Fri | Mar 23, 2018

Insurer to stand trial over non-payment of $34m surgery claim

Published:Friday | February 24, 2017 | 12:00 AMMcPherse Thompson

Jamaica's courts have determined that an overseas insurance provider that baulked at paying out the full medical claim for surgery that was billed at the equivalent of $39 million can be sued in this jurisdiction by the surgeon.

Bupa Global, which is based in the United Kingdom, initially agreed to pay the claim, but that was before it was presented with the bill. It ended up honouring just 12 per cent of the surgeon's invoice.

Dr Roger Hunter, who operated as a consultant at Medical Associates Hospital, filed a lawsuit in the Supreme Court two years ago to force payment of the rest of his bill - a case that Bupa attempted to get the court to throw out. Justice Brian Sykes refused Bupa's application, which means the insurer will have to answer for its decision.

Earlier this month, the Court of Appeal upheld the lower court decision that the lawsuit should proceed. It also ruled against another application by Bupa that the Jamaican court had no jurisdiction to try the claim.

One of the lawyers representing Bupa, Alexis Robinson of the firm Myers, Fletcher & Gordon, said the substantive case will now proceed in the Supreme Court, and may involve a referral to mediation and, if necessary, case management and trial.

However, Robinson said no dates have yet been set for the hearing.

Agreed to pay for the treatment Bupa, which carries on business internationally as a provider of medical insurance, was named as second defendant in a claim brought by Dr Hunter against the company and the family member of a construction executive employed to Kier Group Plc. Bupa is Kier's insurance provider.

Hunter, a consultant spinal surgeon and consultant neurosurgeon at Medical Associates Hospital, performed the surgery on the relative to address spine-related medical complications in 2014.

Before the surgery, Bupa provided written pre-authorisation and agreed to pay for the treatment, but also declared it would only meet costs that are medically necessary to treat the condition.

Hunter subsequently billed Bupa £221,700 (about $39 million), but the insurance provider honoured just £26,900 (around $4.8 million), and refused to pay the balance on grounds that the costs were unreasonable.

The patient also refused to compensate Hunter for the rest of the bill.

In January 2015, the surgeon sued Bupa and the patient in Jamaica's Supreme Court for the outstanding sum of £194,800, which then translated to $34 million in local currency. Bupa was served with the claim in May of that year after Justice Carol Edwards granted permission to Hunter to serve the claim outside of the jurisdiction.

The patient filed a defence to the claim denying liability for the bill.

Bupa challenged Edwards' ruling on jurisdictional grounds in its own Supreme Court application, but Justice Brian Sykes refused to strike out the claim. The insurer's appeal to the higher court was also unsuccessful.

Appellate judge Marva McDonald-Bishop noted that Hunter's argument, that as a consultant to Medical Associates, the hospital was merely the facilitator for the surgery and not the service provider, has given rise to issues that needed to be ventilated in a trial.

McDonald-Bishop said the fact that Bupa had directly paid Dr Hunter and not Medical Associates raises the question as to whether Bupa had a binding undertaking to pay the doctor his fees and not the hospital.