Allstate forced to pay head injury PIP benefits despite discrepancy between claim and ultimate award; abortion history not admitted into evidence

Trina Richard was struck by a car as a 16 year-old high school girl.  She suffered a large hematoma and was treated for a closed head injury at Henry Ford Hospital.  She missed several weeks of school.  Allstate paid a little under $500.00 in medical expenses at that time, with her health insurer picking up the balance, and Trina sought no further treatment for 12 years.  In 2005, Trina complained of almost constant headaches and other head injury symptoms, and sought medical expense coverage from Allstate.

Allstate's adjuster was "skeptical" and sent Trina to a psychologist for an "independent" medical examination.  The defense medical examiner concluded that Trina's behavior was "consistent" with exaggeration or malingering, but reported that he could neither confirm nor deny actual exaggeration.  The treating doctors rejected that conclusion.  Nevertheless, Allstate refused to pay Trina's medical expenses and she filed suit.  Unfortunately, she never returned to Allstate medical authorizations to allow the company to independently confirm her medical records, and  her advisers initially made a claim for six figures in attendant care.

The Court pointed out that Allstate's vague claim that the abortion was relevant "because it is part of what made her into the person she is today..." would justify the admission into evidence of any negative historical fact or perception that a litigant sought to admit into evidence.  The Court also rejected Allstate's claim that it owed no attendant care to family members because they had not submitted a bill to Trina for their services.  The Court noted that within a family, the provider need not bill for services, provided there is evidence that the provider did intend to be paid and anticipated payment at normal market rates.

Among the laundry list of defenses Allstate raised was the claim that one of the providers could not collect for services because it had not filed an assumed name certificate.  The Court pointed out that the provider's corporate name included the professional's name, and thus the "assumed name" statute was irrelevant.

The Court rejected Allstate's claim that since the jury awarded Trina only ten percent of her claim, and an even smaller percentage of her original request, the jury had found her claim to be "fraudulent or so excessive as to have no reasonable foundation."  The higher court agreed with the trial court's assessment that while Plaintiff had asked for too much, and this was evidence of an excessive claim, the evidence was not dispositive:  "just because the plaintiff didn't get everything [she] wanted, doesn't make it automatic fraudulent or excessive."  The claim was not without reasonable foundation:  the Plaintiff simply over-reached in evaluating what she was entitled to [and likely cost herself money in the process].  Simply asking for too much does not "conclusively establish" that a claim is fraudulent.

The Court also dismissed Trina's claim for attorneys' fees.  It noted that there was a reasonable basis for the Allstate adjuster to initially demand a complete investigation of benefits before making payment.  Given the 12 years without medical treatment and Trina's failure to return medical authorizations, she cannot complain that Allstate was unreasonable in seeking to investigate.