896 N.W.2d 85
Mich. Ct. App.2016Background
- Dec 9, 2011 car accident injured Dusaj, who coordinated no-fault and health insurance; no-fault benefits must be reduced by amounts paid or payable under health plan.
- Dusaj received partial day hospitalization for closed head injury; hospital filed Blue Cross/Magellan claim for services starting May 6, 2013.
- Magellan denied medical necessity; denial letter described internal and external appeal processes with time frames and expedited options.
- Plaintiff hospital sought payment from defendant State Farm after Blue Cross/Magellan denial; defendant moved for summary disposition arguing lack of evidence of reasonable efforts.
- Trial court denied summary disposition, then granted defendant’s motion for reconsideration, dismissing case; appellate court reversed and remanded.
- Court emphasizes no-fault act’s purpose of prompt recovery and coordination of benefits to prevent duplicative recovery; Farm Bureau decision discussed but distinguished.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether a plaintiff must appeal a health insurer’s medical-necessity denial before seeking no-fault benefits | Plaintiff argues no appeal is required to show reasonable efforts. | Defendant argues Farm Bureau requires appealing the denial. | No; not required to appeal to establish reasonable efforts. |
| Whether the trial court properly shifted burden of proof on reasonable efforts and whether evidence supported reasonable efforts | Plaintiff presented evidence of attempts to obtain payment from Blue Cross/Magellan. | Court misapplied burden shifting; plaintiff failed to show reasonable efforts. | Trial court abused discretion; not required to appeal and evidence supported reasonable efforts. |
| Whether Adanalic and Tousignant support a broader view that lengthy appeals are not needed to obtain PIP benefits | Reasonable efforts do not require prolonged appeals against health insurer. | Farm Bureau controls require appeal in some circumstances. | Adanalic/Tousignant support avoiding lengthy appeal process; not necessary to appeal to obtain payment. |
Key Cases Cited
- Tousignant v Allstate Ins Co, 444 Mich. 301 (1993) (reasonable efforts to obtain payments from health insurer required)
- Perez v State Farm Mut Auto Ins Co, 418 Mich. 634 (1984) (term ‘payable’ equals required to be provided; reasonable efforts standard origin)
- Adanalic v Harco Nat’l Ins Co, 309 Mich. App. 173 (2015) (reasonable efforts need not be lengthy or costly; avoids duplicative recovery)
- Farm Bureau Gen Ins Co v Blue Cross Blue Shield of Mich, 314 Mich. App. 12 (2015) (unique circumstances with provider agreement; not controlling here)