When Attendant Care Was Owed — But Not Paid

An automobile accident can change a life in an instant. Severe brain injuries, spinal cord trauma, serious orthopedic injuries, and permanent disabilities can leave individuals and families facing an entirely different reality overnight. In the most serious cases, injured persons may require ongoing attendant care—sometimes around the clock—and must depend on others for assistance with daily living.

Attendant care services may include assistance with bathing, dressing, toileting, medication management, mobility, and supervision to prevent injury, particularly in cases involving cognitive impairment. In more severe situations, 24-hour supervision may be medically necessary to ensure safety.

Michigan’s No-Fault insurance system requires auto insurers to pay for reasonably necessary attendant care related to motor vehicle injuries as part of Personal Injury Protection (PIP) benefits — often referred to as first-party No-Fault benefits — subject to the version of the statute in effect on the date of the accident. When properly paid, attendant care benefits may cover the services of professional caregivers or compensate family members who provide care.

However, not every claim was handled correctly. Over time, disputes arose in which insurers were alleged to have:

• Underpaid the number of medically necessary care hours
• Limited or reduced care without adequate support
• Failed to clearly explain available benefits
• Declined to follow medical recommendations for 24-hour care
• Denied claims families believed were valid under Michigan law

In some cases, injured individuals and their families later suspected that benefits had not been fully paid. When that occurs, legal action is necessary to recover unpaid benefits, interest, and other remedies permitted under Michigan law. In particular, fraudulent misrepresentation and fraudulent concealment of benefits owed.

Before evaluating whether attendant care was underpaid, improperly restricted, or wrongfully denied, one question must be answered first:

When did the accident occur?

Michigan’s No-Fault law has undergone significant reform in recent years. The benefits available — and the legal standards that apply — can differ substantially depending on the date of the crash. An accident that occurred before major reform legislation may be governed by very different rules than one that occurred afterward.

Understanding the timeline is the starting point for any analysis of unpaid attendant care benefits.

Understanding Attendant Care Under Michigan No-Fault Law

Before discussing unpaid benefits, it is important to understand what “attendant care” means under Michigan’s No-Fault system.

What Is Attendant Care?

Attendant care means assistance with daily activities that an injured person can no longer safely perform due to accident-related injuries.

Depending on the severity of the injury, attendant care may include:

• Assistance with bathing, dressing, and personal hygiene
• Help with medication management
• Mobility assistance, including transfers, walking support, or wheelchair use
• Supervision to prevent injury in cases involving brain injury or cognitive impairment
• In more serious cases, 24-hour supervision is medically necessary

The central concept is medical necessity. The care must be reasonably necessary as a result of injuries sustained in the automobile accident.

Attendant Care as a First-Party PIP Benefit

Under Michigan’s No-Fault system, attendant care is typically paid through Personal Injury Protection (PIP) benefits — often referred to as first-party No-Fault benefits.

Historically, PIP benefits have included:

• Medical treatment and rehabilitation
• Attendant care services
• Replacement services (limited household assistance)
• Wage loss benefits, subject to statutory limits

It is important to understand that attendant care is a distinct benefit category. It is not medical treatment, and it is distinct from replacement services.

How Attendant Care Differs from Other Benefits

Medical treatment generally refers to care provided by physicians, hospitals, therapists, or other healthcare professionals for diagnosis and treatment.

Replacement services typically involve reimbursement for household tasks the injured person can no longer perform, such as cleaning, yard work, or grocery shopping, subject to statutory limitations.

Attendant care, by contrast, focuses on personal care and supervision necessitated by physical or cognitive limitations resulting from the accident.

Who Can Provide Attendant Care?

Attendant care may be provided by:

• Licensed home health agencies
• Professional caregivers
• In certain circumstances, family members

Michigan law has historically recognized that family members who provide medically necessary care may be eligible for compensation under PIP benefits, provided proper documentation and proof requirements are satisfied.

Again, medical necessity is key. The services must be reasonably necessary because of the accident-related injury and supported by appropriate medical documentation.

Timeline Matters: Michigan No-Fault Reform Changed the Law

Whether attendant care benefits were properly paid often turns on a single critical factor: the date of the automobile accident.

Michigan’s No-Fault law underwent major reform in recent years. Those changes altered how certain benefits are calculated, limited, and reimbursed — particularly for accidents occurring after the reform took effect.

Major Amendments Effective June 11, 2019

On June 11, 2019, significant amendments to Michigan’s No-Fault statute became effective. These revisions altered several aspects of Personal Injury Protection (PIP) benefits, including the treatment of medical expenses and attendant care.

Accidents that occurred before June 11, 2019, are generally governed by the prior version of the statute in effect at the time of the crash.

Accidents that occurred on or after June 11, 2019, are generally governed by the amended statute in effect on the date of the accident.

That distinction can be legally significant.

Fee Schedules Implemented Beginning July 1, 2021

Although the reform legislation was enacted in 2019, certain cost-control measures — including statutory fee schedules for medical providers — became effective beginning July 1, 2021.

These fee-schedule provisions have significantly affected the reimbursement of medical providers and attendant care services. Their application has been the subject of ongoing litigation and appellate review.

Determining whether a claim falls under pre-reform or post-reform rules can materially affect how benefits are calculated and evaluated.

56-Hour Per Week Limitation for Family-Provided Care (Post-Reform Accidents)

For accidents occurring on or after June 11, 2019, the amended statute includes a limitation on compensation for attendant care provided by family members.

In general, the law limits reimbursement for family-provided attendant care to 56 hours per week, unless specific statutory conditions are met.

This limitation does not apply in the same way to pre-reform accidents.

Because of this distinction, the accident date can substantially influence how unpaid or underpaid attendant care claims are analyzed.

Why the Timeline Matters

Before evaluating whether attendant care benefits were underpaid, improperly limited, or wrongfully denied, it is essential to determine which version of Michigan’s No-Fault statute applies.

The governing legal framework can affect:

• What benefits were available
• How benefits were calculated
• Whether statutory caps or limitations apply
• What legal arguments may be raised

In short, the accident date is not a minor detail — it is the starting point for any meaningful analysis of unpaid attendant care benefits.

Accidents Before June 11, 2019

(The Pre-Reform “Unlimited” Era)

Michigan’s No-Fault law operated under a different framework for individuals injured in automobile accidents before June 11, 2019.

At that time, Personal Injury Protection (PIP) benefits generally provided lifetime medical coverage without a dollar cap for reasonably necessary accident-related care.

That distinction is significant.

Pre-Reform Law: Lifetime, Unlimited PIP Coverage

Under the pre-reform statute:

• There were no dollar caps on allowable medical expenses.
• There was no statutory 56-hour limitation on family-provided attendant care.
• Insurers were required to pay reasonably necessary expenses related to the automobile injury.
• This included attendant care services when medically necessary.

Key Legal Principles Under the Pre-Reform Law

Under Michigan’s earlier No-Fault statute:

• Attendant care was payable if it was reasonably necessary as a result of accident-related injuries.
• Payment was based on reasonable charges for services actually provided.
• Insurers had an ongoing obligation to adjust and pay benefits as they became due.

For catastrophically injured individuals requiring long-term or 24-hour supervision, attendant care benefits could represent a substantial component of lifetime PIP coverage.

Importantly, the pre-reform statute did not contain a cap limiting family members to 56 hours per week of reimbursable attendant care.

Where Underpayment Issues Commonly Arose

Even under the pre-reform framework, disputes frequently arose between insurers and injured individuals.

In some cases, insurers were alleged to have:

• Reduced approved attendant care hours without clear medical support
• Declined to follow the physician’s prescriptions, recommending 24-hour supervision
• Failed to clearly explain the scope of available attendant care benefits
• Characterized supervision as “custodial” rather than medically necessary
• Paid partial benefits while disputing or delaying the remainder

In certain situations, disputes did not involve outright denial, but rather whether benefits were underpaid or whether information about available coverage was fully disclosed.

The distinction between denial and concealment can become legally significant depending on the facts.

Potential Legal Theories for Recovery

When attendant care benefits were not fully paid under the pre-reform statute, several legal theories may arise depending on the circumstances.

These may include:

• Fraud
• Fraudulent concealment
• Fraudulent misrepresentation
• Breach of contract (failure to pay benefits owed under the insurance policy)
• Failure to pay PIP benefits under the No-Fault statute
• Claims involving alleged misrepresentation or concealment in appropriate cases
• Statutory interest on overdue benefits
• Potential attorney fee exposure where an insurer’s refusal to pay is determined to be unreasonable

Each theory depends heavily on the documentation, medical support, communications, and timing of the claim.

An Important Limitation: The One-Year-Back Rule

Even in pre-reform cases, Michigan’s No-Fault statute limits how far back unpaid benefits may be recovered.

Often referred to as the “one-year-back rule,” this provision can affect the amount of recoverable benefits depending on when a lawsuit is filed and when expenses were incurred.

Because timing can materially affect recovery, this issue is typically analyzed carefully in unpaid attendant care cases.

Why This Section Matters

For individuals injured before June 11, 2019, the legal framework allowed lifetime medical and attendant care benefits without statutory caps.

However, whether benefits were fully paid — and whether additional recovery may be available — depends on:

• The medical documentation
• The insurer’s payment history
• Communications between the parties
• The timing of any legal action

Every case depends on its specific facts.

Accidents On or After June 11, 2019

The Post-Reform Framework

Individuals injured in automobile accidents occurring on or after June 11, 2019, are governed by Michigan’s amended No-Fault statute.

The reforms significantly changed how certain benefits — including attendant care — are limited, calculated, and reimbursed.

Understanding these changes is essential when evaluating whether benefits were properly paid.

Changes to Attendant Care Under the Amended Statute

The amended No-Fault statute introduced several provisions that directly affect attendant care claims.

1. The 56-Hour Limitation on Family-Provided Care

For post-reform accidents, the statute generally limits reimbursement for attendant care provided by family members to 56 hours per week, unless specific statutory requirements are met.

This limitation applies to care provided by certain non-professional caregivers. It does not automatically apply to licensed commercial providers.

Because this cap did not exist under the pre-reform statute, the accident date is legally significant in assessing potential underpayment.

2. Fee Schedule Controls

Effective July 1, 2021, statutory fee schedules governing reimbursement for many medical providers under PIP coverage took effect.

These cost-control provisions affect:

• Medical services
• Rehabilitation services
• Certain forms of attendant care

The application and interpretation of these fee schedules have been the subject of ongoing appellate litigation.

As a result, evaluating whether benefits were underpaid may require reviewing both:

• The date of the accident
• The dates services were rendered

3. Coverage Selection and Policy Limits

Post-reform policies allow insured individuals to select different levels of Personal Injury Protection (PIP) medical coverage.

Unlike the pre-reform “unlimited” structure, post-reform policies may include capped medical benefit limits depending on the coverage election made at the time the policy was issued.

The amount of available coverage may depend on:

• The PIP coverage level selected
• The declarations page of the policy
• The date of the accident

These variables can materially affect the evaluation of attendant care claims.

Where Disputes May Arise in Post-Reform Cases

Even under the amended statute, disputes may arise regarding:

• Whether attendant care was medically necessary
• Whether the 56-hour limitation was properly applied
• Whether professional care should have been authorized
• Whether reimbursement complied with the statutory fee schedule requirements
• Whether benefits were fully explained and adjusted

In some cases, disputes center on straightforward coverage interpretations. In other cases, disagreement may arise from the application of the amended statute to specific facts.

Because the reform law is relatively recent and has generated appellate decisions, post-reform claims often require careful statutory analysis.

Important Considerations in Post-Reform Cases

Although the amended statute introduced limitations, insurers remain obligated to pay benefits that are legally due under the version of the statute that applies.

However:

• Coverage may be subject to statutory caps
• Family-provided care may be subject to weekly limits
• Fee schedules may affect reimbursement rates
• Timing rules may affect recoverable benefits

As with pre-reform cases, Michigan’s one-year-back rule may also apply in determining the recoverable period for unpaid benefits.

Each case depends on its specific facts, documentation, and timing.

Why the Distinction Between Pre- and Post-Reform Matters

Two individuals with similar injuries may face very different legal frameworks depending solely on the date of the accident.

For that reason, evaluating potential unpaid attendant care benefits begins with determining:

• When the accident occurred
• Which version of the statute applies
• What policy coverage was in effect

Only after identifying the governing framework can a meaningful legal analysis begin.

When Benefits Were Owed — But Not Paid

In both pre-reform and post-reform cases, the core issue is often the same:

Were attendant care benefits that were legally due fully and properly paid?

In some situations, disputes reflect legitimate differences of opinion regarding medical necessity or reimbursement rates. In others, the issue may involve underpayment, delay, or failure to clearly explain available benefits.

Distinguishing between those scenarios requires careful review of the underlying documentation.

Underpayment vs. Denial

When people think of insurance disputes, they often picture an outright denial of benefits. However, disputes involving attendant care are not always that straightforward.

Issues may arise when:

• Approved attendant care hours are reduced without clear medical support
• Physician recommendations are not fully implemented
• Benefits are paid inconsistently over time
• Coverage is interpreted narrowly despite broader medical documentation
• Reimbursement is limited without an adequate explanation

In some instances, benefits may be partially paid while significant portions of medically supported care remain uncompensated.

These situations can be more difficult to recognize than an outright denial.

Disclosure and Explanation of Benefits

Another recurring issue, in some cases, is whether all available benefits were clearly explained to the injured individual or their family.

Attendant care benefits can be complex. In catastrophic injury cases — particularly those involving traumatic brain injury or cognitive impairment — families often rely heavily on information provided by the insurer regarding available coverage.

If benefits are not fully described, or if medically necessary care is not properly evaluated, disputes may arise regarding whether statutory obligations were satisfied.

Whether a situation reflects simple disagreement, administrative error, or something more significant depends entirely on the specific evidence.

Allegations of Fraudulent Concealment or Fraudulent Misrepresentation

In certain cases, litigation has included allegations that benefits were not merely underpaid, but that material information was withheld or misrepresented.

Claims involving alleged fraudulent concealment or fraudulent misrepresentation require substantial factual support. They are not appropriate in every case.

However, when supported by documentation and evidence, courts may evaluate whether the insurer’s conduct complied with its contractual and statutory obligations.

Each situation must be assessed based on its specific record.

Why Timing and Documentation Matter

Unpaid or underpaid attendant care claims often turn on documentation such as:

• Medical records
• Physician prescriptions
• Care logs
• Communications between the insurer and the insured
• Payment histories
• Records reflecting objections or adjustments

Michigan’s No-Fault statute includes timing limitations that may affect recoverable benefits. Accordingly, the chronology of payments and disputes can materially affect the potential recovery.

These matters are typically analyzed carefully and methodically.

Outcomes in Appropriate Cases

In cases where attendant care benefits were determined to have been wrongfully withheld or underpaid, courts have awarded remedies that may include:

• Retroactive payment of unpaid benefits
• Statutory interest on overdue amounts
• Attorney fees where an insurer’s refusal to pay is determined to be unreasonable

In appropriate cases, litigation has resulted in substantial settlements or verdicts.

However, the outcome of any individual case depends on the specific facts, the applicable version of the statute, and the evidence available.

The Central Questions

When reviewing a potential unpaid attendant care claim, key questions often include:

• What benefits were legally available under the applicable version of the statute?
• What care was medically necessary?
• What was actually paid?
• What was not paid — and why?

Only after answering those questions can the situation be meaningfully evaluated.

Practical Indicators That a Claim May Warrant Review

Not every disagreement with an insurance company means benefits were wrongfully withheld. In many cases, disputes are resolved through clarification of medical documentation.

However, in certain circumstances, a structured review of the claim history may be appropriate.

Situations that may justify a closer examination include the following:

1. A Physician Recommended 24-Hour or High-Level Supervision

If medical records reflect a physician’s recommendation for round-the-clock supervision, but payment was approved for substantially fewer hours, it may be appropriate to review how that determination was made.

The relevant question is not simply whether care was provided, but whether the approved hours aligned with documented medical necessity.

2. Approved Hours Were Reduced Without Clear Explanation

In some cases, initially approved attendant care hours are later reduced.

If reductions were made without updated medical documentation or a clear written explanation, a review of the file may help determine whether the adjustment complied with the applicable version of the statute.

3. Family Members Provided Extensive Care Without Full Reimbursement

In many cases — particularly pre-reform accidents — family members provided substantial caregiving services over extended periods.

If documentation reflects consistent, medically necessary care that was not fully reimbursed, it may be appropriate to examine whether all eligible benefits were paid under the governing legal framework.

4. Benefits Were Paid Intermittently or Inconsistently

Irregular payment histories can sometimes signal underlying disputes regarding:

• Medical necessity
• Reimbursement rates
• Documentation requirements

Understanding the reasons behind fluctuating payments can clarify whether the matter was appropriately resolved.

5. Significant Traumatic Brain Injury or Cognitive Impairment Was Involved

Cases involving traumatic brain injury or cognitive impairment often require supervision even when physical mobility improves.

In such circumstances, the full scope of medically necessary attendant care may not always be obvious without careful review of the medical record.

6. The Accident Occurred Before June 11, 2019

For individuals injured before June 11, 2019, the broader lifetime PIP structure and absence of statutory caps may make historical payment decisions worth reviewing in appropriate situations.

The legal framework governing those claims was materially different from the post-reform structure.

Important Perspective

The presence of one or more of these factors does not automatically mean benefits were underpaid or that litigation is appropriate.

Attendant care claims are fact-driven and often complex.

However, when documentation suggests that medically necessary care may not have been fully compensated, a structured legal review can help clarify:

• What benefits were legally available
• What was paid
• Whether any additional remedies may exist under Michigan law

Why a Structured Review Can Be Helpful

These cases often involve:

• Medical documentation spanning years
• Payment logs
• Care records
• Statutory timing limitations

A methodical review can help distinguish between:

• Legitimate coverage disputes
• Administrative adjustments
• Potential statutory violations

Each case depends on its specific record.

Questions Regarding Unpaid Attendant Care Benefits?

Attendant care claims under Michigan’s No-Fault law can be legally complex. Reforms, fee schedules, statutory caps, and timing rules may affect the calculation and payment of benefits. Determining whether benefits were fully and properly paid often requires careful review of medical records, payment histories, and the applicable version of the statute as of the date of the accident.

If a serious auto injury required extensive attendant care and you have concerns that all legally available benefits were not paid, a structured review may help clarify what the law required at the time and how the claim was handled.

Thomas, Garvey & McKenna, PLLC, represents individuals throughout Michigan in matters involving No-Fault and Personal Injury Protection (PIP) benefits. The firm is headquartered in St. Clair Shores and serves clients in Macomb County, Metro Detroit, and throughout the state.

For more information about Michigan No-Fault claims, visit our Personal Injury Overview page or related injury pages. If you would like to discuss the specific facts of your situation, you may contact the firm directly at:

• 586-779-7814
• Toll-free: 1-866-232-5775
• 📍 Serving families throughout Michigan from our St. Clair Shores law office

The firm handles personal injury matters on a contingency-fee basis—no attorney’s fees are owed unless compensation is recovered.

This article provides general information only and is not legal advice. Each case depends on its specific facts and the law applicable at the time of the accident.