Michigan Court of Appeals; Docket #356062; Unpublished
Judges Gleicher, Borrello, and Ronayne Krause; Per Curiam
Official Michigan Reporter Citation: Not Applicable; Link to Opinion
Coordination with Other Health and Accident Medical Insurance [3109a]
In this unanimous, unpublished, per curiam decision, the Court of Appeals affirmed the trial court’s summary disposition order dismissing Plaintiff Jawad Al Shah, MD, PC’s (“Insight”) first-party action against Defendant Liberty Mutual Insurance Company (“Liberty Mutual”). The Court of Appeals held, first, that Ronald Stamps, Insight’s patient/Liberty Mutual’s insured, coordinated his Liberty Mutual no-fault policy with his Health Alliance Plan (“HAP”) health insurance, such that HAP was primarily responsible for his collision-related medical treatment. The Court of Appeals held, second, that because Insight failed to present any evidence in support of its contention that it was entitled to balance bill Liberty Mutual after HAP paid for Stamps’s treatment at a discounted rate, summary disposition was properly granted in Liberty Mutual’s favor.
Ronald Stamps was injured in a motor vehicle collision, after which he received treatment from Insight. Stamps’s no-fault policy, issued by Liberty Mutual, was coordinated with respect to medical treatment, and thus Stamps’s health insurer, HAP, paid for the treatment Stamps received from Insight, albeit at adjusted (discounted) rates. Insight then attempted to balance bill Liberty Mutual in the amount of $32,220.23. When Liberty Mutual refused to pay the outstanding balance, Insight filed the underlying first-party action. Liberty Mutual moved for summary disposition, and at the hearing on the motion, Insight did not know whether it was in HAP’s network, did not know the contents of Stamps’s health insurance policy, and did not know whether Stamps could have received the necessary medical treatment from any other provider within HAP’s network. Thus, the trial court granted summary disposition in Liberty Mutual’s favor.
The Court of Appeals affirmed the trial court’s summary disposition order, first rejecting Insight’s argument that Stamps’ policy was not actually coordinated because “there [was] no evidence Stamps consciously chose to coordinate benefits, and there [was] no evidence Stamps actually received a reduced premium in exchange for coordinating benefits.” The Court of Appeals noted that the policy plainly stated, “ ‘Coordination of Medical Expenses and Work Loss Applies,’ ” and that Michigan law has established that, “ ‘one who signs an agreement, in the absence of coercion, mistake, or fraud, is presumed to know the nature of the document and to understand its contents, even if he or she has not read the agreement.’ ” The Court held that Insight presented no evidence to rebut that presumption, and also noted, regarding Insight’s argument concerning reduced premiums, that “ ‘[s]ection [500.3109a] does not require a health insurer to demonstrate a premium rate reduction to validate a coordination of benefits clause in the certificate of coverage.’ ”
The Court of Appeals next held that, although Insight made the requisite “ ‘reasonable efforts’ ” to obtain payment for its services from HAP, it failed to produce evidence supporting its position that it could then turn to Liberty Mutual for payment of its outstanding balance. Insight did not produce a copy of Stamps’s contract with HAP nor summarize its contents, did not know whether it was in HAP’s network, and did not know whether the treatment Stamps required was available elsewhere in HAP’s network. Thus, the Court held, “[Insight] is precluded from seeking additional payment from defendant to the extent HAP fully paid [Insight] under the terms of Stamps’ contract with HAP.”
“Plaintiff argues that it can now turn to defendant to seek payment for the outstanding balance. On this record, we disagree. Plaintiff provided no evidence of what HAP was required to pay under its contract. Plaintiff did not provide a copy of the contract between HAP and Stamps, and plaintiff did not even provide a summary of its contents. Indeed, plaintiff did not even know whether it was in HAP’s network, let alone whether HAP would or could provide the necessary medical care in-network. Plaintiff is precluded from seeking additional payment from defendant to the extent HAP fully paid plaintiff under the terms of Stamps’s contract with HAP. Farm Bureau, 314 Mich App at 21. Plaintiff may seek reimbursement from defendant if HAP’s contract did not require it to pay for the provided medical care. Tousignant, 444 Mich at 312-313. However, no determination can be made without HAP’s contract. See id.
As noted, plaintiff did not provide a copy of HAP’s contract, nor did it know whether it was in HAP’s network. Rather, the evidence available to the trial court included evidence that HAP made timely payments in response to plaintiff’s billing and reduced the rate of each of those payments. HAP rejected some payments, paid others in full, and paid others in part. In addition, as pointed out by defense counsel at the hearing, HAP’s remittance records balanced out to zero, meaning that no further payments were owed to plaintiff. The fact that HAP made timely rate-adjusted payments suggests HAP complied with its payment obligations under the contract.”