February 15, 2005, Troy, Michigan. Mantese and Associates won a significant victory in the Michigan Court of Appeals on Tuesday, February 15, 2005. In a unanimous three-judge opinion, the Court rejected Auto Club Insurance Company’s attempt to overturn a $371,000 jury verdict that M&A won on behalf of a physician-client in early 2004.

The case arose out of the defendant insurance company’s refusal to pay the physician for the medical care that he was providing to a patient who was insured by the defendant pursuant to the Michigan No-Fault Act. The insurer tried to argue that it did not have to pay for the patient’s care because the accident was not covered under the insurance policy and because the medical charges were too high. However, the jury found in favor of the physician on all counts, rendering a verdict that the insurer’s refusal to pay was in bad faith, and awarding M&A’s client a verdict consisting of 100% of his medical charges, plus 12% interest and attorney fees, for a total judgment of $371,000.

On Tuesday, February 15, 2005, the Court of Appeals rejected Auto Club’s bid to have the verdict overturned, confirming the trial court’s ruling that the insurer was estopped from denying coverage for the medical services provided by the doctor – irrespective of whether coverage actually should have been extended under the terms of the policy – because the insurer had conducted itself as if coverage had applied, admitted that coverage was available, and actually told the doctor that there was coverage. The court held that since the doctor relied on these representations before starting the treatment of his patient, the insurance company would not be permitted to subsequently change positions and deny coverage.

This ruling constitutes a significant victory for health care providers in that it precludes insurance companies that cover their patients from changing positions on coverage mid-stream.

Click here to read the court’s decision: Ruben v. Auto Club, 2005 WL 356279 (Mich. App.)