Michigan Court of Appeals; Docket #359067; Unpublished
Judges Cavanagh, O’Brien, and Rick; Per Curiam
Official Michigan Reporter Citation: Not Applicable; Link to Opinion
Fraudulent Insurance Acts [§3173a]
In this unanimous, unpublished, per curiam decision, the Court of Appeals affirmed the trial court’s summary disposition order dismissing Plaintiff David Rodriguez’s action for No-Fault PIP benefits against Defendant Farmers Insurance Exchange (“Farmers”). The Court of Appeals held that there was no question of fact that Rodriguez committed a “fraudulent insurance act” for purposes of MCL 500.3173a(2), by failing to disclose numerous past injuries and medical events in his application for PIP benefits through the MAIPF.
David Rodriguez was struck by a motor vehicle while a pedestrian, after which he sought PIP benefits through the MAIPF. On his application for benefits, when prompted to disclose his pre-accident injuries, Rodriguez wrote only that he was injured in previous motor vehicle accidents in 2004 and 2015, and that he had suffered injuries to his spine and head. When prompted to disclose the medications he had taken at any time prior to the accident, Rodriguez wrote only that he had taken aspirin and diabetes medication. Rodriguez’s claim was ultimately assigned to Farmers, and Farmers subsequently discovered that Rodriguez had a much larger pre-accident medical history than he had indicated in his application for benefits. He injured his back as a result of being struck by a motor vehicle in 2001; he had spine surgery after a slip and fall at work in 2004; he tore his meniscus after falling off a ladder in 2005; he injured his neck in a motor vehicle accident in 2007; he suffered a hairline fracture of an unidentified bone as the result of a slip and fall accident in 2008; he injured his neck again in a motor vehicle accident in 2011, as well as suffering injuries to his left shoulder and ankle; he had a stroke in 2014; he broke his clavicle and shoulder in 2016; and he suffered a closed head injury in yet another motor vehicle accident in 2017. Furthermore, Farmers discovered that Rodriguez had taken more medications in the pat that he originally disclosed, including Flexeril, Percocet, and Norco. Based on its discoveries, Farmers refused to pay benefits on Rodriguez’s claim and, after Rodriguez filed suit, moved for summary disposition, arguing that Rodriguez was ineligible for benefits through the MAIPF because he committed a “fraudulent insurance act” for purposes of MCL 500.3173a(2). The trial court agreed, granting Farmers’ motion.
The Court of Appeals affirmed the trial court’s summary disposition order, holding that “a reasonable juror could not conclude that the plaintiff was unaware that he was submitting false information” by listing only spine and head injuries as his pre-accident injuries. Secondly, the Court held that Rodriguez’s false statements were material to his claim because, “Even if a claimant can prove that an accident exacerbated or aggravated a preexisting condition, the fact of a preexisting condition is still highly relevant to the issue of causation and, thus, material to the claim and the task of determining eligibility for benefits.”
“In his application for no-fault benefits, plaintiff indicated that he injured his neck, head, ankle, and nose in the accident. Plaintiff indicated that he had prior injuries in 2004 and in 2015 to his spine and his head for which he had surgery. He indicated that his medication history included aspirin and diabetes medication. Plaintiff’s medical records establish that plaintiff omitted many significant facts from his application for benefits. For example, plaintiff was struck by a motor vehicle while riding a bicycle in 2001, resulting in injuries to his back. On February 10, 2004, plaintiff had a workplace slip and fall accident and thereafter had his first spinal surgery. In June 2005, plaintiff fell from a ladder and tore his medial meniscus. On March 7, 2007, plaintiff was involved in a motor vehicle accident and complained of neck pain. In May 2008, plaintiff had a slip and fall accident outside his house, resulting in a hairline fracture on an unidentified bone. On January 28, 2011, plaintiff had a slip and fall accident and complained of neck pain. On July 18, 2011, plaintiff was involved in a motorcycle accident and complained of pain in his neck, left shoulder, and left ankle. In 2014, plaintiff had a stroke. On March 30, 2016, plaintiff suffered a broken clavicle and shoulder. In 2016, plaintiff was involved in a motor vehicle accident, resulting in two herniated discs in his neck. On May 20, 2017, plaintiff went to the emergency room with a complaint of neck pain. On July 17, 2017, plaintiff was involved in a motor vehicle accident, resulting in a closed head injury. Plaintiff’s medical records also revealed that plaintiff’s medication history included significant pain medication, including Flexeril, Percocet, and Norco. A review of the above extensive omissions leaves no question that plaintiff was dishonest in his application for no-fault benefits. A reasonable juror could not conclude that the plaintiff was unaware that he was submitting false information.
Further, the false statements were material to plaintiff’s claim. ‘A statement is material if it is reasonably relevant to the insurer’s investigation of a claim.’ Bahri v IDS Prop Cas Ins Co, 308 Mich App 420, 425; 864 NW2d 609 (2014), abrogated on other grounds by Williams v Farm Bureau Mut Ins Co of Mich, 335 Mich App 574; 967 NW2d 869 (2021). Under MCL 500.3107(1)(a), no-fault coverage is limited to ‘reasonable charges incurred for reasonably necessary products, services and accommodations for an injured person’s care, recovery, or rehabilitation.’ No-fault benefits are only available ‘to the extent that the claimed benefits are causally connected to the accidental bodily injury arising out of an automobile accident.’ Griffith v State Farm Mut Auto Ins Co, 472 Mich 521, 531; 697 NW2d 895 (2005). Even if a claimant can prove that an accident exacerbated or aggravated a preexisting condition, the fact of a preexisting condition is still highly relevant to the issue of causation and, thus, material to the claim and the task of determining eligibility for benefits.”