Michigan Court of Appeals; Docket No. 109072; Published
Judges Danhof, Cynar, and Brennan (with Judge Cynar, Concurring); Per Curiam
Official Michigan Reporter Citation: 185 Mich App 437; 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 published per curiam Opinion, the Court of Appeals rejected the earlier holding in Calhoun v Auto Club Insurance Association (Item No. 1261) and held that where an insured pays a reduced premium to purchase coordinated no-fault coverage, the insured is required to utilize the medical services of an HMO type program before seeking payment from the no-fault insurer.
The plaintiff in this case purchased a coordinated no-fault policy from defendant ACIA and was also enrolled in Health Care Network (HCN), a health care program furnished by his employer. Plaintiff was required under the HCN program to be treated by designated, approved physicians. Plaintiff did not receive treatment from doctors participating in the HCN plan but rather received treatment from non-participating doctors. It was undisputed that the type of treatment rendered to plaintiff was available from doctors who participated in the HCN plan. Defendant refused to pay for any of the medical treatment rendered by doctors who did not participate in the HCN plan.
The court reasoned that when plaintiff chose coordinated no-fault benefits, plaintiff agreed to make HCN the primary insurer, and thus, lost the right to choose which insurer will pay benefits. The court stated that the purpose of the coordination provisions of §3109a of the Act was to reduce insurance costs by lessening the cost of no-fault policies in dual coverage situations. The court said: "In the face of such strong policy considerations, we do not believe that the statutory scheme allows an insurer to simply ignore an existing health care benefit and frustrate the entire coordination program, a program which provided a statutorily mandated reduced insurance premium for plaintiff in this case."
In rejecting the previous Court of Appeals holding in Calhoun, the court stated: "We disagree with the Calhoun court's holding that an insured who selected coordinated medical benefits coverage in his no-fault policy in exchange for a reduced premium was not required to seek treatment from his primary health insurer, but could seek treatment elsewhere at the expense of the no-fault insurer. We believe that this holding is incorrect, and the Calhoun decision is not persuasive to this court. To further the purpose of §3109a we hold that an insured, who pays a reduced premium in exchange for coordinated medical benefits coverage is required to seek benefits provided by the primary insurer before seeking payment from the no-fault insurer." The court concluded its opinion by stating that its decision "was made in the factual context in which the insured shows coordinated coverage and the no-fault insurer accordingly charged a lower premium. We express no view as to what the result would be when the insured does not so elect and the no-fault premium is not correspondingly reduced."
Judge Cynar filed a separate concurring opinion limited to "the specific facts of this case." Judge Cynar said that a coordinated no-fault insured "is under some duty to seek out comparable health benefits offered by the primary insurer. I nevertheless envision that there may be any number of fact patterns which may limit the extent of that duty, and consequently, necessitate a different result."
