Michigan Court of Appeals; Docket No. 176215; Unpublished
Judges Jansen, Reilly, and Sosnick; 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:
Evidentiary Issues
CASE SUMMARY:
In this unanimous per curiam unpublished Opinion, the Court of Appeals held Auto Club did not owe PIP benefits for medical expenses incurred from non-HMO providers, where plaintiff had coordinated benefit coverage and health insurance through a health maintenance organization which had primary responsibility for plaintiffs medical expenses, and plaintiff had failed to provide medical evidence that necessary medical care was unavailable or inadequate through his HMO.
In this case, under §3109a of the no-fault act, plaintiff sought medical benefits from his health maintenance organization, Health Alliance Plan (HAP), as his primary coverage. The physicians at HAP apparently advised plaintiff that they had provided him with all of the services they felt were medically appropriate, and plaintiff therefore sought services from non-HMO affiliated physicians. Auto Club refused to pay these expenses, arguing that it was not responsible for plaintiffs medical bills covered under HAP, based upon the Supreme Court holding in Tousignant v Allstate Insurance Company, 444 Mich App 301; 506 NW2d 844 (1993) (Item No. 1630), which held that a no-fault insurer is not liable for medical expenses that the insured's health care insurer is required under its contract to pay for or provide.
Plaintiff argued that Tousignant did not preclude his claim where the necessary medical care was unavailable or of inadequate quality at HAP facilities. Plaintiff relied upon language in Tousignant indicating that it did not preclude claims where the applicable HMO would not or could not provide the medical care needed.
In its holding affirming the trial court grant of summary disposition in favor of Auto Club, the Court of Appeals held that the language relied upon in Tousignant did indeed suggest an exception to the general rule of Tousignant may exist, when the primary health care provider could not or would not provide the medical care needed, or where the quality of the available care from the primary health care provider was such that it can be said that the benefit was not available. However, the court did not feel the obligation to resolve this issue in the instant case, because plaintiff had failed to provide medical evidence that necessary medical care was unavailable or of inadequate quality. The only evidence was plaintiffs own affidavit which the Court of Appeals held was inadequate under MCR 2.119(B)(1) because plaintiff was not competent to testify to the facts stated in the affidavit regarding the quality of care of his medical provider.
