Case Name: LaMOTHE v. AUTO CLUB INSURANCE ASSOCIATION
Court: Michigan Court of Appeals
Jurisdiction: Michigan
Decision Date: 1995-12-15
Citations: 214 Mich. App. 577
Docket Number: Docket No. 171729
Parties: LaMOTHE v AUTO CLUB INSURANCE ASSOCIATION
Judges: Before: Taylor, P.J., and McDonald and J. G. Collins, JJ.
Reporter: Michigan appeals reports; cases decided in the Michigan Court of Appeals.
Volume: 214
Pages: 577–592

Head Matter:
LaMOTHE v AUTO CLUB INSURANCE ASSOCIATION
Docket No. 171729.
Submitted July 12, 1995, at Lansing.
Decided December 15, 1995, at 9:25 a.m.
Leave to appeal sought.
George LaMothe brought an action in the Ingham Circuit Court against his no-fault automobile insurer, Auto Club Insurance Association, after the defendant refused to pay a portion of the plaintiffs health care expenses resulting from an automobile accident that the defendant determined to be unreasonable expenses. However the defendant agreed to defend and indemnify the plaintiff in the event the medical providers filed suit against the plaintiff for the unpaid balance of their bills. The court, Peter D. Houk, J., granted summary disposition for the defendant. The plaintiff appealed.
The Court of Appeals held:
1. The plaintiffs claim failed to state an actionable claim for breach of contract.
2. The plaintiff failed to state a cause of action, even if a breach of contract could be established, because he has suffered no damages as a matter of law. Because the plaintiff failed to plead and prove tortious conduct independent of the breach of contract claim, damages for emotional distress and anxiety are not recoverable. Furthermore, the plaintiff cannot recover his actual attorney fees because he has failed to state a cause of action for breach of contract.
3. The defendant’s promises to- defend and indemnify the plaintiff in the event he is sued by the health care providers for their outstanding balances are enforceable.
4. The trial court properly determined that the plaintiffs allegations of fraud were not specifically pleaded and, thus, were insufficient to state a claim. Dismissal of the claims of fraud was appropriate.
Affirmed.
McDonald, J., concurring in part and dissenting in part, stated that the majority was correct in holding that the allegations of fraud were insufficient to state a claim, but disagreed that summary disposition was proper. The plaintiff’s complaint clearly sets forth a claim of breach of contract. The plaintiff raised a question of fact regarding the material issue whether the defendant paid all reasonable and necessary medical expenses submitted by the plaintiff for payment. The trial court should not have granted the motion for summary disposition. The evidence indicates that the plaintiff has been exposed to harassment, collection attempts, and disparagement of credit, and has incurred liability as a result of the dispute between the health care providers and the defendant. The promises made by the defendant to defend and indemnify the plaintiff from the medical providers’ suits are unenforceable. To deny the plaintiff access to the courts on the basis of such promises is a denial of due process and impairment of the plaintiff’s contractual rights. The order granting summary disposition should be reversed and the matter should be remanded for a trial regarding the issue of reasonable charges and necessary services.
References
Am Jur 2d, Automobile Insurance § 359; Estoppel and Waiver §§ 48, 71; Fright § 33.
See ALR Index under Automobile Insurance; Emotional Injury; Estoppel and Waiver.
1. Insurance —No-Fault — Reasonable Expenses.
An insurer does not breach its contract of no-fault automobile insurance where it pays a reasonable fee for reasonably necessary products, services, and accommodations provided to an insured for an accidental bodily injury covered by personal protection insurance; the fact that the amount paid is less than the amount charged by the' health care provider does not constitute a breach of contract where the amount paid is necessary and reasonable and the insurer agrees to defend and indemnify the insured in the event the health care provider sues the insured for the balance (MCL 500.3107[l][a], 500.3157; MSA 24.13107[l][a], 24.13157).
2. Contracts — Actions — Damages.
Damages for emotional distress and anxiety are not recoverable in an action for breach of contract where the plaintiff does not allege and prove tortious conduct existing independently of the breach of contract.
3. Estoppel — Insurance — No-Fault — Promises to Defend and Indemnify.
Either judicial estoppel or promissory estoppel may be invoked to preclude a no-fault automobile insurer from successfully declining to defend and indemnify an insured in the event the insured is sued by health care providers for the amount of services, products, or accommodations provided to the insured after an automobile accident but not paid by the insurer on the basis of the insurer’s determination that the amount billed was either unnecessary or unreasonable and the insurer has informed the court that it would provide such defense and indemnity and the court relied on that information in granting the relief sought by the insurer.
Fowler, Tuttle, Clark & Coleman (by Larry D. Fowler), for the plaintiff.
Willingham & Coté, P.C. (by Steven A. Mitchell and Marianne E. Samper), for the defendant.
Before: Taylor, P.J., and McDonald and J. G. Collins, JJ.
Recorder’s Court judge, sitting on the Court of Appeals by assignment.

Opinion:
Taylor, P.J.
Plaintiff appeals as of right the trial court's order granting summary disposition for defendant. We affirm.
Plaintiff was injured in an automobile accident. Defendant was plaintiff's automobile no-fault insurer and, pursuant to the insurance policy, was responsible for the payment of "reasonable charges incurred" for plaintiff's medical services. Defendant paid its portion of plaintiff's expenses until 1992, when it instituted a company-wide system of medical bill audits to determine what constituted a reasonable charge for a medical service. Through the audit process, defendant determined that some of plaintiff's expenses were not reasonable, and, therefore, refused to pay that portion of the health care expenses it determined to be unreasonable, including payments for home care services to Diane LaMothe, plaintiff's daughter._
Plaintiff filed suit, claiming that defendant's failure to pay all medical bills in full constituted a breach of the insurance contract and fraudulent conduct. In particular, plaintiff asserts that the audits were motivated by a fraudulent intent to establish a "test case for aaa for the purpose of diminishing benefits to the plaintiff."
The trial court granted summary disposition pursuant to MCR 2.116(0(10), holding that plaintiff did not provide adequate proof of damages to create a genuine issue of material fact for trial. In the alternative, the trial court found that plaintiff did not state a claim for breach of contract and granted summary disposition pursuant to MCR 2.116(C)(8). The court further found that the allegations of fraud were mere speculation unsupported by specific facts as required by MCR 2.116(G)(4).
By way of overview, after the circuit court issued its opinion in this case, this Court addressed in a different case most of the issues raised by plaintiff and disposed of them utilizing reasoning similar to that employed by the circuit court. See McGill v Automobile Ass'n of Michigan, 207 Mich App 402; 526 NW2d 12 (1994). In McGill, a case with facts similar to this case, several persons injured in automobile accidents sued their insurers for the insurers' failure to pay the plaintiffs' medical expenses in full. Rather than pay the amount billed in full, the insurers, in reliance on the policy language, the automobile no-fault insurance statute, and an interpretive statement of the Commissioner of Insurance, paid only the charges they determined were necessary and reasonable. Id. at 404. As a protection to the insureds, the insurers agreed to defend and indemnify their insureds in the event that the medical providers filed suit against the insureds. The insurers also promised to attempt to protect the insureds' credit ratings from the adverse effect of the nonpayment of the providers' bills. On the basis of these facts, the McGill Court concluded that the insureds had suffered no damages resulting from the insurers' partial payment of medical bills. Id. at 407. The same situation pertains here and McGill is dispositive.
While acknowledging the applicability of McGill, plaintiff argues McGill was wrongly decided and that the trial court in this case erred in granting defendant's motion for summary disposition and dismissing his suit. We disagree with plaintiff and will supplement in this opinion those matters that were earlier discussed in McGill.
In this case, the trial court held, and we concur, that plaintiff's complaint failed to state an actionable claim for breach of contract. MCR 2.116(C)(8). There has been no breach of the contract. Plaintiff alleged that "defendant, aaa, has failed, refused and neglected to pay health care benefits as provided in MCL 500.3109a; MSA 24.13109(1)." This statement is simply incorrect. Defendant has not refused to pay health care benefits due plaintiff. To the contrary, defendant has paid and continues to pay those charges reasonably incurred for reasonably necessary products, services, and accommodations for plaintiff's care. The mere fact that those amounts are not the same as the amounts charged by the health care provider does not, as plaintiff would have it, constitute a breach of the contract. Indeed, contrary to plaintiffs contention, if the insurance company paid the bills regardless of their reasonability, that action would, in fact, be in violation of the insurance contract.
Plaintiff also has failed to state a cause of action because even if a contract breach could be established, he has suffered no damages as a matter of law. Plaintiff's complaint claims that as a result of defendant's alleged breach of contract, he has suffered outstanding bills, a blemished credit rating, emotional stress and anxiety, and attorney fees. Plaintiff concedes that the only damage he has suffered as a result of the outstanding bills and blemished credit rating is the threat of receiving annoying or harassing telephone calls from creditors. Plaintiff's attorney stated at the summary disposition hearing, "I think spoiled dinner certainly is the right analysis" for damages that plaintiff suffered as a result of the outstanding bills and blemished credit rating. However, applying the doctrines springing from the venerable Hadley v Baxendale, 9 Exch 341; 156 Eng Rep 145 (1854), these are not cognizable damages in a contract action. Damages for emotional distress and anxiety, as well as damages for annoying telephone calls during dinner, are not recoverable in a breach of contract action absent allegations and proof of tortious conduct existing independently of the breach of contract. Kewin v Massachusetts Mutual Life Ins Co, 409 Mich 401, 419- 421; 295 NW2d 50 (1980); Isagholian v Transamerica Ins Corp, 208 Mich App 9, 17; 527 NW2d 13 (1994); Taylor v Blue Cross & Blue Shield of Michigan, 205 Mich App 644, 657; 517 NW2d 864 (1994); Tennant v State Farm Mutual Automobile Ins Co, 143 Mich App 419, 425; 372 NW2d 582 (1985). Accordingly, because plaintiff in this case has failed to plead and prove tortious conduct independent of the breach of contract claim, damages for emotional distress and anxiety are not recoverable. Furthermore, plaintiff cannot recover his actual attorney fees because he has failed to state a cause of action for breach of contract.
Notwithstanding the fact that refusing to pay unreasonable medical expenses is allowed under the insurance contract, in an effort to hold the insured harmless should the health care provider sue the insured, the insurer has agreed to fully defend and indemnify the insured from liability for necessary services priced in excess of what the insurer considers to be reasonable and customary. This removes the insured from jeopardy, yet the dissent here contends that in both McGill and in this case the insurers' promises to defend and indemnify the plaintiffs are not enforceable and, echoing the claim of plaintiff, are "nothing more than unenforceable promises to do the right thing." Post at 590. We respectfully believe this position is incorrect and is premised upon faulty legal analysis.
Defendant's promise to defend and indemnify plaintiff must be analyzed in terms of judicial and promissory estoppel.
With regard to judicial estoppel, like the insurers in McGill, the insurer in this case made representations to the courts that it would defend and indemnify plaintiff. Because these representations were relied upon by courts to grant the relief sought by the insurer, the doctrine of judicial estoppel would be invoked to preclude the insurer from successfully declining to defend and indemnify. Paschke v Retool Ind, 445 Mich 502, 509; 519 NW2d 441 (1994).
Regarding promissory estoppel, assuming the matter was not disposed of by utilization of judicial estoppel, a test of the enforceability of the promise would inevitably arise in a circumstance in which a health care services provider filed suit against an insured for outstanding medical bills and the insurer refused to defend and indemnify the insured. Surely, the insured would invoke promissory estoppel and the court would undoubtedly acknowledge the efficacy of the doctrine to preclude the insurer from denying coverage. See Huhtala v Travelers Ins Co, 401 Mich 118; 257 NW2d 640 (1977); Nygard v Nygard, 156 Mich App 94, 99-100; 401 NW2d 323 (1986).
In short, regardless of the likelihood for success, what is clear is that once a health care services provider sues an insured for any outstanding balance, the insurer would be estopped to renege on its promise to defend and indemnify the insured, which is simply to say that the promise is enforceable.
Moreover, the probability of a health care services provider suing an insured for an amount in excess of what is reasonable seems remote. The reason is that such a suit, freighted with the burden of seeking the unreasonable, would in all probability be unsuccessful. As our Supreme Court said in dicta concerning this situation:
We question, in any event, the Court of Appeals apparent conclusion that if the insurer is not made liable for even unreasonable and unnecessary expenses it will inevitably fall to plaintiff to pay those expenses. To the extent that plaintiff has any liability for these expenses in the event his insurance does not pay, it is presumably contractual. It seems unlikely that plaintiff would have an express agreement with [the doctor] or the hospital to pay unreasonable and unnecessary medical expenses, and equally as unlikely that he would have an implied contractual duty to do so. See 61 Am Jur 2d, Physicians, Surgeons, and Other Healers, § 158, pp 290-291. And, while we need not resolve the issue in this case, it seems unlikely that medical expenses found to be unreásonable or unnecessary in a no-fault action would be found recoverable in a contract action against plaintiff. [Nasser v Auto Club Ins Ass'n, 435 Mich 33, 55-56, n 10; 457 NW2d 637 (1990).]
Further, in the circumstance where the health care services provider felt that the reasonability determination of the insurer was flawed, it is also unlikely that the provider would be so impolitic as to sue the insured rather than the insurer for the difference. Again, the reason is the very practical one of the provider placing itself on the wrong side of a David and Goliath match-up. Thus, we can anticipate that health care services providers, as practical litigants, would bypass the insured and directly sue, pursuant to third-party beneficiary theories, the entity with prospects identical to their own for engendering jury sympathy — the insurer.
With regard to the allegations of fraud, we conclude that the trial court properly determined that they , were not specifically pleaded, and, thus, were insufficient to state a claim. General allegations will not suffice to state a fraud claim. Van Marter v American Fidelity Fire Ins Co, 114 Mich App 171, 184; 318 NW2d 679 (1982). Further, as noted in MCR 2.116(G)(4), and Easley v Univ of Michigan, 178 Mich App 723, 726; 444 NW2d 820 (1989), mere speculations are not sufficient to overcome a motion for summary disposition. As a result, plaintiff's claims of fraud were appropriately dismissed pursuant to MCR 2.116(C)(8) and (10).
Affirmed.
J. G. Collins, J., concurred.
This contractual provision is in harmony with the requirement in the automobile no-fault insurance statute that requires insurers to pay for all reasonable and necessary medical expenses. MCL 500.3107; MSA 24.13107.
We believe plaintiff mistakenly cited § 3109a in his brief. Section 3109a concerns deductibles and exclusions, not personal protection insurance benefits. We assume plaintiff intended to cite § 3107(l)(a), MCL 500.3107(l)(a); MSA 24.13107(l)(a).
Further, this scrutiny by the insurance company would be compelled even if the contract itself did not provide for it because the statute controlling these contracts for automobile insurance requires it. Under the Michigan automobile no-fault insurance act, MCL 500.3101 et seq.; MSA 24.13101 et seq., insurers are responsible for "all reasonable charges incurred for reasonably necessary products, services and accommodations for an injured person's care, recovery, or rehabilitation." MCL 500.3107(l)(a); MSA 24.13107(l)(a). Furthermore, in the same statute, the Legislature has decreed that a health care provider cannot lawfully charge more than a reasonable amount for those products, services, and accommodations. MCL 500.3157; MSA 24.13157. Thus, not only should an insurer audit and challenge the reasonableness of bills submitted by health care providers, but the providers should expect no less.
In this case, defendant sent plaintiffs attorney a letter that stated in pertinent part:
To the extent that your client's claim for damages in the above stated case relates to any alleged balances for any medical bills for which some payment has been made, it is the position of acia that it has paid to those medical providers all that they are entitled to receive under the Michigan no fault act. Any alleged balances in the medical bills are not George LaMothe's responsibility and he does not have any personal liability for them. If any of the medical providers bring a claim against George LaMothe, acia will defend and indemnify him. In fact, acia will waive any technical defects and allow the provider to sue the acia directly so that George LaMothe won't even have to be a party to the litigation.
This is similar to McGill where the insurers "stated expressly that they will defend and indemnify [the] plaintiffs in the event that [the] plaintiffs are sued by their providers for the outstanding balance." Id., at 406. Furthermore, the defendants in both cases represented to the trial court and this Court that they would defend and indemnify the plaintiffs.
This promise is enforceable regardless of the period of limitation in the policy that controls presentment of claims to the insurer. Thus, the fact that that period is shorter than the period the provider has to sue the insured is irrelevant to the enforcement of the insurer's promise, supplemental to the policy, to defend and indemnify whenever the provider might sue the insured.