MIC GENERAL INSUR V HEALTHPLUS OF MICH
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STATE OF MICHIGAN
COURT OF APPEALS
MIC GENERAL INSURANCE CORPORATION,
UNPUBLISHED
Plaintiff-Appellant,
v
No. 196207
Genesee Circuit Court
LC No. 95-37810-CZ
HEALTHPLUS OF MICHIGAN, INC.,
Defendant-Appellee.
Before: Markman, P.J., and McDonald and Fitzgerald, JJ.
MARKMAN, J. (concurring).
I concur with the majority that this case should be reversed and remanded. However, I would
do so exclusively in order to determine whether a referral to the Craig Institute or any other
rehabilitation facility was ever sought by the Fullers. If such a request for referral was made, then I
believe that the medical reasonableness of defendant's denial of the referral under the Group Services
Contract must be determined.1 It is implicit in the HMO contract that decisions to refer or to not refer
must be reasonably grounded lest the health insurer routinely be able to shift costs to the no-fault insuror
where personal protection benefits have been coordinated with other health and accident coverage.
Federal Kemper Ins Co, Inc v Health Ins Administration, Inc, 424 Mich 537, 546; 383 NW2d 590
(1986); Michigan Mutual Ins Co v American Community, 165 Mich App 269, 274-275; 418
NW2d 455 (1987). Such an inquiry into the medical reasonableness of a referral decision would
include an evaluation of Judy Fuller's injuries as well as the respective medical resources available to her
inside and outside of the HMO.
However, if a request for referral was not made by the Fullers pursuant to the HMO contract,
then this is the end of the trial court's inquiry, in my judgment, and it must grant summary disposition in
favor of defendant.2 It is well-understood that a party entering into a contract for medical services with
an HMO thereby sacrifices some measure of their freedom with regard to their choice of provider.
While they remain free to obtain the services of any provider they choose, they are entitled to
reimbursement from the HMO only to the extent that such provider is either within the purview of the
HMO or else is a non-affiliated provider who has been specifically authorized by the HMO pursuant to
its own procedures. To the extent that Westfield Co v Grand Valley Health Plan, 224 Mich App
-1
385; 568 NW2d 854 (1997) supports the proposition that HMO contract provisions need not be
construed in the same manner as other contract provisions because to do so would potentially be to
place “form over substance,” I respectfully reject this holding and abide by it only under the
requirements of MCR 7.215(H). Further, I would retain jurisdiction.
/s/ Stephen J. Markman
1
This would also encompass an assessment of the reasonableness of defendant's conduct either in
failing to act upon a proper referral request or in failing to comply with its own procedures established in
connection with referral requests.
2
An exception might obtain if there were emergency medical care provisions in the HMO contract that
arguably applied to the instant circumstances. I am not aware, however, of any such provisions having
been invoked by plaintiff or by the Fullers.
-2
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