Michigan Court of Appeals; Docket #300256; Unpublished
Judges O'Connell, Murray, and Donofrio; 2-1 per curiam: Judge Murray concurring in part and dissenting in part
Official Michigan Reporter Citation: Not Applicable, Link to Opinion Link to Dissent
On July 29, 2013, the Michigan Supreme Court REVERSED this decision in part; Link to Opinion
Coordination of Benefits Act [MCL 550.251, et seq]
In this 2-1 per curiam Opinion, Judge Murray partially concurring and dissenting, the Court of Appeals reversed the trial court Order granting summary disposition in favor of Blue Cross/Blue Shield of Michigan (BCBSM) in a case involving whether the BCBS health insurance policy coordinated with the no-fault auto insurance benefits provided under the Auto Club Insurance Association (ACIA) policy.
Plaintiff Harris was injured while riding a motorcycle which was hit by a vehicle insured by ACIA. Harris also had a health insurance contract with BCBSM. The ACIA no-fault policy was acknowledged to be a policy that provided "uncoordinated" benefits and, thus, full coverage for plaintiff's medical expenses. However, the parties disputed whether the BCBSM health insurance policy coordinated with the no-fault policy.
In reversing the trial court determination that the BCBSM policy coordinated benefits with the no-fault policy, the Court of Appeals analyzed the health insurance contract language upon which the trial court relied and ultimately determined that the trial judge erred in determining that the language required coordination with the no-fault policy.
The specific language relied upon, included a provision that the health insurance policy would coordinate benefits payable under the policy pursuant to the Coordination of Benefits Act, MCL 550.251. The health policy stated that to the extent that the services covered under the policy are also covered and payable under another "group health care plan," then the health policy would combine its payment with that of the other plan to pay the maximum amount it would routinely pay for the covered services.
The Court of Appeals held that BCBSM's reliance on this language is misplaced. The Coordination of Benefits Act does not include a no-fault insurer among the defined entities with which the health care providers will coordinate or a mechanism for coordination. Further, the court stated that a no-fault policy was not a "group health care plan." Haefele v Meijer, Inc, 165 Mich App 485 (1987). The court also rejected BCBSM's reliance on language in its contract that it was not obligated to pay for services that are covered under any other "health care benefits plan." The court stated that a no-fault auto insurance policy is not a "health care benefits plan."
The court also rejected BCBSM's argument that the expenses involved are not payablebecause the policy provides that it does not have to pay for expenses for which "you legally do not have to pay or for which you would not have been charged if you did not have coverage under this certificate." In addressing this issue, the court relied upon the decisions in Shanafelt v Allstate Insurance Company, 217 Mich App 625 (1996) and Bombalski v Auto Club Insurance Association, 247 Mich App 536 (2001), for the proposition that an expense is incurred when the plaintiff becomes liable for the expense by accepting medical treatment. The Court of Appeals rejected BCBSM's argument that Shanafelt and Bombalski did not apply because they were applicable only for purposes of the No-Fault Act and did not apply to the health insurance policy. The rationale of Shanafelt and Bombalski that a party receiving services has a legal obligation to pay for them when rendered and incurs the expense even if the expense is paid by an insurer, is applicable in this case, although the phrase and context are different. BCBSM's contention that plaintiff was not obligated to pay his medical expenses because ACIA paid them on his behalf is incompatible with Shanafelt.
The final provision on which BCBSM relied was the "other coverage" language of its contract. BCBSM argued that the language of the contract gives it a right to a lien or a right of reimbursement from any money the insured person receives through a judgment, settlement, or otherwise in connection with a claim for damages for personal injury. The Court of Appeals held that this language is directed at tort actions wherein the plaintiff may recover both economic and noneconomic damages, and does not apply to no-fault auto insurance benefits.
Based upon its analysis of the contract language, the majority determined that the trial court Order granting summary disposition in favor of BCBSM should be reversed and the matter remanded for further proceedings.
Judge Murray in his concurring in part/dissenting Opinion, dissented from the majority's conclusion that the Order granting BCBSM's motion for summary disposition should be reversed. Judge Murray would conclude that the contract between BCBSM and plaintiff precluded plaintiff from receiving a "double recovery."
In his dissent, Judge Murray would hold that plaintiff was not "legally obligated" to pay for the medical expenses involved since ACIA, the No-Fault insurer, had already paid their full cost. Therefore, under the plain language of the BCBSM policy, there was no legal obligation of the plaintiff to pay those expenses. Judge Murray would affirm the trial court determination as to its grant of summary disposition in favor of BCBSM.