Major v. Auto Club Insurance

462 N.W.2d 771, 185 Mich. App. 437, 1990 Mich. App. LEXIS 349
CourtMichigan Court of Appeals
DecidedSeptember 12, 1990
DocketDocket 109072
StatusPublished
Cited by10 cases

This text of 462 N.W.2d 771 (Major v. Auto Club Insurance) is published on Counsel Stack Legal Research, covering Michigan Court of Appeals primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Major v. Auto Club Insurance, 462 N.W.2d 771, 185 Mich. App. 437, 1990 Mich. App. LEXIS 349 (Mich. Ct. App. 1990).

Opinions

Per Curiam.

Defendant appeals by leave granted the denial of its motion for summary disposition. MCR 2.116(0(10). This action involves a claim by plaintiff against defendant for payment of medical benefits pursuant to the no-fault insurance act, MCL 500.3109; MSA 24.13109. The sole issue before this Court is whether an insured, who pays a reduced premium to the no-fault insurer in exchange for coordinated medical benefits coverage, is required to seek benefits from the primary insurer before seeking payment from the no-fault insurer. We answer in the affirmative and reverse the trial court’s decision.

The facts of this case are not in dispute. In 1985, plaintiff was injured in a nonwork-related automobile accident. At the time of the accident, plaintiff was enrolled in Health Care Network (hcn), a health care program furnished by his employer. Plaintiff was required under that program to be treated by designated approved physicians. Plaintiff also had coordinated medical benefits coverage through defendant, his automobile insurer. Plaintiff did not receive treatment from doctors participating in the hcn plan, but received his treatment from nonparticipating doctors. It is alleged and not disputed that the type of treatment that defendant received was available from doctors who participated in the hcn plan. Plaintiff sought payment [439]*439from defendant for these medical expenses. Defendant refused to pay for any of the medical treatment rendered by doctors who did not participate in the hcn plan. Defendant cited the coordinated benefits provision of the insurance policy and indicated that the provision required that plaintiff be treated by hcn doctors. Plaintiff filed suit against defendant for payment of medical benefits.

Defendant brought a motion for summary disposition, arguing that defendant was not required to pay benefits for medical expenses incurred outside of the hcn program due to the coordinated benefits provision of the policy.

In denying defendant’s motion for summary disposition, the trial court contrasted the language of the medical coordination provision and the absence of any cooperation requirement with the specific recitation of the insured’s various obligations in seeking mandatorily required benefits as set forth in a provision explaining the mandatory coordination features of MCL 500.3109; MSA 24.13109 for an insured seeking government benefits. The trial court concluded:

The obligation of the insured to seek available government benefits and the consequence for failure to pursue them are quite explicit, and yet that language is not used regarding other medical insurance. The difference in treatment carries the natural implication that those provisions do not apply in the latter instance and, accordingly, that the deduction for benefits available but not sought applies only to government benefits. The insurer, presumably, was free to articulate the same explicit duty and penalty regarding other medical insurance but it has simply not done so in this contract.

On appeal, defendant contends that the trial [440]*440court erred in denying its motion for summary disposition. Defendant argues that by choosing coordinated medical benefits plaintiff agreed to make hcn the primary insurer and may not choose which insurer will pay benefits. We agree.

A motion for summary disposition under MCR 2.116(0(10) tests whether there is factual support for a claim. The court must consider the pleadings, affidavits, depositions, admissions and other documentary evidence available to it. Dumas v Auto Club Ins Ass’n, 168 Mich App 619, 626; 425 NW2d 480 (1988).

The moving party must identify by supporting affidavit those facts which it believes cannot be genuinely disputed. Slaughter v Smith, 167 Mich App 400, 403; 421 NW2d 702 (1988). The party opposing the motion has the burden of showing that a genuine issue of disputed fact exists. Dumas, supra. The opposing party may not rest upon mere allegations or denial in the pleadings, but must, by affidavit or other documentary evidence, set forth specific facts showing that there is a genuine issue for trial. MCR 2.116(G)(4); Metropolitan Life Ins Co v Reist, 167 Mich App 112, 118; 421 NW2d 592 (1988), lv den 431 Mich 877 (1988).

The coordination provision of plaintiffs policy states:

If the Declaration Certificate shows Coordinated Medical Benefits, sums paid or payable to or for you or any relative shall be reduced by any amount paid or payable under any valid and collectible: individual, blanket or group disability or hospitalization insurance; medical, surgical or hospital direct pay or reimbursement health care plan; Workers’ Compensation Law, disability law of a similar nature, or any other state or federal law; or car or premises insurance affording medical expense benefits. [Emphasis in original.]

[441]*441It is uncontested that plaintiffs declaration certificate showed coordination of medical benefits.

This coordination provision is required to be offered to insureds pursuant to MCL 500.3109a; MSA 24.13109(1), which provides:

An insurer providing personal protection insurance benefits shall offer, at appropriately reduced premium rates, deductibles and exclusions reasonably related to other health and accident coverage on the insured. The deductibles and exclusions required to be offered by this section shall be subject to prior approval by the commissioner and shall apply only to benefits payable to the person named in the policy, the spouse of the insured and any relative of either domiciled in the same household.

Our Supreme Court in Federal Kemper Ins Co, Inc v Health Ins Administration, Inc, 424 Mich 537, 551-552; 383 NW2d 590 (1986), explained the broad policy rationale behind the coordinated benefits provision of § 3109a:

[T]o contain both auto insurance costs and health care costs, while eliminating duplicative recovery. Further, this result is consistent with the legislative scheme vesting in insureds, rather than insurers, the option of coordinating benefits.

On these grounds, the Supreme Court declared that an insured’s health insurance coverage was to be the primary insurer regardless of policy language which attempted to force the opposite result. The Court based its holding on the Legislature’s purpose in enacting § 3109a: reducing insurance costs by lessening the cost of no-fault policies in dual coverage situations. In the face of such strong policy considerations, we do not believe that the statutory scheme allows an insured to simply [442]*442ignore 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.

Plaintiff claims that defendant contractually agreed, under the policy, to pay any expenses not covered by plaintiff’s hcn plan irrespective of whether or not plaintiff sought treatment under the hcn plan first. In contrast, defendant claims that plaintiff agreed that hcn would be the primary insurer and therefore plaintiff had a duty to seek treatment under the hcn plan first. Both parties rely on two cases which had not been decided at the time the trial court denied defendant’s motion, Calhoun v Auto Club Ins Ass’n, 177 Mich App 85; 441 NW2d 54 (1989), lv den 434 Mich 894 (1990), and

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Major v. Auto Club Insurance
462 N.W.2d 771 (Michigan Court of Appeals, 1990)

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Bluebook (online)
462 N.W.2d 771, 185 Mich. App. 437, 1990 Mich. App. LEXIS 349, Counsel Stack Legal Research, https://law.counselstack.com/opinion/major-v-auto-club-insurance-michctapp-1990.