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A Better Partnership
November 03, 2015

COA: An injured party’s failure to submit to a medical examination or an examination under oath does not establish, as a matter of law, ineligibility under no-fault act

In the consolidated appeal of Chiropractors Rehabilitation Group, P.C. v. State Farm Mutual Automobile Insurance Company, Nos. 320288; 322317, the Michigan Court of Appeals held that healthcare providers have standing under the Michigan no-fault act to obtain personal injury protection (“PIP”) benefits for treatment rendered.  In addition, their eligibility to recover is dependent upon the injured party’s eligibility for said benefits, but an injured party’s failure to submit to a medical examination (“ME”) or an examination under oath (“EUO”) does not establish, as a matter of law, that the party is ineligible for no-fault benefits.  The Court affirmed the trial court’s denial of State Farm’s motions for summary disposition in both cases, and reversed the order denying State Farm’s motion to amend its affirmative defenses in Docket No. 322317, and remanded the case for further proceedings.
 
In Docket No. 320288, Raynard Jackson allegedly sustained injuries while a passenger in an automobile.  Jackson made a claim for PIP benefits and State Farm requested that Jackson submit to a ME and an EUO.  Jackson failed to appear multiple times and State Farm informed him that it was suspending his claim for benefits.  When Chiropractors Rehabilitation Group, P.C. (“Chiropractors”) sought payment for treatment of Jackson, State Farm refused to pay, claiming that it was not responsible because Jackson failed to cooperate in its investigation; Chiropractors filed suit claiming that it was entitled to payment under the no-fault act.  The trial court denied State Farm’s motion for summary disposition and found that questions of fact existed as to whether Jackson was eligible for coverage.  On appeal, the circuit court affirmed the trial court’s order.
 
Similarly, in Docket No. 322317, Ricky Johnson allegedly sustained injuries while a passenger in an automobile insured by State Farm.  Johnson made a claim for PIP benefits and State Farm requested that Johnson submit to an EUO.  Johnson failed to cooperate and State Farm suspended his claim.  Elite Health Centers, Inc. (“Elite”) sought payment for treatment of Johnson and State Farm refused; Elite filed suit seeking payment of outstanding medical expenses.  The trial court denied State Farm’s motion for summary disposition and found that a healthcare provider has a right to a separate cause of action.  It also denied State Farm’s motion to amend its affirmative defenses.  The circuit court then denied State Farm’s application for leave to appeal.  The Court of Appeals granted leave to appeal in both cases.
 
In Docket No. 322317, State Farm argued that healthcare providers lack standing to bring an action against an insurer under the no-fault act to obtain PIP benefits.  The Court analyzed this argument under the statutory scheme of the no-fault act and held that the Michigan Legislature “intended to confer standing on a healthcare provider to bring a claim against an insurer in order to enforce its right to be reimbursed for medical services rendered to an injured party insured under the applicable no-fault policy.”  The Court concluded that State Farm’s argument lacked merit based on the no-fault act and applicable case law.
 
Next, in both cases, State Farm argued that a healthcare provider’s ability to seek PIP benefits depends on an injured party’s eligibility to receive PIP benefits and as such the claims in these cases were barred as a matter of law.  The Court reviewed Michigan case law and agreed that a healthcare provider’s eligibility is dependent upon an injured party’s eligibility to receive no-fault PIP benefits, but disagreed that the healthcare providers’ claims were barred as a matter of law at the current state of the proceedings.  The Court also reviewed MCL 500.3153, which governs the consequences for a claimant refusing to submit to an examination.  The Court ultimately held that Jackson’s failure to submit to a ME and an EUO and Johnson’s failure to submit to an EUO did not, as a matter of law, establish that they were not entitled to PIP benefits.
 
Finally, in Docket no. 322317, the Court reversed the trial court’s denial of State Farm’s request for leave to amend its affirmative defenses as it concluded that its amendment was not futile and allowed under MCR 2.118(A)(2).  The Court of Appeals remanded the cases for further proceedings.

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