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What to do when insurance companies insist on their case manager

March 20, 2017 by Steven M. Gursten

Auto accident victims have right under No-Fault to hire their own case manager, and insurers’ duty to pay for ‘services’ doesn’t let them demand who provides it

Insurance Case Manager
An insurance company claim adjuster cannot override a car accident victim’s right to choose his or her own case manager. But that doesn’t mean some Michigan auto insurance companies won’t try to push hard to control an automobile accident victim’s medical care and treatment more than they should.

Friend or foe? Advocate or spy? Does the case manager that your claims adjuster is demanding you use going to truly care about you ­— or is the case manager a ruse to control the costs of treatment and medically manage your case to keep the costs down for the insurance company.

These are real concerns, and these concerns become even greater when the claims adjuster is insisting you use a case manager that he or she wants. Is the case manager there to help you recover the medical care and treatment that you need, under the Michigan No Fault Act, for your motor vehicle accident-related care, recovery or rehabilitation?

Or is the case manager there just to keep costs down for the insurer?

As an attorney, I’ve been watching adjusters demand that my clients use a specific case manager for over two decades. Too often, it turns out the case manager that your adjuster is demanding you use is not the one that has your best interests in mind.

Fortunately, accident victims have a choice.

Under Michigan’s No Fault Law, auto accident victims can choose their own case manager

That’s why in most cases, my own clients will opt for a case manager of their own choice and not one that the claims adjuster is trying to foist onto them.

Under Michigan’s No Fault auto insurance laws, motor vehicle accident victims have the legal right to hire their own case manager — one of their choosing.

And their auto insurer is obligated under our auto law to pay for it.

Even when the law is clear, I still see many adjusters trying to force their own, hand-picked case manager (read: cost and treatment spy) on my clients. I’ve seen letters insisting that my client MUST use their case manager and I’ve had adjusters threaten that they will not pay for any other case manager than the one that they want the accident victim to use.

When this happens (and it is happening more and more as Michigan has no bad faith or consumer protection laws to protect a car accident injury victim from abuse) the following issue arises:

Can an insurance company claim adjuster override a car accident victim’s right to choose his or her own case manager?

The answer is: No.

But that doesn’t mean some Michigan auto insurance companies won’t try to push hard to control an automobile accident victim’s medical care and treatment more than they should.

Below I’ll discuss the steps that Michigan auto accident attorneys can take to push back on this overreaching by auto insurance companies, plus I’ll share the strategy that one of our own Michigan Auto Law attorneys uses for handling this problem.

Why insurer does not have authority over choice of case manager for car accident injury victims

An auto insurance company has the legal duty to pay No Fault PIP benefits to cover any injured car accident victim’s need for case manager services.

But that doesn’t allow the insurer to control who the case manager will be.

First, the No Fault insurer has an obligation to pay for case manager “services” so long as they’re “reasonably necessary” to the auto accident victim’s “care, recovery or rehabilitation.” (MCL 500.3107(1)(a))

Second, there is nothing in the No Fault law granting insurers the right to dictate who medical care the providers will be, or to put their own opinion of what “services” are reasonably necessary to be covered and paid for by No Fault insurance benefits.

‘Use our case manager or we won’t pay!’

Here’s what Acuity Insurance recently told one of our own clients:

“At this time, it is undetermined if your medical treatment is necessary/or related to the motor vehicle accident … and therefore, in order to consider payment of any PIP benefits under [the] policy … we will need you to cooperate in contacting [the case manager that we have selected to manage your claim] … Acuity was also advised that another Case Management Company contacted [our chosen case manager] stating per your request, that you would like them to be the case management company on this claim. Please note that per Acuity request, we have hired [the case manager that we selected] to be the case management company on this claim and therefore no other bills nor reports from other entities will be taken into consideration.”

Charming, right?

At least it leaves no doubt as to whose interests the insurer-selected case manager will be serving.

Questioning insurance company’s legal “Acuity” over demand of certain case manager

For auto attorneys facing a similar insurer attack on their clients, they may be interested in how Thomas James, one of our attorneys, responded.

In his letter to Acuity’s adjuster, i.e., “MI Field Claim Representative,” Tom made the following points:

“I agree with you that [my client] needs a nurse case manager to assist her managing her appointments and I am sure you are aware that our Michigan no-fault act gives insured the right to select their own medical providers including nurse case managers.”

“If [Acuity’s chosen case manager] is retained as an agent of Acuity [to determine “if [my client’s] medical treatment is necessary/or related to the motor vehicle accident”] rather than part of [my client’s] treatment team that is important for [my client] and myself to know because it has different implications on the standard of care expected from [Acuity’s chosen case manager]. It would be unfair to [my client] to mislead her into believing [Acuity’s chosen case manager] was retained by Acuity as her case manager when in actuality [Acuity’s chosen case manager] is merely an agent of Acuity who has no interest in assisting in her medical rehabilitation.”

“Lastly, making blanket statements that ‘no other bills nor reports from other entitles will be taken into consideration’ is unreasonable. MCL 500.3107 provides coverage for ‘[a]llowable expenses consisting of all reasonable charges incurred for reasonably necessary products, services and accommodations for an injured person’s care, recovery, or rehabilitation.’ Choosing to ignore or not consider medical evidence or medical reports before receipt could lead to poor decision making and an incorrect conclusion.”

Attorneys, stand firm. Do not allow your clients to be bullied by the claims adjuster into using a case manager who will put the insurance company’s best interests over your client.

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