Michigan Court of Appeals; Docket No. 178642; Published
Judges Gribbs, Markey, and T. G. Kavanagh; Unanimous; Per Curiam
Official Michigan Reporter Citation: 224 Mich App 385; 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 maintenance organization (HMO) which provided medical benefits to a person injured in a motor vehicle accident was "health and accident coverage" within the meaning of the coordination provisions of § 3109a of the No-Fault Act, and therefore, in a coordinated no-fault insurance policy, was the primary insurance for any physical injuries sustained in a motor vehicle accident. The court noted that where the insured chooses coordination under §3109a, the insured's health coverage becomes the primary insurance for any physical injuries sustained in a motor vehicle accident "to the extent the health insurer has agreed to pay for or provide the necessary medical care." Tousignant v Allstate Insurance Company (Item No. 1630). The court rejected the argument of Grand Valley Health Plan (GVHP) that as an HMO it was not an insurance company, and therefore, did not satisfy the definition of “other health and accident coverage” on the insured. GVHP argued that it was only a “health care provider" and not an insurance company. The court, in reliance upon its decisions in West Michigan Health Care Network v Transamerica Insurance Company of America, 167 Mich App 218 (1988) (Item No. 1147) and Calhoun v Auto Club Insurance Association (Item No. 1261), held that "an HMO under these circumstances may be considered a health coverage insurer."
The court also rejected GVHP's argument that it was not required to pay for services it had not agreed to pay in advance because the expenses had not been “provided, arranged or authorized" by a GVHP physician. The court noted that there was no allegation that the insured simply opted to use physicians of his choice who were not participants in his HMO. Further, it appeared from the parties’ briefs, that the required services were not even available directly from the HMO. The court noted that although an insured is required to obtain payment and services from their HMO to the extent available under Tousignant, supra, there is no claim that the services at issue were available directly from GVHP in this case. The court further noted that GVHP had originally approved and paid for the care of the patient's primary physician, and that subsequent care had flowed from that primary physician's original involvement. The court refused to elevate form over substance under these facts.
[Editor's Note: This case was inadvertently omitted from prior supplements.]
