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Manheimer v. Desai

August 20, 2009


On appeal from Superior Court of New Jersey, Law Division, Special Civil Part, Bergen County, Docket No. DC-024432-08.

Per curiam.


Submitted August 11, 2009

Before Judges Lihotz and Baxter.

Defendants Rita and Gaurang Desai appeal from a November 12, 2008 judgment, entered in favor of plaintiff Jeffrey Manheimer, DMD, following a bench trial, and the subsequent denial of their reconsideration motion. Plaintiff's complaint sought payment for dental services rendered, along with attorney's fees and costs. Defendants did not dispute services were rendered, but argued plaintiff's fee was limited by the contractual insurance payment he received. The trial judge determined defendants misinterpreted the insurance contract, which limited plaintiff's allowed fee to a standard rate, pursuant to a schedule issued by UNICARE. The plan required defendants pay the difference between that allowed fee and the amount actually paid to plaintiff by UNICARE. Accordingly, the trial judge entered judgment in favor of plaintiff for $8,686.31, plus attorney's fees and costs. Following our consideration of the arguments presented, review of the record, and applicable law, we affirm.

The facts are undisputed. Defendants contracted with plaintiff to provide dental services for themselves and their children. Defendant Rita Desai, as the patient, executed a financial policy agreement assuming financial responsibility for dental services to be satisfied at the time service was provided. Plaintiff performed various dental work from September 2007 through March 2008.

Defendants were covered by a primary dental insurance carrier, UNICARE, and a secondary provider, Local 371. Plaintiff agreed to submit his bills to defendants' dental insurance carriers for payment. Nevertheless, pursuant to the parties' agreement, the obligation to pay remained defendants' responsibility and, in the event payment was not made, there was a contractual provision requiring additional payment of collection costs, including interest of 1.5% per month (18% per year) and reasonable attorney's fees.

After services were performed for defendants and their children, plaintiff submitted each bill for payment of those services to defendants and UNICARE. When UNICARE made payment to plaintiff, it issued an explanation of benefits (EOB). The EOB listed the fee submitted by plaintiff, UNICARE's allowed fee for the specific service, which usually was less than the fee request submitted, and a percentage of the allowable fee UNICARE agreed upon for each service. The percentage of the amount paid varied from fifty to one-hundred percent. Also, certain treatments were excluded by the scope of the insurance coverage. Once the insurance payment was received, plaintiff adjusted the bill to reflect the balance to be paid by defendants, that is, the UNICARE allowed fee and the amount paid by UNICARE.

Plaintiff also submitted his bills to Local 371. Any payments from that insurance benefit were transmitted to defendants directly. Defendants also received the EOB from Local 371. A dispute arose when plaintiff requested verification of the sums paid by Local 371. Plaintiff sought to send those statements to UNICARE. Defendants declined to release the Local 371 statements. Without those statements, apparently, UNICARE would not provide reimbursement for certain services, and the bills went unpaid.

When plaintiff requested payment from defendants, they refused to pay the bills. Therefore, plaintiff filed suit. At trial and before this court on appeal, defendants asserted they had no obligation to plaintiff because plaintiff's fee for services was limited to the actual sums UNICARE paid. In support of their argument, they rely upon statements found in the EOB, which include: "YOU ARE NOT RESPONSIBLE FOR DIFFERENCE BETWEEN THE DENTIST'S SUBMITTED FEES AND THE DENTIST'S CONTRACTUAL FEES" and "YOUR DENTIST IS A CONTRACTED PROVIDER AND HAS AGREED TO ACCEPT YOUR PLAN'S ALLOWABLE FEES."

The trial court rejected defendants' interpretation of the EOB and entered judgment for plaintiff, determining defendants owed plaintiff the difference between the allowed fee and the amounts paid by UNICARE. Defendants also were to pay for services not reimbursed by UNICARE because of defendants' refusal to release the EOB from Local 371. The court denied defendants' motion for reconsideration and this appeal ensued.

Our review of a trial court's factual findings is limited. The general rule is that "[f]indings by the trial court are considered binding on appeal when supported by adequate, substantial, and credible evidence." Rova Farms Resort, Inc. v. Investors Ins. Co. of Am., 65 N.J. 474, 484 (1974). Since a trial court hears the case, sees and observes the witnesses, and hears them testify, it has a better perspective than a reviewing court in evaluating the veracity of witnesses. Ibid. Consequently, we do "not disturb the 'factual findings and legal conclusions of the trial judge unless... convinced that they are so manifestly unsupported by or inconsistent with the competent, relevant and reasonably credible evidence as to offend the interests of justice.'" Ibid.

When interpreting a contract, "the court's goal is to ascertain the 'intention of the parties to the contract as revealed by the language used, taken as an entirety; and, in the quest for intention, the situation of the parties, the attendant circumstances, and the objects they were thereby striving to attain....'" Driscoll Constr. Co., Inc. v. State, Dept. of Transp., 371 N.J. Super. 304, 313 (App. Div. 2004) (quoting Onderdonk v. Presbyterian Homes of N.J., 85 N.J. 171, 184 (1981) (internal citations omitted)). Typically, the interpretation of a contract is a legal question for the court. Id. 313-14.

The trial judge credited the testimony of Barbara Shock, plaintiff's office manager, who reviewed each bill for service, identifying plaintiff's fee submitted to UNICARE, the amount allowed under the UNICARE contract, and the amount actually paid. The judgment entered represented defendants' agreed obligation to satisfy the difference between the amount allowed and the amount paid by UNICARE. Judge Harz's findings that (1) the fees billed by plaintiff represented the differential between UNICARE's allowed fees and the amount reimbursed; and (2) defendants were contractually obligated to provide the payments ...

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