Wayne County Circuit Court; Docket No. 86-623665-AV; Unpublished
Judge Roland L. Olzark; Written Opinion
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 well-reasoned written Opinion by Judge Roland Olzark, the Court held that the defendant insurer could not use its coordination of benefits clause to require that its insured seek accident-related medical care with only those providers which would be covered under the insured's health insurance. This case was appealed from the 36th District Court in which the insurance company s motion for summary disposition had been granted on this issue.
Plaintiff’s no-fault insurance policy contained a coordination of benefits clause requiring that sums "paid or payable" to the insured under private health insurance would be subtracted from amounts due and payable under the no-fault policy. Plaintiff, as a fringe benefit of his employment, had accident health insurance coverage, but that coverage required that he seek treatment at only the Woodland Medical Clinic. Any health care provided by any other facility or physician would not be covered under plaintiff’s health insurance.
The plaintiff chose to seek health care for accident-related injuries at a facility other than the Woodland Clinic. Auto-Owners refused payments of these benefits and contended that plaintiff was required by his coordination of benefits clause to seek treatment within the terms of his health maintenance insurance coverage. The district court agreed with Auto-Owners and on appeal, the Wayne County Circuit Court reversed.
Judge Olzark reasoned that, based upon a reading of the insurance policy language, the insured was not under any duty to seek treatment with only those physicians covered under his health insurance. Had the insurance company meant to impose such a duty, it should clearly have expressed that intent in the policy. Since the treatment provided to plaintiff was not covered, mere were no benefits "paid or payable" under the health insurance which would require coordination.
Judge Olzark also rejected the public policy argument that cases decided under §3109(1) requiring an insured to "seek" available governmental benefits, likewise required the insured to seek health care only within the coverage of his health policy. In analyzing these cases [Perez (Item No. 701) and Gregory (Item No. 934)], the court noted the legislative authority for coordination of benefits was contained in §3109a which does not contain the clause "required to be provided." Since this statutory phrase "required to be provided" appeared to be the basis for the finding in Perez, supra and Gregory, supra, that an insured must pursue his governmental benefits, its absence from §3109a and the insurance policy would appear to indicate that the above cited cases did not have application to this situation. Judge Olzark also noted that since the primary purpose of §3109(1) is to reduce no-fault premiums by eliminating duplicative recovery, it is helpful to note that in this case, there is no duplicative recovery since the medical bills were not paid or payable under plaintiff’s health insurance. The Court also rejected the "flood gate" argument of the insurance company that it would enable insureds to "pick and choose" which insurance company will bear the cost of medical treatment. In this case, the plaintiff is merely choosing who will be his doctor.
