Detroit, Mich. — In a recent decision by the Michigan Court of Appeals, a bid by Rhonda Fountain to secure personal protection insurance (PIP) benefits for knee injuries sustained in a bicycle accident was partially overturned. The court ruled that Fountain failed to prove the reasonableness of the rates charged for her medical services, a necessary criterion under Michigan’s no-fault insurance act.
Fountain, who was struck by a vehicle while cycling on Telegraph Road near 8 Mile Road, received an initial diagnosis of a fractured left knee on the day of the accident. She sought treatment from Lederman & Kwartowitz, where her fracture was managed and subsequently healed by mid-January 2018. However, her treatment continued due to degenerative changes noted in her knee subsequent to the healing of the fracture.
State Farm Mutual Automobile Insurance Company, Fountain’s insurer, provided approximately $130,000 in PIP benefits covering medical and related services until September 2018. This cessation of benefits followed an independent medical examination which concluded that Fountain’s fracture had healed and no further knee treatments were necessary.
Unsatisfied with State Farm’s decision, Fountain pursued additional PIP benefits, asserting ongoing knee and back problems required continued medical attention. This led her to undergo further treatment and surgery in 2019. She also sought services from other health providers, including Phase One Rehab.
The Wayne County Circuit Court initially ruled partly in her favor, awarding her $22,393.76. This covered unpaid services from Phase One Rehab and some treatments at Lederman & Kwartowitz, plus penalty interest and attorneys’ fees. However, her claims for back-related injuries and some additional knee treatments were dismissed.
Upon appeal, the Michigan Court of Appeals amended this decision. The judges opined that the evidence provided by Fountain, which included an account ledger, failed to substantiate that the charges from Lederman & Kwartowitz were customary or reasonable. They stated that leaving the jury to speculate on the appropriateness of the charges was impermissible, leading to the verdict that Fountain did not adequately meet the burden of proof, necessitating a directed verdict in State Farm’s favor concerning the disputed charges.
Furthermore, the appeals court vacated the claims for penalty interest and adjustments in the award of attorneys’ fees. The panel concluded that State Farm’s refusal to cover Phase One Rehab’s services was not unreasonable. This decision hinged on medical records which suggested Fountain’s continued knee issues stemmed from degenerative conditions rather than the accident.
While the court upheld the charges awarded for Phase One Rehab, it rescinded the attorneys’ fees linked to Lederman & Kwartowitz’s services, emphasizing that the denial of these claims was based on substantial evidence and was not unjustified.
This judgment sends the case back to Wayne County for further proceedings, as the complexities of no-fault insurance law continue to challenge the determination of what constitutes reasonable medical charges in accident-related injuries.
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