WPC zbn3tAPe'~BVO\d|ן> Z*JOWǔ\d!]p7~Lcڝ@~pW"Ԛa^,f!y'NCAE ]#W20HJGն  7 Ȍh`'U*_[;5sCH_yk[xC*~a0'a D`.j=hҬчʗ+_{ <2 5ԐৎT'dUvwDz9mxv: D:b;  _պzx=VB43J}x{NW '!  e÷2Mz+]oCl>W&NW\ V?*8$2ר~zy4GjZ%okG0n0^>b тHn%"-A#Hs[y__*# LU :W % 0(b w@4 . 0l 0DOM  U:########## B] AQz 0D 0D 0D D/]] B D3HP LaserJet 4SiHPPCL5MS,,,,,,0nLh,  AZ"Arial RegularX($- - %D&'()D*+b,b-.Ӏy&RBRBRB3|x7 XX      1    IKings18:44(TheLivingBible).((3$ !      0  (#$  0   XX      2    ThecomplaintalsoallegedthatthehospitalviolatedtheTennesseeConsumerProtectionAct,  Tenn.CodeAnn.4718101,et.seq.;thatthecontractwiththehospitalwasanadhesioncontract;andthatthehospitalhadviolatedadutyofgoodfaithandfairdealing.Allthevarioustheoriesarebasedontheallegationthatthehospitalschargesareunreasonable. C6XX      3    Thecourtwasnotbreakingnewgroundinthisapproach.InMercyHospitalv.Carr,297So.2d  598(Fla.3dDCA1974),thewritingsignedbythepatientsaidthatallchargesareinaccordancewithexistingstandardandcurrentratesassetforthinregularscheduleswhichareavailableforinspectionandreview.Findingthatthislanguagecreatedacontract,thecourt,neverthelesssaid(withoutcitation)thatthepatientwasnotboundbythechargesputinthecontract asheisentitledtoquestionthereasonablenessthereof.297So.2dat599.SeealsoPaynev.HumanaHospitalOrangePark,661  So.2d1239(Fla.DCA1995).   6XX     4    Thehospitalalsoreliesona1995trialcourtdecision,VanderbiltUniversityv.Everett,No.93C  2126(DavidsonCounty).Inthatcase,theagreementreferredtothehospitals regularcharges.Thecourtheldthatthereferencewastothehospitals chargedescriptionmaster,alistofmorethan35,000items,whosechargeswereadjustedonanannualbasis.TheEverettcaseisnotbeforeusforreview, X andthetrialcourtsdecisionisobviouslynotbindingonthiscourt. ""  XXXX=h XX   Ad FILEDXX =h  August27,1999CecilCrowson,Jr.AppellateCourtClerkdAh             ,cAZ"Arial Regular d!"#$&C<< CLevel 1Level 2Level 3Level 4Level 5(3$ !  (3$ !  ($$   1  ((' dxdP Pd'dxd !  TR[A' Legal3'A' Legal3'T7XXdd7    F4XX  OaOa,+[+,,f,...r )<,(j 8` `@E` 8ttxP,  rߛ.@  INTHECOURTOFAPPEALSOFTENNESSEE  @(ATNASHVILLE XXF4Ԉ  JANEDOEandherhusband 8   )   JOHNDOE,ontheirbehalf, 8   ) p  andonbehalfofallotherpersons  ) V  similarlysituated,     8   ) <    0      8   ) Plaintiffs/Appellees, 8   )  AppealNo. X    0      8   )  01A019806CV00306 >  МVS.  0      8   ) $    0      8   )  DavidsonCircuit   МHCAHEALTHSERVICESOF 8   )  No.92C2041   H!  #    TENNESSEE,INC.,d/b/a   8   )   МHCADONELSONHOSPITAL, 8   ) l   0      8   ) Defendant/Appellant. 8   ) 8 @ APPEALEDFROMTHECIRCUITCOURTOFDAVIDSONCOUNTY@#ATNASHVILLE,TENNESSEE@ THEHONORABLEHAMILTONV.GAYDEN,JR.,JUDGEG.GORDONBONNYMAN,JR.203SecondAvenue,NorthNashville,Tennessee37201RALPHI.KNOWLES1355PeachtreeStreetAtlanta,Georgia30309JOHNA.DAYKATHRYNBARNETT150FourthAvenue,NorthNashville,Tennessee37219 AttorneysforPlaintiffs/AppelleesH.LEEBARFIELD,IIJAMESO.BASS,JR.ROBERTE.COOPER,JR.E.CLIFTONKNOWLES2700FirstAmericanCenterNashville,Tennessee372382700 AttorneysforDefendant/Appellant@$AFFIRMEDANDREMANDED  0      8      @ BENH.CANTRELL,  0      8      @ PRESIDINGJUDGE,M.S.CONCUR:CAIN,J.̜COTTRELL,J.,[  ,++ ]XX@tt(OPINION XX]Ԉ :^5; f    0 Thisdeceptivelysimplecontractquestionmaybelikethecloud aboutthesizeofamanshand   #  1      ׀thatproducedagreatstorm.Atissueiswhetherapatients H promisetopayahospitals chargesincorporatesbyreferencethehospitalssecret,proprietarylistmaintainedforbillingpurposes.TheCircuitCourtofDavidsonCountyϜheldthatthepromisedidincorporatethelistbyreference,butheld,nevertheless,thatthechargeshadtobereasonable.Weconcurintheresultreachedbythetrialcourtbutonadifferentbasis.Thereforeweaffirm.@- I.  ,   0 JaneDoesoughtadmissiontoaDonelsonhospitalforamedicalprocedure.Shewascoveredbyinsurancethroughherhusbandsemployer,andshesignedaform,furnishedbythehospital,pertainingtothepaymentofherbill.Wereproduceithereinitsentirety:8 80 ! !Icertifythattheinformationgivenbymeiscorrect.Iherebyauthorizepaymentto HCADonelsonHospital    insurancebenefitshereinspecifiedandotherwisepayabletomebutnottoexceedthetotalchargesforthishospitalconfinement.Inapplyingforpaymentof[sic]underTitleXVIIIorTitleXIXoftheSocialSecurityAct,Irequestpaymentofauthorizedbenefitstobemadeonmybehalf.IunderstandIamfinanciallyresponsibletothehospitalforchargesnotcoveredbythisauthorization.Ifurtherassumeresponsibilityforpaymentofreasonableattorney/and/orcollectionfeesintheeventsuchcostsareincurredinthecollectionofthisdebt. 0 0    0 Ms.Doesinsurancepaiditsshareofthebillandthehospitalbilledherforthebalanceof$1,346.21.Ms.Doeandherhusbandaskedfortimetopaythebalance,butaftersixmonths,thehospitalturnedtheaccountovertoacollectionagency.TheDoessuedthehospitalforadeclaratoryjudgmentthatthehospital breacheditscontractwiththembydemandingunreasonablechargesforitsgoods `4/5 andservices.   #  2      ׀Thecomplaintalsosoughttorepresentaclassofplaintiffssimilarly   situated.  0 Thehospitalfiledananswerdenyingthematerialallegationsofthecomplaintandacounterclaimfortheunpaidbill.Thepartieswarilycircledoneanotherforoverfouryears.Duringthatperiodthecourtdidenteranorderconditionallyallowingtheactiontobemaintainedasaclassaction.Finally,thehospitalmovedforsummaryjudgmentonthegroundthatthe chargesMs.Doeagreedtopayonheradmissionreferredtothehospitals chargemaster,aconfidentiallistofthechargesmadebythehospitalforallitsgoodsandservices.  0 ThetrialjudgeheldthattheuseofthechargemasterdidnotviolatetheConsumerProtectionAct,didnotamounttobadfaith,andwasnotabreachofcontract.Inafootnotethecourtalsoheld:8 80 ! !  TheCourtfindsthatthecontractisnotanopenpricecontract,butacontractincorporatingapricetermbyreference.Suchcontractsarevalid: Ifapromiseindefiniteastopriceiscapableofbeingmadecertainbyanobjectivestandardthroughextrinsicfacts,itwillbeenforced.WillistononContracts4:27;Vanderbiltv. `'"% Everett,No.93C2126.Thisdoesnot,however,dispose P(#& oftheissueofthereasonablenessofthechargescontainedonthechargemaster,nordoesitaddresstheissueregardingtheroleofthirdpartypayorsinestablishingameetingoftheminds. 0 0    0 Thecourtwentontosay:8 80 ! !  Theseissues,thepracticalnecessityofmaintainingaChargeMasterlistofover7,000itemsandservicesasaseparatedocumentfromapatient/hospitalcontract, 3.2 Oa  assignmentofbenefits,guaranteeofpayment,etc.underscoresandillustratestheuniquenessofthefieldofhospital/healthcareendeavorswhenviewedthroughthelensofconventionalcontractlaw.Hospitalsare+Oa  +$/e  $concernedwithdeliveringcriticalcaretodiverseand,Oa  ,disparatetypesofpatientsandtypesofsituations.This#/e  #dutyisgivengreatweightbythecourtinaddressingtheparametersofwhatkindofevidencemaybeconsideredinarrivingatatestofwhetherthepricesofitemsorservicesareunreasonable,arrivedatinbadfaith,orareϜunconscionable.ThisongoingdutyofcriticalcareisalsobeingconsideredbytheCourtinsofarastheclassactiondesignationisconcerned,andthewaydamages,ifany,aretobecomputed. 0 0  8 80 ! !  Simultaneoustodeliveryofthiscriticalcareservicetothepublicisthenotionthatthepatientsshouldnothavetopaymorethanisreasonableunderthecircumstances.Andthehospitalshouldnotbeallowedtoreapthebenefitofanunfairbargain.Indeterminingwhatisunreasonableorunconscionableorinbadfaith,therearemanyconsiderationstobetakenintoaccount,assuredlysomeofwhichthecourtisyettobemadeawareof.Nevertheless,thefactthatatoothbrushcostssubstantiallymoreatthisdefendantsSummithospitalisnotevidenceinandofitselfthatthereexistsanunreasonableorunconscionablepriceorthatthepricewasarrivedatinbadfaith.Theevidencewillreflectwherethepriceisreasonable. 0 0  8 80 ! !  Inthiscase,reasonablenessmaybeshownbyacombinationoffactors,includingbutnotlimitedto,theoverallprofitabilityofthehospital,theinflatingeffectofindigentcare,andtheeffectoncompetitionofthirdpartyϜpayors,i.e.,insurancecompanies,havingamuchleanerfinancialobligationthanitappearstotheaverageperson/patient,resultinginincreasedcostofservicestothepatient. 0 0    0 Itseemstousthatthecourtappliedahospitalexceptiontothegenerallawofcontracts.Whilefindingthatthecontractincorporatedapricetermbyreference(presumablythechargemaster),thecourt,nevertheless,heldthatthehospitals chargeshadtobereasonable.   %  3      כThehospitalurgesustoreturntoorthodoxyandhold 0,/ Oa  thatoncethecourtfindsthatthechargemasterwasincorporatedbyreference,the,Oa  ,inquiryisover.  %  4      כ   ,Oa  ,##@- II.  p   0 Weagreethatthequestionbeforeusconcernsanorthodoxcontractprinciple,butwedisagreeastotheeffectofthewrittenpromisesignedbyMs.Doe.Thepartiesdonotdisagreeabouttheprinciple.Ms.Doeconcedesthatthemodernviewofcontractformationincludesthefollowing:8 80 ! !Certaintywithregardtopromisesdoesnothavetobeapparentfromthepromiseitself,solongasthepromisecontainsareferencetosomedocument,transactionorotherextrinsicfactsfromwhichitsmeaningmaybemadeclear. 0 0  RichardA.Lord,WillistononContracts4:27(FourthEd.1990).Seealso P Restatement(2d)Contracts33Comment(a)(1981).Mostoftheauthoritiescited 0 bybothpartiesstandforthatprinciple.SeeLitsingerSignCo.v.AmericanSignCo., ` 227N.E.2d609(Ohio1967);CobbleHillNursingHome,Inc.v.Henry&Warren @ Corp.,548N.E.2d203(N.Y.1989);Beneventov.RJRNabisco,Inc.,No.896266,   1993WL126424,at*5(S.D.N.Y.April1,1993);WillistononContracts4:27;Corbin "  onContracts𛀜4.4(RevisedEd.1993);FarnsworthonContracts3.8c. $"   0 Thequestion,however,iswhetherinthiscasetheagreementreferredtosuchextrinsicmatters.AswereadthepromiseintheformMs.Doesignedthereisnoreferencetoany document,transactionorotherextrinsicfacttowhichreferencecouldbemadetoascertaintheamountshepromisedtopay.Herpromisewastopay chargesnotcoveredbythisauthorization.  1-0   0 Thehospitalscontentionthattheterm chargesreferstothecharge masterbegsforanexaminationofwhatthechargemasteris.Itisalist,maintainedbythehospitalschieffinancialofficer,containing295pagesofover7,000items.Thelistissecret&andnevershowntopatients&.Itisadjustedonaweeklybasis'based'(inpart('uponthehospitalsfinancialcondition')ascoststothehospitalincrease).Whenitisupdated,theearlierversionofthechargemasterisnotpreservedorarchived.Thepricestothehospitalaremarkedupbyamathematicalformuladesignedtoproduceatargetedamountofprofitforthehospital.Patientsarenotchargedaccordingtothelistatthetimetheyenterthehospital,noratthetimethegoodsorservicesarefurnished,butatthetimethebilliscompiled. * 0 Notallpatientsarebilledaccordingtothechargemaster.Thehospitalhasnegotiatedwithonelargeinsurancecompanyforlowerratesforthegoodsandservicesfurnishedtopatientscoveredbythatcompany.InadditionpatientscoveredbyMedicareandTennCarearechargeddifferentrates.*++**++* 0 * 0 Wedonotthinkthechargemasteroffersanindependent,objective,orverifiablemeansofdeterminingtheamountofthechargesMs.Doeagreedtopay,andthereforewedonotbelievethatitbecamepartofheragreement.Havingmadethatdetermination,wenowhavetheoptionofdeclaringthecontract(oratleasttheportioninvolvinguncoveredcharges)unenforceable,becauseitlacksanessentialterm.JamestownonSignalv.FirstFederalS&L,807S.W.2d559(Tenn.App. "  1990).However,wearereluctanttodoso,becauseMs.Doehasnotadvocatedsuchanaction.Further,thelawdoesnotfavorthedestructionofcontracts,particularlywhenoneofthepartieshasperformedhispart.Minorv.Minor,863S.W.2d51(Tenn. P(#& App.1993).  0 Wethereforeadoptthesameconclusionthetrialcourtdid%(althoughwehaveperhapsreacheditbyadifferentroute)%andweagreethattheplaintiffisonlyobligatedtopaychargesthatarereasonable.Atthesametime,wedonotwishtoimplythatwefavortheruleapparentlyadoptedbytheFloridacourtthatahospitalbillmustalwaysbe reasonable.Thereasonisthatsucharulewouldultimatelyplacetheburdenofdeterminingreasonablenessonthecourts,ratherthanonindividualswhopossessknowledgeandexpertiseintheincreasinglyarcaneworldofmedicalcosts.Webelieverather,thatintheabsenceofapatientsassent 0948 toanindependent,objectiveandverifiablepriceterminthecontract,apromisetopayfairvalueforthegoodsorservicesfurnishedisimplied.  0 TheorderdenyingsummaryjudgmenttothehospitalontheissuediscussedhereinisaffirmedandthecauseisremandedtotheCircuitCourtofDavidsonCountyforfurtherproceedings.Taxthecostsonappealtotheappellant.̛̜  0      8   _________________________________  0      8   BENH.CANTRELL,  0      8   PRESIDINGJUDGE,M.S.CONCUR:_____________________________WILLIAMB.CAIN,JUDGE_____________________________PATRICIAJ.COTTRELL,JUDGE  `'"%   XXYG @.-INTHECOURTOFAPPEALSOFTENNESSEE  @(ATNASHVILLE̛̜- -XYGXJANEDOEandherhusband 8   ) 4  JOHNDOE,ontheirbehalf, 8   ) $ t andonbehalfofallotherpersons  )  d similarlysituated,     8   )  AppealNo.#XXYGA#XYGX T    0      8   )  01A019806CV00306#XXYGB#XYGX D   Plaintiffs/Appellees, 8   )   4    0      8   )  DavidsonCircuit#XXYGC#XYGX $  МVS.  0      8   )  No.92C2041#XXYGD#XYGX     0      8   )    МHCAHEALTHSERVICESOF 8   )   @       TENNESSEE,INC.,d/b/a   8   )  Affirmedand  МHCADONELSONHOSPITAL, 8   )  Remanded    0      8   ) Defendant/Appellant. 8   ) d #XXYGE#XYGXXXYG @uu'JUDGMENT  D XYGX  0 Thiscausecameontobeheardupontherecordonappealfromthe p CircuitCourtofDavidsonCounty,briefsandargumentofcounsel;uponconsiderationwhereof,thisCourtisoftheopinionthatinthejudgmentofthetrialcourtthereisnoreversibleerror.  0 InaccordancewiththeopinionoftheCourtfiledherein,itis,therefore,orderedandadjudgedbythisCourtthatthejudgmentofthetrialcourtisaffirmed.ThecauseisremandedtotheCircuitCourtofDavidsonCountyforanyfurtherproceedingsandforthecollectionofthecostsaccruedbelow.  0 CostsofthisappealaretaxedagainstHCAHealthServicesofTennessee,Inc.,Principal,andBass,Berry&SimsPLC,Surety,forwhichexecutionmayissueifnecessary.Ӝ̛  0      8 ______________________________________  0      8 BENH.CANTRELL,PRESIDINGJUDGE,M.S.  0      8 ______________________________________  0      8 WILLIAMB.CAIN,JUDGE  0      8 ______________________________________  0      8 PATRICIAJ.COTTRELL,JUDGE-%%