COB/Going Out of Health Network For Medical

Written by Steven Matz on . Posted in .

“I was hurt in a car accident. If I want to go to a doctor who is not in my health care network, will my no-fault auto insurance pay that doctor’s bills?”

Most likely not. If you have a health network plan that only covers doctors in the plan, you need to get permission from your health plan to go to an “outside” doctor if you want the health plan to cover the service. You usually aren’t going to get that permission, unless you are seeking a service that isn’t covered by your plan in the first place, or unless there are no doctors in your plan who are involved in the specialty you need.

If you don’t get approval from your health plan in advance to seek a service outside the plan, don’t expect your health plan to cover it. If your injuries were auto-related, you might think that you can go to any doctor you wish, and that your car insurance will cover any service that was “out of network” with your health insurance.

Unfortunately, Michigan no-fault coverage doesn’t work that way. If you go “out of network” on your health coverage for reasons other than those mentioned above, neither your health coverage nor your car insurance has to pay the bills for those services. The idea behind this is that your health insurance under these types of plans is supposed to pay for your care, and you can’t try to get around the network rules and make the auto coverage pick up the tab.

Please also remember that your no-fault carrier always has the right to question whether the care you are seeking is reasonable, necessary, and related to the collision. It is the auto carrier, not you, who gets to make that decision initially. This is another reason that you want to stay within the boundaries of your health insurance coverage (if you have any) when you are in a car accident. There is never any guarantee that your car insurance is going to pay for any care you receive, and going out of the “mainstream” for exotic treatments or to unfamiliar “specialists” increases the chances that you will end up having to pay for your treatments out of your own pocket.

Source: 251 Mich App 260; 444 Mich 301

Written By Steven Matz

Steven J. Matz is a founding shareholder of Matz Injury Law. The firm’s concentration is on personal injury litigation, with an emphasis on traumatic brain injury. Mr. Matz earned a Bachelor of Arts degree with high distinction and highest honors in 1974 from the University of Michigan and a Juris Doctor degree in 1977 from The George Washington University National Law Center. Mr. Matz lectures and publishes in a number of areas, including ethics, marketing, trial tactics, and head injury. Mr. Matz has served on the Michigan Association for Justice Executive Board and currently serves the Michigan Attorney Discipline Board as a Hearing Panel Chairman and Master. He is also a member of the State Bar Committee for Character and Fitness.
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The maximum contingency fee permitted by law is actually 33 1/3%. Michigan court rules require that the attorney fee be computed on the net sum recovered after deducting all disbursements properly chargeable to the enforcement of the claim.

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