Michigan Court of Appeals; Docket No. 206172; Unpublished
Judges Hood, Holbrook, Jr., and Whitbeck; Unanimous; Per Curiam
Official Michigan Reporter Citation: Not Applicable; Link to Opinion 
STATUTORY INDEXING:
Coordination with Other Health and Accident Medical Insurance [§3109a]
Coordination with HMO and PPO Coverages [§3109a]
TOPICAL INDEXING:
Not Applicable
CASE SUMMARY:
In this unanimous per curiam unpublished Opinion, the Court of Appeals upheld State Farm's denial of medical expense payments under a coordinated no-fault insurance policy, where plaintiff sought to obtain treatment at a headache clinic in Chicago outside of her health maintenance organization plan with Paramount Health Care Plan.
The HMO plan denied plaintiff and her primary physician's request to refer plaintiff for treatment at the headache clinic in Chicago, on the basis that such services sought were available within the provider network. Plaintiff chose not to appeal the decision of her HMO to deny her the referral, and instead, sought the treatment and submitted the bills to State Farm, her no-fault insurer.
The Court of Appeals upheld State Farm's denial of the claim for these medical expenses on the grounds that under section 3109a and the Supreme Court decision in Tousignant v Allstate Insurance Company, 444 Mich 301 (1993) (Item No. 1630), plaintiff was obligated to obtain payment and services from her health maintenance organization first, to the extent that there was health coverage available from her health insurer for this treatment.
In this case, the HMO medical director denied plaintiff’s request for an out-of-plan referral. The plan asserted that the requested services were available through the provider, and plaintiff did not appeal the HMO decision denying these benefits. In response to State Farm's motion for summary disposition, plaintiff failed to submit affidavits, depositions, or other documentary evidence which would have supported her assertion that the out-of-plan provider would provide a more appropriate and more effective type of treatment that was not available within the plan.
