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How long does an insurance company have to cover a person’s injuries after an accident? When will treatment no longer arise out of the car crash? When medical complications happen in the course of treatment, auto insurance adjusters may find ways to refuse to pay, but the Michigan No-Fault Act is clear: medical complications are covered.
An accident causes an injury, which causes a surgery, which causes an infection, which requires a second surgery, and so on. At what point can an auto insurance company stop payment? A recent unpublished Michigan Court of Appeals decision, Conners v State Farm Mutual Auto Ins Co, says the question is whether the condition and benefits arise out of the accident.
Kenneth Conners was injured in a pedestrian accident on October 25, 2012. Conners was standing in the street when he was hit on the right side and thrown onto the hood of the car. He suffered a “right intertrochanteric hip fracture,” for which he underwent surgery.
State Farm, the insurance company for the driver who hit Conners, agreed that the hip fracture was related to the accident and paid his medical treatment and surgery.
Later, Conners suffered a medical complication: nonunion of the intertrochanteric fracture – the bone had failed to heal properly. He underwent “revision” surgery to correct the problem. As he recovered from the second surgery, Conners had a reaction to a drug given to him and suffered a fever and altered mental status (AMS). He and the hospital again filed no-fault claims for this second round of treatment, but this time State Farm refused to pay.
The insurance company took the position that, because Conners had failed to follow medical advice during his recovery from the first surgery, his negligence (and not the accident) was the cause of the nonunion, the revision surgery, and the resulting drug reaction. It claimed if Conners had only followed doctors instructions by not smoking, eating right, and staying off of his injured leg, the medical complications would never have occurred. The trial court agreed, ruling that the hip fracture and the nonunion were two separate injuries and that there was no evidence tying the second injury to the accident.
The Court of Appeals disagreed. It examined the causal connection between Conners’ medical complications and the accident. MCL 500.3105(1) requires no-fault insurance companies to pay benefits “for accidental bodily injury arising out of the ownership, operation, maintenance or use of a motor vehicle as a motor vehicle….” When determining whether a given injury “arose out of” the motor vehicle accident, the court quoted earlier cases stating:
“[T]his Court has established that an injury arises out of the use of a motor vehicle as a motor vehicle when “the causal connection between the injury and the use of a motor vehicle as a motor vehicle is more than incidental, fortuitous, or ‘but for.’ ”
The court found a direct causal connection between the initial injury and the medical complications. It noted, “Thus, the ‘revision’ surgery for that fracture was simply further treatment of the initial injury.” Because evidence existed to say the accident caused the second injury in a direct way, the court could not enter summary judgment against the injured party or the medical provider.
The court noted that Conners’ noncompliance may have slowed the healing process, but this does not defeat causation. An injured plaintiff is not required to show that the accident is the only cause for his or her injuries, or even a proximate cause. Only that there is something more than an incidental, fortuitous, or “but for” relationship.
Not all of Conners’ subsequent injuries were covered, though. The court upheld summary judgment regarding a second greater trochanter fracture, a subcapital fracture, and foot pain. There was no evidence, the court said, to believe that these injuries were connected to the original motor vehicle accident.
Judge Elizabeth L. Gleicher would have gone further. In a partial dissent, she noted that the majority made this an issue of causation, rather than the reasonable and necessary treatment of Conners’ injuries. She viewed the case not through the lens of MCL 500.3105(1), but through MCL 500.3107(1)(a), which states:
“Allowable expenses consisting of all reasonable charges incurred for reasonably necessary products, services and accommodations for an injured person’s care, recovery, or rehabilitation.”
In her view, once the causal connection between the accident and the original injury (here the hip fracture) is established, any treatment or services reasonably necessary for the person’s care, recovery, or rehabilitation should be covered. Since State Farm did not challenge the reasonableness of the treatment, it should not be able to avoid paying benefits for any treatment that relates to the original injury.
In Judge Gleicher’s view, allowing State Farm to read issues of proximate cause and comparative fault into the payment of benefits for medical complications defeats the purpose of the Michigan No-Fault Act. She wrote:
“Challenges of the causal relationship between every incurred expense and the accident giving rise to the involved injury would bring the first-party no-fault system to a crashing halt.”
If allowed to progress on this theory, anything from medical malpractice to a patient’s inability keep a wound clean could cut that person off from benefits directly related to the motor vehicle accident. Such a line of thinking would put fault back into the No-Fault Act and allow insurance providers to challenge every treatment.
The Michigan No-Fault Act is intended to protect those injured in motor vehicle accidents against the cost of treatment. If insurers believe they can get around paying by pointing to a patient’s deviation from a medical plan, it makes them, not the doctors, the final authority on what treatment is reasonably necessary.