination is ‘not the prerogative of the [c]ourt.'” The appeals court agreed. The Appellate Division further affirmed the trial court’s finding which concluded that the defendant doctor “is an out-of-network provider who may, within the bounds of ethics, charge a rate he believes is commensurate with the quality of his service.” Interestingly, during trial, the Judge excluded evidence comparing his rates to other rates in the market from the jury finding that “[h]is charges compared to that of other providers was not relevant.”

This is not the first time that Aetna battled with out-of-network providers and lost. Aetna has been previously been fined by the New Jersey Department of Banking and Insurance for not paying out-of-network providers “a benefit large enough to insure that the non-participating provider does not balance bill the member…”

If you have questions regarding this recent decision, have an out-of-network dispute with an insurer, or have other health law question, please contact our office