Medicos Pain & Surgical Specialists, S.C. v. Travelers Indemnity Company of America , 103 N.E.3d 965 ( 2018 )

2018 IL App (1st) 162591
No. 1-16-2591
Fourth Division
April 26, 2018
______________________________________________________________________________
IN THE APPELLATE COURT OF ILLINOIS
FIRST JUDICIAL DISTRICT
______________________________________________________________________________
MEDICOS PAIN & SURGICAL SPECIALISTS, S.C., and )
AMBULATORY SURGICAL CARE FACILTY, LLC, ) Appeal from
) the Circuit Court
Plaintiffs-Appellees, ) of Cook County
)
v. ) 12-L-04140
)
TRAVELERS INDEMNITY COMPANY OF AMERICA, and ) Honorable
BLACKHAWK STEEL CORP., ) Brigid M. McGrath,
) Judge Presiding
Defendants-Appellants. )
JUSTICE McBRIDE delivered the judgment of the court, with opinion.
Justice Ellis concurred in the judgment and opinion.
Justice Gordon specially concurred, with opinion.
OPINION
¶1 Medicos Pain & Surgical Specialists, S.C. (Medicos), and Ambulatory Surgical Care
Facility, LLC (Ambulatory), provided surgical care to a machine operator who was injured at
work, Javier Mendoza, but had to wait several years for payment from Mendoza’s employer,
Blackhawk Steel Corporation (Blackhawk), and Blackhawk’s workers’ compensation insurer,
Travelers Indemnity Company of America (Travelers). Medicos and Ambulatory filed suit in the
circuit court and were awarded statutory interest pursuant to section 8.2(d) of the Workers’
Compensation Act (Act). 820 ILCS 305/8.2(d) (West 2010). 1 Section 8.2(d) states that late
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The parties’ arguments before the trial court and this court have included a mixture of
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payments to a medical service provider “shall incur interest at a rate of 1% per month payable to
the provider.” 820 ILCS 305/8.2(d) (West 2010). In this appeal, Blackhawk and Travelers
contend the interest award of $37,229 entered against them in 2016 is flawed for multiple
reasons, including that while this appeal was pending, this court determined in 2017 that
Medicos, Ambulatory, and other medical service providers who sued for statutory interest in
Marque Medicos do not have a private right of action for the failure of an employer or insurer to
comply with the interest provision of the Act. Marque Medicos Fullerton, LLC v. Zurich
American Insurance Co., 2017 IL App (1st) 160756, 83 N.E.3d 1027, pet. for leave to appeal
denied, No. 122568 (Ill. Nov. 22, 2017). Medicos and Ambulatory respond that in this instance,
however, they successfully proved the elements of their promissory estoppel claim seeking
statutory interest. Although they make no attempt to distinguish Marque Medicos, the appellees
also contend there are no grounds for reversing the trial court’s decision. Marque Medicos, 2017
IL App (1st) 160756.
¶2 The pertinent facts and legal principles are as follows. Mendoza severely injured both of
his shoulders and lacerated his nose while at work in mid-2010, when he fell off a truck from a
height of approximately four feet and landed on his left side. Mendoza was treated in a hospital
emergency room and put on work restrictions until cleared by a physician. Rest, physical
therapy, and other conservative treatment did not improve Mendoza’s mobility or decrease his
pain. He underwent further diagnostic testing, which revealed the severity of his injuries, and
references to section 8.2(d) and section 8.2(d)(3). Section 8.2(d)(3) was added by 2011
amendments to the Act, which reorganized that subsection and shortened the grace period for the
accrual of interest. Pub. Act. 97-0018 (eff. June 28, 2011) (recodifying and amending 820 ILCS
305/8.2(d) into 820 ILCS 305/8.2(d)(1)-(3)). Mendoza’s injuries and the billing events at issue in
this case occurred prior to the effective date of the 2011 amendments, but the amendment to
section 8.2(d) makes no impact on our disposition of this appeal. Here, we refer to section 8.2(d)
(820 ILCS 305/8.2(d) (West 2010)).
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came under the care of orthopedic surgeon Dr. Ellis Nam, who recommended immediate surgery
on both shoulders. Medicos faxed a one-page surgery approval request form to Travelers and
received its faxed response before Dr. Nam repaired Mendoza’s left rotator cuff in late 2010.
Ambulatory exchanged similar faxes with Travelers before Dr. Nam repaired Mendoza’s right
rotator cuff in early 2011. Medicos and Ambulatory share corporate offices and are owned by the
same physician. The two one-page forms identified the procedures to be performed and
contained a line for marking “Approved” or “Denied.” Although Travelers ticked the approval
line, the forms do not indicate the amounts that would be charged for the listed medical services.
¶3 About two years after Mendoza’s accident, Medicos and Ambulatory attached the
approval faxes and other exhibits to a complaint alleging they issued bills to Travelers and
Blackhawk for $166,944, but received only $1714. The medical care providers claimed the
insurer and employer were liable for the remaining balance under the equitable theory of
promissory estoppel, as well as statutory interest under section 8.2(d) of the Act. 820 ILCS
305/8.2(d) (West 2010). Under the legal theory of promissory estoppel, “ ‘a promise made
without consideration may nonetheless be enforced to prevent injustice if the promisor should
have reasonably expected the promisee to rely on the promise and if the promisee did actually
rely on the promise to his or her detriment.’ ” Newton Tractor Sales, Inc. v. Kubota Tractor
Corp., 233 Ill. 2d 46, 51, 906 N.E.2d 520, 523 (2009) (quoting Black’s Law Dictionary 591 (8th
ed. 2004)); Centro Medico Panamericano, Ltd. v. Laborers’ Welfare Fund of the Health &
Welfare Department of the Construction & General Laborers’ District Council, 2015 IL App
(1st) 141690, ¶ 12, 33 N.E.3d 691 (setting out the elements the plaintiff must prove). The
defendant’s promise must be unambiguous. Newton Tractor Sales, 233 Ill. 2d at 51; Centro
Medico, 2015 IL App (1st) 141690, ¶ 12. According to Medicos and Ambulatory, the two
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approval faxes amounted to an unambiguous promise to pay Mendoza’s surgical bills (even
though the faxes did not specify an amount or percentage of any charges or refer to the Act’s
schedule of allowable medical fees). Although Medicos and Ambulatory sought the balance of
the medical bills, the complaint suggests the purpose of their lawsuit was to collect statutory
interest, not the underlying bills. Medicos and Ambulatory titled the first paragraph of their
pleading “Nature of the Case,” and stated: “1. This suit seeks to recover statutory interest that has
accrued and is immediately due and payable as a result of medical services provided by
Plaintiffs. In addition, Defendants have damaged Plaintiffs by approving certain surgical
procedures in advance, to induce Plaintiffs to allow those procedures to be performed in their
facility[,] and thereafter failing to pay for those procedures.” Another indication that the lawsuit
was about the statutory interest, not the underlying bills, is that it is well established by statute
and precedent that compensation owed for an employee’s accidental injuries, including “all the
necessary first aid, medical and surgical services, and all necessary medical, surgical, and
hospital services thereafter incurred” (820 ILCS 305/8(a) (West 2014)), is an issue over which
the Illinois Workers’ Compensation Commission (Commission) has exclusive jurisdiction and
that the role of the circuit court in compensation proceedings is limited to review only of the
Commission’s determinations. Marque Medicos, 2017 IL App (1st) 160756, ¶ 18.
¶4 Amendments to the Act in 2005 limited the amount that providers could charge for
covered medical services but added the interest provision of section 8.2(d) of the Act. Marque
Medicos, 2017 IL App (1st) 160756, ¶¶ 19-20 (discussing the history of section 8.2(d)). The
2005 version of section 8.2(d) indicated, in relevant part, “In the case of nonpayment to a
provider within 60 days of receipt of the bill which contained substantially all the required data
elements necessary to adjudicate the bill or nonpayment *** [in accordance with] the fee
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schedule established in this Section, the bill, or portion of the bill, shall incur interest at a rate of
1% per month payable to the provider.” Marque Medicos, 2017 IL App (1st) 160756, ¶ 20
(quoting Pub. Act 94-0277, § 10 (eff. July 20, 2005)). Further amendments to the Act in 2011
reduced the maximum medical fees by 30% but shortened the 60-day grace period to 30 days
and, for the first time, mandated “ ‘[a]ny required interest payments shall be made within 30 days
after payment.’ ” Marque Medicos, 2017 IL App (1st) 160756 (quoting Pub. Act 97-0018, § 15
(eff. June 28, 2011)).
¶5 Consistent with the Act, Medicos and Ambulatory’s action in the circuit court was stayed
pending arbitration of Mendoza’s claim before the Commission. There was no dispute as to the
necessity of Mendoza’s two surgeries. The arbitration proceedings focused on the types of
medical service charges and the amounts, whether penalties and attorney fees should be imposed,
and whether Mendoza, who was 44 when the accident occurred, had been permanently injured.
Mendoza did not seek interest on any of the medical service charges.
¶6 In February 2013, the arbitrator issued a ruling based on the testimony, the documentary
evidence, and the medical fee schedule contained in the Act. Travelers had made interim
payments for Mendoza’s two surgeries and reduced the bills by roughly half. The arbitrator
determined the remaining charges were “reasonable and necessary” and awarded Medico an
additional $29,708 and Ambulatory an additional $38,554. The arbitrator rejected Mendoza’s
contention that, because the surgeries were preauthorized, all the bills should have been paid and
that he was entitled to penalties pursuant to sections 19(k) and 19(l) of the Act and attorney fees
pursuant to section 16 of the Act (820 ILCS 305/16, 19(k), 19(l) (West 2012). The arbitrator
found that although the need for the surgeries had not been in contention, “there was clearly a
disagreement as to whether all the charges stemming from those surgeries were reasonable and
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whether the outstanding fee schedule charges were accurately calculated [or had been double
billed in error].” The arbitrator also found that Mendoza was entitled to permanent partial
disability benefits. When Mendoza received the award payment, he remitted it to Medicos and
Ambulatory.
¶7 The parties to the circuit court case (the employer, the insurer, and the two surgical care
providers) returned to court and prepared for a bench trial limited to the issue of interest.
Medicos and Ambulatory sought section 8.2(d) interest totaling $17,927 for the first surgery,
section 8.2(d) interest totaling $19,303 for the second surgery, and $2208 in 5% prejudgment
interest. 820 ILCS 305/8.2(d) (West 2010). During opening arguments, counsel for Medicos and
Ambulatory made clear that his clients were asserting a statutory claim only:
“What remains here is purely a claim for interest under Section [8.2(d)(3)] of the
Illinois Workers’ Compensation Act. There are very few factual matters that go into an
analysis of what my clients [are] owed under that statute, and that’s all that’s at issue in
this trial, Judge.
***
Judge, as a brief opening, a couple of remarks. [This is a] case about payment of
interest on late paid medical bills. There’s a provision of the Illinois Workers’
Compensation Act that we’ve already mentioned, Section 8.2(d)(3)[,] that sets forth the
circumstances under which a provider of medical services is entitled to the payment of
interest at 1 percent per month on late paid medical bills.
Under Section 8.2(d)(3), the facts that are relevant are: Was there a medical bill, was
that medical bill sent and received by the employer and the payor of the bill.
Was that bill accompanied by all of the necessary data elements for adjudication of
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the bill. Was that bill paid, in this case, within 60 days of receipt, and if not, was interest
paid within 30 days after payment of the bill.
What you’ll hear in this trial, Judge, is a series of dates. You’ll hear about the date of
services provided for two surgeries were performed in September 2010 and February
2011.
Shortly after those surgical procedures were performed at my client’s facilities,
facility bills were sent to Travelers, one of the defendants in this case. There’s really no
dispute about the fact that the bills were sent, that they were received. You will hear
about the dates when those things happen because the dates are what really matter under
the statute. When was something received, if it wasn’t paid within 60 days after receipt,
interest begins to accrue at 1 percent per month.”
¶8 The only witnesses at the one-day bench trial were the sole owner of Medicos and
Ambulatory (Dr. Derrick Wallery) and a Travelers claims case manager who was called as an
adverse witness (Deborah Nerad). Their testimony established the billing dates, that the bills
were presented in detail in an industry-standard format known as UB-04 and were accompanied
by detailed medical records, and that the bills were not paid until required by the Commission.
At no point in the trial did Medicos or Ambulatory attempt to introduce the approval faxes or
argue that they were relevant.
¶9 After the witnesses testified, the parties filed written closing arguments. Travelers and
Blackhawk also tendered Circuit Court Judge Rita M. Novak’s ruling issued just six days prior in
four consolidated proposed class actions known as Marque Medicos LLC v. Zurich American
Insurance Co., Nos. 2015 CH 1580, 15 CH 4946, 15 CH 4949, and 15 CH 4951, in which a
group of medical service providers sued a group of workers’ compensation insurers alleging they
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were in violation of section 8.2(d)(3). 820 ILCS 305/8.2(d)(3) (West 2014). Judge Novak had
ruled that the medical service providers, which included Medicos and Ambulatory, could not
pursue their statutory interest claims under theories of an implied-in-fact contract, an implied
private right of action under the Act, or as third-party beneficiaries of various workers’
compensation insurance policies, and she dismissed the proposed class actions with prejudice.
Medicos and Ambulatory objected to the presentation, without leave of court, of Judge Novak’s
new ruling, and further contended that the promissory estoppel action they were asserting against
Travelers and Blackhawk was factually and legally different from the issues that had been
addressed by Judge Novak.
¶ 10 At a hearing on March 11, 2016, the trial judge acknowledged Judge Novak’s ruling but
awarded the full amount of interest claimed by Medicos and Ambulatory.
¶ 11 Travelers and Blackhawk sought reconsideration, arguing that the promissory estoppel
claim as to underlying bills became moot once the Commission entered its award and that it was
inappropriate for the court to proceed solely on the statutory interest claim. They also contended
the award of prejudgment interest was unwarranted. The trial judge ruled that the elements of
promissory estoppel had been satisfied, but she deducted the prejudgment interest from the
award and entered an amended judgment for only section 8.2(d) interest. 820 ILCS 305/8.2(d)(3)
(West 2010). That judgment is now on appeal.
¶ 12 Travelers and Blackhawk first argue that the award should be reversed because the
medical service providers failed to prove promissory estoppel as alleged in their complaint,
because they did not introduce into evidence or even mention the preauthorization faxes on
which they purportedly relied to their detriment, and because they further failed to present any
testimony regarding any of the elements of a promissory estoppel claim. The appellants contend
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Medicos and Ambulatory instead pursued a statutory interest claim based solely on their billing
history and that a judgment on the unproven promissory estoppel allegations is reversible error.
They point out that in the case that proceeded before Judge Novak, she rejected all of Medicos
and Ambulatory’s statutory interest claims and dismissed the case with prejudice. We add that
while the current parties were briefing their arguments, another panel of this appellate court
affirmed Judge Novak’s judgment against the medical service providers and that the Illinois
Supreme Court denied a petition for leave to appeal. Marque Medicos, 2017 IL App (1st)
160756, pet. for leave to appeal denied, No. 122568 (Ill. Nov. 22, 2017). In the alternative,
Travelers and Blackhawk argue that the trial court lacked subject-matter jurisdiction to address
the claim because all disputes regarding compensation and interest under the Act are within the
exclusive jurisdiction of the Commission. Another alternative argument they make is that the
arbitration proceedings operate as res judicata as to all forms of compensation and statutory
interest because, although medical service providers do not have a right to appear before the
Commission, these providers were in privity with Mendoza and Mendoza could have pursued the
claim to section 8.2(d) interest. 820 ILCS 305/8.2(d) (West 2010). Travelers and Blackhawk
conclude that we should reverse the interest award and remand the case with directions to the
trial court to enter judgment against Medicos and Ambulatory.
¶ 13 Medicos and Ambulatory respond that the theory of promissory estoppel became
irrelevant when the Commission upheld the arbitrator’s award for medical service fees and the
parties returned to the circuit court to address the issue of interest and that the trial evidence
showed late payment, which, under the Act, entitled Medicos and Ambulatory to section 8.2(d)
interest. 820 ILCS 305/8.2(d) (West 2010). Medicos and Ambulatory contend the appellants’
main argument is an attempt to distract this court from the real issue at hand, which is that
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Medicos and Ambulatory were entitled to statutory interest, “not by [promissory estoppel or]
quasi-contract, but by the plain language of the Act.” Medicos and Ambulatory cite Marque
Medicos, 2017 IL App (1st) 160756, ¶ 38, but only for its conclusion that the trial court properly
exercised subject-matter jurisdiction over common-law claims regarding section 8.2(d)(3)
interest, and that the Commission is not authorized to resolve such common-law or statutory
claims. Medicos and Ambulatory also contend that res judicata was not triggered by the
Commission’s final order, because the Commission has no authority over promissory estoppel or
other common-law claims.
¶ 14 The appellees’ contention that the common-law theory of promissory estoppel became
irrelevant after the Commission awarded Mendoza compensation under the Act is a weak
attempt to excuse the appellees’ failure to prove the elements of their common-law claim. It
cannot be seriously contended that the Commission’s award to Mendoza, which was based
entirely on his statutory right to compensation for a work-related injury, somehow established
that (1) Traveler’s presurgical faxes to Medicos and Ambulatory were an unambiguous promise
to pay the surgical bills, (2) that Medicos and Ambulatory relied on that promise, (3) that the
reliance was expected and foreseeable, and (4) that the reliance was detrimental to Medicos and
Ambulatory. Newton Tractor Sales, 233 Ill. 2d at 51 (setting out the elements of promissory
estoppel); Centro Medico, 2015 IL App (1st) 141690, ¶ 12 (same). The Commission’s award had
no effect on the promissory estoppel claim.
¶ 15 With or without the allegations that were intended to invoke the common-law theory of
promissory estoppel, the plaintiffs’ only basis for claiming interest was section 8.2(d) of the Act.
The complaint made this limitation clear. This limitation was further confirmed by (1) counsel’s
introductory remarks at the one-day trial, (2) the fact that the trial evidence and testimony was
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limited to the bills and omitted even a mention of the approval faxes, (3) counsel’s concluding
remarks that interest should be awarded because “it took my client nearly four years to get paid,”
(4) and a posttrial brief in which the plaintiffs argued that by “prov[ing] all the elements required
by 805 ILCS 305/8.2(d)(3) by a preponderance of the evidence,” they became entitled to
judgment.
¶ 16 We conclude that Marque Medicos is controlling. Before reaching the merits of the
appeal, the Marque Medicos court held that the circuit court properly exercised subject-matter
jurisdiction over a complaint that purported to rely on a common-law theory. Marque Medicos,
2017 IL App (1st) 160756, ¶ 38. The reviewing court then held that the plaintiff medical service
providers had no private right of action to be compensated for the purported failure of the
defendant workers’ compensation insurer and employer to comply with the interest provision of
section 8.2(d)(3) of the Act. Marque Medicos, 2017 IL App (1st) 160756, ¶ 38. As the court
explained in Marque Medicos, a party may assert a right to be compensated for the violation of a
statute only if a private right of action was authorized by the legislature. Marque Medicos, 2017
IL App (1st) 160756, ¶ 57. There is no language in the statute that expressly authorizes a private
right of action. A private right of action may be implied by statute only where “(1) the plaintiff is
a member of the class for whose benefit the statute was enacted; (2) the plaintiff’s injury is one
the statute was designed to prevent; (3) a private right of action is consistent with the underlying
purpose of the statute; and (4) implying a private right of action is necessary to provide an
adequate remedy for violations of the statute.” Marque Medicos, 2017 IL App (1st) 160756,
¶ 57. The failure to satisfy any of the four factors is fatal to a claim. Marque Medicos, 2017 IL
App (1st) 160756, ¶ 57. In Marque Medicos, the court affirmed the circuit court’s finding that
medical service providers, which included Medicos and Ambulatory, could not satisfy the first
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factor. This court also rejected the medical service providers’ argument that because the payment
obligations of section 8.2(d) of the Act were to be made to medical service providers and no one
else, medical service providers should be considered members of the class benefited by the Act
and capable of satisfying the first factor. Marque Medicos, 2017 IL App (1st) 160756, ¶ 58. The
argument was rejected because it is well established that the fundamental purpose of the Act is to
protect employees by providing them with prompt and fair compensation for work related
injuries, regardless of fault. Marque Medicos, 2017 IL App (1st) 160756, ¶ 60. Further,
“[the interest payment mandated] by section 8.2(d)(3) of the Act is but one of the many
provisions in the Act designed to encourage the ‘prompt’ payment of compensation by an
employer or insurer and to penalize any failure to make such prompt payment of
compensation. [Citation.] While providers might receive some benefit from the specific
interest provision contained in section 8.2(d)(3) of the Act, that benefit is at most
incidental and was provided solely in an effort to serve the legislature’s primary goal of
compensating employees completely and promptly.” (Emphases in original.) Marque
Medicos, 2017 IL App (1st) 160756, ¶ 60.
¶ 17 Accordingly, the court concluded that the medical service providers’ claim for statutory
interest failed as a matter of law, and it affirmed the circuit court’s dismissal with prejudice.
Marque Medicos, 2017 IL App (1st) 160756, ¶¶ 61, 75.
¶ 18 Medicos and Ambulatory do not argue any grounds for reconsidering the analysis and
holding in Marque Medicos.
¶ 19 We find that regardless of whether Medicos and Ambulatory intended to proceed under
the promissory estoppel theory or purely on a statutory basis, ultimately their only basis for
claiming interest was section 8.2(d) of the Act and that the claim failed because medical service
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providers are not members of the class for whose benefit the Act was enacted. Marque Medicos,
2017 IL App (1st) 160756, ¶ 61. Consistent with Marque Medicos, we find that the plaintiff
medical service providers failed to state a claim upon which relief could be granted and that the
trial court erred in awarding the statutory interest, which the plaintiffs sought in their single
count pleading. As a result of this conclusion, we need not address the appellants’ other
arguments. We vacate the amended judgment order at issue on appeal.
¶ 20 Vacated.
¶ 21 JUSTICE GORDON, specially concurring:
¶ 22 I agree with the majority that the circuit court of Cook County must be reversed because
the plaintiffs had no private right of action, but I believe that finding is based solely on the rule
that the Workers’ Compensation Act (Act) is the exclusive remedy for all provisions of the Act
unless the Act says otherwise. 820 ILCS 305/5(a) (West 2010). The legislature has vested
exclusive original jurisdiction in the Workers’ Compensation Commission over matters
involving an injured worker’s rights to benefits under the Act and an employer’s defenses to
claims under the Act. 820 ILCS 305/1 et seq. (West 2010). The role of the trial court in workers’
compensation proceedings is to act in an appellate capacity only on a properly filed matter
governing a decision of the Workers’ Compensation Commission. 820 ILCS 305/5(a) (West
2010). Section 8.2(d) of the Act states that late payments to a medical service provider “shall
incur interest at a rate of 1% per month payable to the provider.” 820 ILCS 305/8.2(d) (West
2010). The injured worker did not request enforcement of section 8.2(d) in the proceedings
before the Workers’ Compensation Commission, and the plaintiffs were not parties in that
proceeding. The circuit court of Cook County had no jurisdiction to decide the issue of interest
and cannot decide any of the theories advanced by plaintiffs.
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