Michigan Court of Appeals; Docket #362042; Unpublished
Judges Rick, Shapiro, and O’Brien; Per Curiam
Official Michigan Reporter Citation: Not Applicable; Link to Opinion
STATUTORY INDEXING:
Entitlement to PIP Benefits: Arising Out of / Causation Requirement [§3105(1)]
Standards for Deductibility of State and Federal Governmental Benefits [§3109(1)]
TOPICAL INDEXING:
Not Applicable
SUMMARY:
In this unanimous, unpublished, per curiam decision, the Court of Appeals reversed the trial court’s summary disposition order dismissing Plaintiff Spectrum Health Hospitals’ (“Spectrum”) action for no-fault PIP benefits against Defendant Citizens Insurance Company of America (“Citizens”). The Court of Appeals held, first, that a question of fact existed as to whether injuries sustained by Spectrum’s patient, Timothy Wolf, arose out of a motor vehicle accident that occurred in 2018, or whether Wolf’s injuries arose out of one of two work-related incidents that occurred in 2019 and 2020, respectively. The Court of Appeals held, second, that Citizens could not refuse to pay Wolf’s PIP benefits simply because Wolf failed to use reasonable efforts to obtain workers’ compensation benefits.
On September 24, 2018, Wolf suffered a grade three AC joint separation in his left shoulder as a result of being hit by a motor vehicle while riding a moped. On June 24, 2019, Wolf aggravated his left shoulder injury while reaching under a desk at work, and although his employer documented the incident and Wolf went to the emergency room afterward, no further imaging was done of his left shoulder until December of 2019, when x-rays showed that his AC joint separation had progressed to grade five. On January 6, 2020, Wolf again aggravated his left shoulder injury at work, and again, his employer documented the incident and Wolf went to the emergency room. The note from his January visit to the emergency room stated that Wolf’s AC joint separation had progressed from 13 mm in 2018 to 4 cm in 2020. Moreover, it stated that Wolf’s ‘acute injury is actually work-related now.’
Following Wolf’s January 2020 trip to the emergency room, Citizens stopped paying his PIP benefits altogether. Citizens then moved for summary disposition in the action Wolf filed against it, arguing (1) that, due to the two intervening work incidents, Wolf’s shoulder injuries could no longer be said to have ‘arisen out of’ the 2018 motor vehicle accident for purposes of MCL 500.3105(1); and (2) that Wolf was barred for PIP benefits under MCL 500.3109(1) because he failed to use reasonable efforts to obtain workers’ compensation benefits for his shoulder injuries. The trial court agreed with Citizens in the latter regard, granting its motion.
The Court of Appeals reversed the trial court’s summary disposition order, holding, first, that a question of fact existed as to whether Wolf’s ongoing need for treatment of his left shoulder arose out of the 2018 motor vehicle accident, or out of the two intervening work incidents. The Court found the evidence inconclusive as to whether Wolf’s AC joint separation “naturally worsened over time or whether intervening events caused [it] to worsen to the point that surgery was required.”
“Reviewing the evidence in this case, Wolf sustained a grade 3 AC joint separation as a result of the 2018 accident. He testified that he went back to work shortly after the accident, and that, while he hoped his injury would get better over time, it never did in part because of ‘repetitive use’ at work. In June 2019, Wolf at the very least severely aggravated (if not further injured) his shoulder at work by reaching under his desk, which caused Wolf so much pain that he had to leave work and go to the emergency room. No images were taken of Wolf’s shoulder at the ensuing emergency room visit, however, so it is unclear how much, if any, damage was done to the shoulder in the June 2019 incident. Eventually, in December 2019, images of Wolf’s shoulder were taken, and the images revealed that Wolf’s shoulder had worsened to a grade 5 AC joint separation. Dr. Boyd opined at that time that Wolf’s shoulder would ultimately require surgery. Then, in January 2020, Wolf had to go to the emergency room a second time because he experienced increased pain in his shoulder while lifting materials at work. While the report from this visit stated that Wolf still had a grade 3 AC joint separation, the radiology report from the visit confirmed that the AC joint separation had widened from 13 mm to 4 cm. Also, notably, the emergency room report noted that Wolf’s injury ‘is actually work-related now,’ further muddying whether Wolf’s grade 5 AC joint separation was caused by the 2018 accident or an intervening event. Two days following Wolf’s January 2020 visit to the emergency room, Dr. Boyd confirmed that Wolf’s grade 5 AC joint separation shoulder would require surgery. All this evidence, taken together, creates a murky picture whether Wolf’s AC joint separation naturally worsened over time or whether intervening events caused Wolf’s injury to worsen to the point that surgery was required. . . .
From this evidence, a juror could reasonably conclude that Wolf’s injury requiring surgery was caused by the 2018 accident, even though that accident took place two years before the surgery . . . [or] that, while Wolf’s grade 3 AC joint separation was caused by the 2018 accident, the passage of time (two years) and intervening events (incidents at work that caused Wolf to seek emergency-room treatment to address his shoulder pain) rendered Wolf’s grade 5 AC joint separation that required surgery too attenuated from the 2018 accident.”
The Court of Appeals held, second, that Citizens could not refuse to pay Wolf’s PIP benefits based on Wolf’s failure to use reasonable efforts to obtain workers’ compensation benefits. The Court listed three reasons for this holding: (1) Citizens was perfectly capable of pursuing workers’ compensation benefits, itself, on Wolf’s behalf; (2) it was unclear whether Wolf would even qualify for workers’ compensation benefits for his shoulder injuries; and (3) nothing in MCL 500.3109(1) permits an no-fault insurer to refuse to pay PIP benefits based on an insured’s failure to use reasonable efforts to obtain workers’ compensation benefits.
“Despite this, Wolf’s failure to pursue workers’ compensation benefits did not entitle defendants to summary disposition for at least three reasons. First, as plaintiffs point out, defendants themselves could have pursued workers’ compensation benefits on behalf of Wolf. See Adanalic v Harco Nat Ins Co, 309 Mich App 173, 188-189; 870 NW2d 731 (2015). As such, Wolf’s failure to pursue workers’ compensation benefits did not preclude the practical application of MCL 500.3109(1), nor did it frustrate that statute’s purpose.
Second, defendants are only entitled to subtract ‘[b]enefits provided or required to be provided,’ and the parties dispute whether Wolf’s injuries would have qualified for workers’ compensation benefits . . . Only the workers’ compensation bureau could resolve the parties’ dispute over whether the injury suffered by Wolf was in the course of his employment.
The third reason that Wolf’s failure to pursue workers’ compensation benefits did not entitle defendants to summary disposition is that nothing in MCL 500.3109(1) suggests that it absolves defendants of their responsibility to pay PIP benefits. Under MCL 500.3105(1), defendants remain liable for PIP benefits if Wolf’s injury requiring surgery arose from the motor-vehicle accident.”
