Michigan Court of Appeals; Docket No. 196207; Unpublished
Judges Markman, McDonald, and Fitzgerald; 2-1 (with Judge Markman Concurring); 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In this unpublished per curiam Opinion, the Court of Appeals addressed the issue of coordination of benefits between a no-fault first-party carrier and a health maintenance organization, where the injured person sought treatment at a facility that was not affiliated with the defendant HMO. After finding that the defendant HMO was obligated to provide primary coverage for the automobile accident injuries, the Court of Appeals remanded the case to the trial court to determine whether the charges were subject to coverage under the HMO plan.
The case arose out of injuries sustained by a woman named Judy Fuller in an automobile accident that left her quadriplegic. Fuller was insured under a policy of no-fault automobile insurance issued by plaintiff MIC General Insurance Corporation and an HMO plan through Healthplus of Michigan, Inc. The health coverage apparently was not issued through an ERISA qualifying employment benefits plan. Both the no-fault policy and the HMO plan contained coordination of benefits clauses providing that their respective coverages were secondary to other insurance available for the subject automobile accident related injuries. The Court of Appeals, citing Federal Kemper v Health Insurance Administration, 424 Mich 537 (1986) (Item No. 897), held that the coordination of benefits clause contained in the no-fault policy controlled, thereby making the HMO coverage primary and the no fault policy secondary.
The primary issue before the court was whether the rehabilitation expenses incurred by Ms. Fuller at a facility not affiliated with the defendant HMO were subject to coverage under the HMO plan. The Court of Appeals held that determination must be made as to whether the HMO's denial of coverage was unreasonable under the circumstances. The HMO plan provided coverage for charges incurred at a non-member facility if the required services were not available through a participating member. Here, the Court of Appeals was unable to determine from the lower court record as to whether the defendant HMO offered the Fullers any alternative rehabilitative services to those offered by the non-member facility. In the event that the insured simply chose to seek treatment from a non-participating provider, no coverage would be available under the HMO plan. Therefore, the Court of Appeals remanded the case to the trial court to determine whether a referral to the non-participating facility was requested and unreasonably denied.
Judge Markman wrote a concurring opinion, stating that if a request for a referral was made by the Fullers, he would hold that the medical reasonableness of the defendant HMO's denial of the referral must be determined. The decision regarding the referral "must be reasonably grounded lest the health insurer routinely be able to shift costs to the no-fault insurer where personal protection benefits have been coordinated with other health and accident coverage." This inquiry into the medical reasonableness of the referral decision would include evaluation of the injuries, as well as the medical resources available to the injured person through the HMO plan.
