Court upholds verdict against State Farm for refusing to pay Case Manager's services
Community Resource Consultants was forced to sue State Farm Mutual when the insurer refused to pay PIP expenses [in this case--auto accident-related medical expenses] on behalf of four insureds. Although an insured enjoys the right to choose his or her own case manager, insurers prefer that the case manager be directly engaged by the insurer and more firmly under the insurer's control. In this manner, insurers have greater control over costs and a sympathetic ear at all meetings with health care providers. Many case managers derive most or all of their work from a particular insurer and "know where their bread is buttered:" certainly their loyalty to a particular insured patient is challenged by this significant financial interest.
When an insured chooses his or her own Case Manager, the insurer often exerts a form of passive resistance or obstructionism to make life difficult for the patient and the case manager. The latter circumstance appears to have arisen with respect to Community Resource, which was forced to sue in Macomb County Circuit Court after State Farm refused to pay for care management services rendered on behalf of four different insured individuals. Community Resource secured a verdict against State Farm in the trial court which was substantially upheld on appeal, despite State Farm's argument that the health care provider's billings "lacked sufficient detail." The Court of Appeals did grant a directed verdict with respect to the bills related to one of the four patients, as it found that Community Resource did not admit into evidence adequate proof of the causal relationship between a car accident and the services rendered.