Tousignant v Allstate Insurance Company; (COA- PUB, 4/6/1992; RB #1538)


Michigan Court of Appeals; Docket No. 122987; Published  
Judges Michael Kelly, Marilyn Kelly, and Weaver (with Judge Weaver, Dissenting)  
Official Michigan Reporter Citation:  193 Mich App 415; Link to Opinion alt    

Coordination with Other Health and Accident Medical Insurance [§3109a]  
Coordination with HMO and PPO Coverages [§3109a]

Not Applicable   

In this 2-1 decision by Judge Michael J. Kelly with Judge Weaver dissenting, the Court of Appeals resolved a conflict among other panels in the Court of Appeals, and held that a person insured under a coordinated no-fault policy is not required to seek all possible treatment from physicians working for his/her HMO plan before being entitled to submit medical expenses to the no-fault insurer, where the no-fault coordination of benefits clause did not require the injured person to seek treatment from a member of the HMO organization as a prerequisite to obtaining no-fault medical benefits.  

The plaintiff in this case was insured under a coordinated benefits policy issued by Allstate and also was entitled to receive medical care through Health Alliance Plan, a health maintenance organization (HMO). The plaintiff first sought and obtained treatment through her HMO, but then decided to be treated by dentists and doctors who were not members of the HMO. Those expenses were not covered by the HMO and plaintiff then submitted the claim to her auto insurer. The plaintiff did not assert that the medical care she received from the non-HMO doctors was unavailable through her HMO. The no-fault insurer denied the claim on the basis of the no-fault coordination clause.  

The court noted that there was a conflict among two other panels of the Court of Appeals regarding this issue, as is reflected in the opinions in Calhoun v Auto-Club, 177 Mich App 85 (1989), Iv den 434 Mich 895 (1990) and Major v Auto-Club (Item No. 1415). The court noted, "in Calhoun this court held that an insured who selected coordinated medical benefits coverage in his no-fault policy in exchange for a reduced premium was not required to seek treatment from his primary health insurer, but could seek treatment elsewhere and be covered by the no-fault carrier. In Major, the opposite result was reached. The Major court held that an insured who pays a reduced premium in exchange for coordinated medical benefits coverage, is required to seek benefits provided by the primary insurer before seeking payment from the no-fault insurer. We resolve the conflict by following Calhoun. We believe Calhoun represents the better reasoned view We agree with the Calhoun court that although plaintiff’s HMO was considered the primary health care insurer, plaintiff’s failure to seek all possible health care through her HMO does not preclude her recovery from defendant for medical expenses not covered by her HMO. Nothing in the language of the coordination of benefits clause contained in the no-fault contract requires plaintiff to seek all possible treatment through her HMO before she may receive no-fault insurance benefits for medical care not covered by her health coverage. We also agree with Calhoun that if defendant had intended that plaintiff seek all possible health care benefits from her HMO prior to making a claim for benefits under her no-fault policy, 'defendant should have included specific language to that effect in its coordination of benefits clause.' Calhoun."  

The court also went on to state that, "we believe our decision today is in accord with the policies underlined in §3109a.... Since plaintiff cannot recover the medical expenses in question from her HMO, no double coverage or recovery is involved."  

Judge Weaver dissented, stating that she would follow the Major decision, which she found more consistent with the objective of eliminating duplicative recovery. Judge Weaver also relied upon a Pennsylvania Superior Court decision which primarily focused on those health benefits that were "available" to the insured before the insured took unilateral action to seek non-HMO medical treatment.