Issued and entered November 27, 2002 by Frank M. Fitzgerald, Commissioner

ORDER

I
PROCEDURAL BACKGROUND

On October 6, 2002, Petitioner XXXXXXXXX filed a request for external review with the Commissioner of the Office of Financial and Insurance Services (Commissioner) under the Patient’s Right to Independent Review Act, MCL 550.1901 et seq. After an assessment of the material submitted, the Commissioner accepted the request.

The issue involved is contractual in nature. There is no medical issue; therefore, review by an Independent Review Organization is not required. The Commissioner reviews contractual issues under MCL 550.1911(7). On November 12, 2002, the Office of Financial and Insurance Services (OFIS) received from Paramount Care of Michigan (Paramount) the information it used to make its final adverse determinations in Petitioner’s case.

II
FACTUAL BACKGROUND

Petitioner has been a Paramount subscriber since August 2000. She seeks coverage for testing and treatment from a gynecologist who is not in Paramount’s network of service providers.

Petitioner requires testing and treatment for irregular menstruation. On July 23, 2002, her primary care physician submitted a referral for her to receive those services from a gynecologist that is not on Paramount’s list of participating providers. Paramount did not approve the referral, because the services Petitioner requires are available from other gynecologists within its network of providers. Petitioner initiated Paramount’s internal grievance process on August 6, 2002, and Paramount reached a final adverse determination in her case on September 5, 2002.

III
ISSUE

Did Paramount properly deny Petitioner coverage for health care from an out-of-network gynecologist?

IV
ANALYSIS

PETITIONER’S ARGUMENT

Petitioner argues Paramount should provide coverage for testing and treatment from her long-time gynecologists because she does not want to see a new doctor for the services she needs. Petitioner contends Paramount improperly denied her coverage for necessary medical care; therefore, Paramount’s final adverse determination in this matter should be reversed.

PARAMOUNT’S ARGUMENT

Paramount argues it properly denied Petitioner coverage for out-of-network services because Petitioner must receive health care within Paramount’s provider network to be eligible for coverage. Paramount notes there are approximately 15 in-network gynecologists in Petitioner’s service area that she could go to for the medical care she needs. Therefore, its final adverse determination in Petitioner’s case should be upheld.

COMMISSIONER’S REVIEW

The Commissioner carefully reviewed the arguments and documents presented by the parties. The focus of this analysis is whether services from Petitioner’s out-of-network gynecologist are a covered benefit according to the Paramount Care of Michigan Subscriber Certificate and Member Handbook. A portion of the documents suggests it is necessary to use an in-network obstetrician/gynecologist. In fact, page 14 of the Certificate and Handbook states:

For obstetrical/gynecological care only, a female Member may see her Primary Care Physician or a Paramount participating gynecologist.

You do not need a referral from your Primary Care Physician to see a participating gynecologist. Simply choose the specialist you wish to see from those listed in the Participating Physician and Facilities directory and make an appointment.

However, a different portion of the Certificate suggests it is not necessary to use an in-network “OB/GYN.” Page 26 of the Certificate and Handbook states:

GENERAL LIMITATIONS

• To be covered by Paramount, the health services you receive must be from Paramount Participating Providers, except for Emergency Medical Conditions, OB/GYN [obstetrical/gynecological] care, routine eye exams or with prior written approval from Paramount. [emphasis added]

This coverage limitation specifies that OB/GYN care is exempt from the requirement to use an in-network provider. The OB/GYN exemption is of course contrary to “in-network” requirement stated on Certificate page 14. The contradiction of coverage terms makes it difficult to determine whether the “in-network” requirement applies.

Adding to the confusion, one must consider another portion of the Certificate’s GENERAL LIMITATIONS section. On page 30 it suggests that office visits are covered for a participating OB/GYN. The language notes:

Office visits (C/L) Covered for:

• Your Primary Care Physician or participating OG/GYN specialist for
  OG/GYN conditions

This language is contrary to the OB/GYN exemption noted in text of page 26.

The Certificate is not clear as it relates to using a participating OB/GYN. A contractual provision (or group of provisions) that causes confusion is subject to legal analysis governing “ambiguous terms.” The Michigan Supreme Court’s definition of ambiguity in an insurance policy includes “contract provisions capable of conflicting interpretations.” Auto Club Ins. Ass'n v. DeLaGarza, 433 Mich 208, 214 (1989).
In Petitioner’s case, the language on pages 14 and 30 of the Certificate and Handbook state that female members must see gynecologists within Paramount’s network of service providers, but the language on page 26 states gynecological care is exempt from the “in-network” requirement. The conflict within the coverage language is evidence the contract is capable of conflicting interpretations. The Commissioner finds the Certificate and Handbook is ambiguous relating to the “in-network” requirement for OG/GYN coverage.

The Michigan Supreme Court requires ambiguities in insurance contracts to be interpreted in favor of coverage. Henderson v. State Farm Fire & Cas. Co., 460 Mich 348 (1999); Raska v. Farm Bureau Mut. Ins. Co., 412 Mich 355 (1982). The Commissioner therefore finds the Paramount Certificate and Member Handbook affords Petitioner coverage for the out-of-network gynecological care she seeks. Accordingly, Paramount’s final adverse determination in Petitioner’s case is reversed.

V
ORDER

The Commissioner ORDERS that Paramount’s September 5, 2002, final adverse determination in Petitioner’s case is reversed. Paramount must provide Petitioner with coverage for health services she obtains from the gynecologist for whom her primary care physician submitted a referral. Petitioner may report any complaint regarding payment to the Health Plans Division of the Office of Financial and Insurance Services at 1-877-999-6442.

This is a final decision of an administrative agency. Under MCL 550.1915, any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the Circuit Court for the county where the covered person resides or in the Circuit Court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Services, Health Plans Division, Post Office Box 30220, Lansing, MI 48909-7720.