Mich. Supreme Court Upholds Insurers’ Right to Only Pay Reasonable Medical Charges

March 15, 2005

The Supreme Court of Michigan recently ruled that the state’s No-Fault Insurance Act, prohibits health care providers from charging more than a reasonable fee for services and left it up to lower courts to determine what is reasonable when a dispute arises.

In the case of Advocacy Organization for Patients & Providers V. Auto Club Insurance Association, et al., the Supreme Court upheld the Michigan Court of Appeals ruling that the No-Fault Act expressly permits and the legislative intent was that insurance carriers review medical invoices for the reasonableness of the fees being charged. The plaintiffs argued that medical providers are entitled to charge whatever fee they deem appropriate, so long as they charge patients with or without insurance the same fee – regardless of the reasonableness. The defendants argued that the plaintiff’s position was contrary to the clear mandate of the No-Fault Act that medical providers charge a reasonable amount for the products, services and accommodations offered to patients.

“This decision is a major victory for insurers providing no-fault automobile coverage in Michigan,” said Robert Hurns, legislative database manager and counsel for the Property Casualty Insurers Association of America (PCI), which filed an amicus brief in the case. “Clearly, just because a provider designates a charge as ‘customary’ does not automatically make that charge ‘reasonable.'”

The trial court ruled the insurers were entitled to review any medical charges and pay only those determined to be reasonable. The trial court further ruled that even though a medical provider’s charge does not exceed the amount the provider customarily charges in cases not involving insurance, that fact alone does not establish that the charge is reasonable.

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