Trial de-novo win where carrier did not respond to verification objection letter and wins. July 17, 2017

Global Liberty Ins. Co. v Jonathan Lewin, M.D., P.C., 2017 NY Slip Op 50897(U)(Sup. Ct. Nassau Co. 2017)

Here are the cliff note facts.

  • Carrier delayed surgical bill for (a) films and (b) MRI films.
  • Delay letters were sent to MRI center and Surgeon
  • Surgeon write backs and says we do not have MRIs, get them from Doshi.  Here are HIPPA requests.
  • Carrier did not respond

Lower arbitrator  applied the rule that the carrier who does not respond to communications always loses.  Here is the quote from the lower arbitrator (17-15-1015-7475):

Respondent issued 2 requests for additional verification from Applicant provider here. The requests are dated 4/28/15 and 5/28/15. Respondent was seeking an AOB, surgical photos from the surgeon and MRI films from Doshi Diagnostics. Respondent also provides the 2 verification requests sent to Doshi Diagnostics. It is Respondent’s position that these requests were never complied with. Applicant points out that on May 21, 2015, Excel Surgery Center sent the surgical photos requested to Respondent. Applicant argues that this was never acknowledged by Respondent. Respondent argues that their 2nd verification dated 5/28/15 was their response to the 5/21115 response by Excel Surgery Center. Applicant argues that that is an insufficient response because it is identical to the first verification request dated 4/28/15 and in no way acknowledges the receipt of the films. In addition, Applicant provide an Affidavit from a Mike Manzo, billing manager for MD Capital Advisors, a billing company that handles the billing for Applicant provider. This is a very credible Affidavit. He explains that they attempted to respond to the verification request on May 21, 2015 via FAX to Respondent, but the FAX did not go through. Thereafter, they mailed their response to Respondent postmarked June 2, 2015. They provide a copy of the return receipt green card stamped June 2,
2015 and signed by someone at Respondent insurance company. What was sent was a letter indicating that they could not provide the films and pictures because it was not in their possession but in the possession of Doshi Diagnostics and Excel Surgery Center. They attach medical authorizations for Respondent to use to help to obtain those items. Applicant never received any response from Respondent after June 2,2015 . There was never any other correspondence received from Respondent. The claim was neither paid nor denied.

I find in favor of Applicant here. The evidence is clear here that Applicant complied with the verification requests and that there was never a response from Respondent after the June 2, 2015 compliance. As such, I find the claim overdue
and owing and I find in favor of Applicant.  So too here, I find that Applicant complied with the verification requests and there never was a response from Respondent. The claim is overdue and owing.

Master Arbitrator rubber stamped it.  Award was over $5,000.00

Trial de novo was commenced.  Court held as follows:

(1) Based upon the affidavit of Regina Abbatiello, plaintiff’s no-fault claims adjuster, plaintiff establishes that the surgery was performed on March 24, 2015, and the bill from defendant was received on April 9, 2015. The bill was delayed pending receipt of operative photographs and MRI films. By written request dated March 20, 2015, plaintiff requested, inter alia, “a copy of the R/Shoulder MRI films” from Doshi Diagnostic Imaging Services. Apparently, plaintiff did not receive the MRI films, and it sent a second written verification request to Doshi dated April 20, 2015.

Not having received the MRI films, plaintiff, by written requests dated April 28, 2015 and May 28, 2015, notified defendant and requested a copy of the right shoulder MRI films from defendant. The letters are addressed to Jonathan Lewin MD PC, and they state in relevant part, “[a]lso awaiting a copy of the R/Shoulder MRI films from Doshi Diagnostic MRI which were requested from the MRI facility and the doctor’s office. Once received the claim will be reviewed and processed.” Ms. Abbatiello’s affidavit avers that the MRI films were never received from either Doshi or from defendant Lewin.

Based upon the foregoing, plaintiff has established its prima facie entitlement to summary judgment as a matter of law that the claim is not overdue, since the additional verification remains outstanding, and that defendant is not entitled to reimbursement for no-fault benefits a/a/o Mary King related to the motor vehicle accident that occurred on December 17, 2014

(2) The affidavit of Mike Manzo, billing manager for MD Capital Advisors, states that MD Capital Advisors is the third party billing company for FJ Orthopedics PLLC, which is not a party to this action. In fact, the affidavit appears to have been submitted in connection with the prior arbitration entitled FJ Orthopedics PLLC / Mary King, Applicant and Global Liberty Insurance Company of New York. Thus, it is unknown to the Court how Mr. Manzo’s affidavit is germane to defendant Lewin named in this action. Assuming, however, that his affidavit is relevant, because it relates to the assignor in this matter (Mary King), Mr. Manzo speaks to the issue of the surgical photographs, which is not the subject of the summary judgment motion. Moreover, his affidavit is vague as to “the verification response” and “requested documents” allegedly submitted to plaintiff on June 2, 2015; however, the response was likely the letter on FJ Orthopedics letter head, signed by Mike Manzo, dated May 21, 2015, which is annexed to Manzo’s affidavit. That letter states that, “your request for MRI films and color photos of surgey (sic) for the above mention (sic) claim is overly burdensome as neither our client FJ Orthopedics nor the patient Mary King does not (sic) have access to the actual films. . . The films are in Doshi Diagnostic’s possession . . . therefore, we enjoin you to obtain the actual films . . . with the attached medical authorizations signed by Mary King.”

Court conclusion

(3) Defendant’s submissions do nothing to raise a triable issue of fact as to the failure to provide the MRI films, nor do the submissions controvert the established fact that plaintiff attempted to get the films directly from Doshi first, by sending a first request and then a follow-up request, and when it received no films, plaintiff notified defendant of the request. Plaintiff sent the verification requests directly to Doshi, and plaintiff also timely informed the applicant, the defendant in this action, of the nature of the verification sought, and from whom it was sought, after the initial requests went unsatisfied (Doshi Diagnostic Imaging Servs. v. State Farm Insurance Co., 16 Misc 3d 42[App Term 2d Dept 2007]; see also Advantage Radiology, P.C. v. Nationwide Mutual Insurance Company, 55 Misc 3d 91 [App Term 2d Dept 2017]).

(4) The fact that FJ Orthopedics, albeit not a party to this action, may have provided plaintiff with a HIPPA authorization for the films does not constitute a response to the request for verification. Plaintiff did not need a HIPPA authorization to obtain the films (Eagle Surgical Supply, Inc. v. GEICO Insurance Co., 41 Misc 3d 134[A][App Term 1st Dept 2013]), and in any event, FJ Orthopedics’ statement made in its May 21, 2015 letter that the request “is overly burdensome” is evidence of its lack of motivation to satisfy plaintiff’s verification request.

Defendant has failed to raise a material, triable issue of fact; therefore, plaintiff’s summary judgment motion is granted.

The Court correctly held that it is not enough to object to verification.  If the carrier requests the verification from the party who has it, the apt Applicant must at times engage in an effort to procure it.  Had the carrier requested the MRI films from the surgeon,  an objection letter was tendered and the carrier ignored that letter, then it would be a different fact pattern and the surgeon should win that fact pattern.

We shall see if AAA picks up on this distinction or if we are going to continued to be bombarded with the famous line without context from 13 years ago: “[a]n insufficient response requires action by the insurance company to either deny the claim for failure to provide all the requested information or, more appropriately in light of the goals of the No Fault law, to send a follow up verification request, acknowledging the material received and further requesting the omitted material.” All Health Med. Care, P.C. v. Gov’t Employees Ins. Co., 2 Misc. 3d 907, 913 (Civ. Ct. Queens Co. 2004)

Arrest warrant not issued July 17, 2017

Cadlerock Joint Venture, L.P. v Forde, 2017 NY Slip Op 05416 (2d Dept. 2017)

“Contrary to the plaintiff’s contention, the Supreme Court providently exercised its discretion in denying the plaintiff’s motion pursuant to CPLR 2308(a), in effect, for the issuance of a warrant of arrest to bring the defendant before the Supreme Court, upon his alleged failure to comply with a postjudgment judicial subpoena duces tecum dated October 23, 2013, and an order of contempt of that court dated March 6, 2014 (see Rackowicz v Feldman, 22 AD3d 553, 553-554). CPLR 2308(a) sets forth the penalties applicable to the disobedience of a judicial subpoena. The available penalties include the issuance of “a warrant directing a sheriff to bring the witness into court” (CPLR 2308[a]). Here, the court declined to issue such a warrant, finding that the plaintiff could avail itself of “all other remedies pursuant to the CPLR to collect” a judgment in favor of the plaintiff and against the defendant. We find no basis in the record to disturb that determination.”

I am clearly no fan of debtors prisons and “locking up” people who simply cannot afford to pay their debts.  Yet, when someone wilfully ignores legal process, is held in contempt of court and fails to purge or attempt to purge, why is arrest not unreasonable?  All the Court did here is insulate a certain lack of respect that the debtors-bar have to the court system.

Plaintiff is now supposed to continuously issue information subpoenas and subpoena duce tecums, while Defendant knows there is minimal penalty for not responding.  It does not seem right.

Very interesting discussion on Perl July 17, 2017

Santos v Traylor-Pagan, 2017 NY Slip Op 05502 (1st Dept. 2017)

“Plaintiff failed to raise a triable issue of fact as to whether his carpal tunnel syndrome was causally related to the accident (Perl v Meher, 18 NY3d 208, 217-218 [2011]). This Court, in Rosa v Mejia (95 AD3d 402, 404 [1st Dept 2012]), opined that the decision in Perl did not abrogate the need for at least a qualitative assessment of injuries soon after an accident. This Court then affirmed the dismissal of a plaintiff’s case where the plaintiff had presented no admissible proof that she saw any medical provider for any evaluation until 5½ months after her accident (id.). Plaintiff here was treated on the date of the accident and released from the emergency room at Westchester Medical Center, where he was diagnosed with a right elbow laceration, which was treated with three sutures. He never had any further medical treatment until he first saw an orthopedist 13½ months after the accident, and then allegedly had a few months of physical therapy, although there are no details of any such therapy in the record. He did not see a neurologist about his carpal tunnel syndrome until almost four years after the accident

I always read Perl for the proposition that issues regarding qualitative evaluation and “causation” following the accident were questions of fact for the jury.  I think the Second Department reads Perl the same way as they have not kicked a case on contemporaneous treatment issues since Perl.  Remember, the crux of this case is that causation is not established without contemporaneous treatment.  In the no-fault world, the same argument could hold since the burden on summary judgment for lack of causation is the same in the 5102(d) and first-party benefit sense.

It was not the partner affirmation this time June 29, 2017

Island Life Chiropractic, P.C. v Commerce Ins. Co., 2017 NY Slip Op 50856(U)(App. Term 2d Dept. 2017)

“Defendant’s motion sought summary judgment on the ground that the amount of available coverage had been exhausted. Although the insurance policy had been issued in Massachusetts, defendant acknowledged that, pursuant to New York law, the insurance policy provided $50,000 in personal injury protection benefits. Defendant further contended that claims exceeding $50,000 had been received and that defendant had paid $50,000 in accordance with 11 NYCRR 65-3.15. However, defendant failed to establish, as a matter of law, an exhaustion of the [*2]coverage limits of the insurance policy at issue, as defendant did not demonstrate that the policy had been exhausted at the time the claim at issue was complete (see 11 NYCRR 65-3.15; Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294 [2007]). Consequently, defendant did not establish its entitlement to summary judgment dismissing the complaint.”

My thought here is straight forward.  We all agree that the Massachusetts $10,000 PIP policy was deemed to $50,000 because the accident occurred in New York.  Does this mean that 65-3.15 applies?

Defendant for reasons I will never understand stated that claims were paid in accordance with 65-3.15.  By doing this, counsel for the carrier kicked down the door in this case, begging a court to apply priority of payment rules and, therefore, allowing a finding that coverage exceeding the policy maximum could be afforded.

The correct argument appears to be that under a choice of law analysis, Massachusetts law applies to the $50,000 coverage limit.  Therefore, once $50,000.00 in coverage is exhausted, there is nothing left on the policy.  That is because except for New York, no other state (absent bad faith) ever requires an insurance carrier to pay more than the monetary limits of a policy under so-called “priority of payment”

Now, Commerce n/k/a Mapfre will go over policy.   Leave it to Rybak to torture people.


The poor man’s DJ is no more June 29, 2017

Fresh Acupuncture, P.C. v Interboro Ins. Co., 2017 NY Slip Op 27214 (App. Term 2d Dept. 2017)

The Appellate Term about seven years ago gave us  Five Boro Psychological Servs., P.C. v AutoOne Ins. Co., 27 Misc.3d 89 (App. Term 2d Dept. 89), which broadly gave Civil Court DJ jurisdiction for matters involving insurance companies where the amount in dispute is less than $25,000.   Today, that Court took it away from us.  So goes the “poor man” DJ, i.e., $45 for an index number, no motion fee and no RJI fee.

As to a background on this, we obtained a judgment from Supreme Court that various providers were not entitled to no-fault benefits for whatever the reason was.  We never knew about Fresh Acupuncture.  Remembering Five Boro, I said, lets bring a poor man’s DJ in Manhattan.  Apparently, this new panel of judges believe CCA 212-a should be given a narrow reading.  Well, what can I say, they wear the robes; I am just a practitioner who keeps a blog and writes tons of motions and appeals.

But I think the real issue here is with the trial de-novos that rumor has certain firms like to bring in Civil New York.  It would seem like the smart practitioner would default on those and move to confirm the underlying arbitration award in Civil Court, Queens County.

I have no real opinion as to whether this decision is “right” or “wrong”.  I think practically, the lower courts should all have broad subject matter jurisdiction of matters that is within their monetary limits.  I also think the concept of a Village Court and Town Court should be abolished.  Term limits would be nice.  Thus, I am voting to hold a constitutional convention this election day.