Pepaj v Allstate Insurance Company (COA – UNP 3/18/2021; RB #4239)


Michigan Court of Appeals; Docket # 352498; Unpublished
Judges Swartzle, Markey, and Tukel; Per curiam
Official Michigan Reporter Citation: Not Applicable; Link to Opinion

Allowable Expenses: Reasonable Necessity Requirement [§3107(1)(a)]

Not Applicable

In this unanimous unpublished per curiam decision, the Court of Appeals affirmed the trial court’s summary disposition order dismissing Plaintiff Gjok Pepaj’s first party action for no-fault PIP benefits.  The Court of Appeals held that the trial court did not err in ruling that Pepaj failed to create a genuine issue of material fact as to whether the medical treatments and attendant care he received were reasonably necessary for his care, recovery, or rehabilitation pursuant to MCL 500.3107(1)(a).

Gjok Pepaj was injured in a motor vehicle accident in 2014 and filed an initial first-party action against Allstate shortly thereafter.  That lawsuit settled in 2016, with Pepaj releasing Allstate “from liability for all expenses incurred before December 8, 2016, and any expenses for replacement services incurred after December 8, 2016.”  Pepaj then filed a second first-party action action against Allstate, arguing that Allstate had wrongfully failed to pay for attendant care and medical expenses he incurred after December 8, 2016.  In support of his claims for benefits, Pepaj submitted medical bills (without the corresponding medical records) which indicated that he had presented to his doctors on numerous occasions complaining of cervicalgia.  The trial court held that these bills did not definitively link his care or treatments to any accident-related injuries, nor provide a discernible basis for Pepaj’s claim that he required attendant care.  Thus, the trial court granted summary disposition in Allstate’s favor.

The Court of Appeals affirmed the trial court’s summary disposition order, first rejecting Pepaj’s argument that he was entitled to reimbursement from Allstate for medical treatment he had received after December 8, 2016.  The Court noted that while Pepaj’s records indicated that he complained to his doctors of cervicalgia on numerous occasions, nothing in those records “would permit the inference that the medical services or expenses resulted or arose from the motor vehicle accident.”

"With respect to the billing statements for medical and psychological services rendered after December 8, 2016, including those referencing cervicalgia, i.e., neck pain, the statements do not in any form or manner provide evidence that the associated services and expenses were reasonably necessary, just that Pepaj obtained the services and incurred the costs.  For all we know, the reference to cervicalgia for billing purposes may simply have indicated that Pepaj saw the physician on the basis of subjective complaints of neck pain.  And even assuming that it constituted a formal diagnosis, there is no elaboration that would permit the inference that the medical services or expenses resulted or arose from the motor vehicle accident.  Pepaj was able to produce a mountain of medical records for services provided before December 8, 2016, which pertained to whether the medical expenses were reasonably necessary."

The Court of Appeals similarly rejected Pepaj’s argument that the attendant care he received after December 8, 2016 was reasonably necessary given any accident-related injuries he may still have been suffering from at the time such care was rendered.  The Court held that the only evidence Pepaj presented in support of his claim that his attendant care was reasonably necessary was his “own subjective belief” that it was.

"But we agree with the court’s general rejection of the claim for attendant care expenses because Pepaj failed to submit externally verifiable objective evidence that attendant care services were reasonably necessary.  His reliance on his own subjective perception or belief that he needed attendant care services did not suffice to create a genuine issue of material fact.  And, for the reasons discussed earlier in connection with medical and psychological services the billing statements simply do not provide any basis to find that attendant care services and expenses were reasonably necessary."