Viviane Etienne Medical Care, P.C. v Country-Wide Ins. Co., 2011 NY Slip Op 77673(U) (Motion No: 2011-04221)(2d Dept. 2011)
Lower decision citation: Viviane Etienne Medical Care, P.C. v. Country-Wide Ins. Co., 31 Misc.3d 21 (App. Term 2d, 11th & 13th Jud. Dis. 2011).
This was the case, if you recall, where the Appellate Term, Second Department for the first time construed Carothers v. Geico, 79 AD3d 864 [2d Dept 2010]). I have this gut feeling the Appellate Division is going to reverse the Appellate Term this time.
NYU-Hospital for Joint Diseases v Esurance Ins. Co., 2011 NY Slip Op 04436 (2d Dept. 2011)
“Esurance issued a denial of claim, which incorrectly stated the amount of the claim and the amount in dispute. Esurance denied the claim, inter alia, because Cancian allegedly was intoxicated at the time of the accident.
The hospital then commenced this action seeking payment of its bill, and moved for summary judgment on the complaint arguing, among other things, that the denial of claim was untimely, fatally defective for the above-mentioned mistakes, and that Esurance’s defense that Cancian was intoxicated was unsupported by the evidence.
“A proper denial of [a] claim [for no-fault benefits] must include the information called for in the prescribed denial of claim form (see 11 NYCRR 65-3.4[c]) and must promptly apprise the claimant with a high degree of specificity of the ground or grounds on which the disclaimer is predicated'” (St. Barnabas Hosp. v Allstate Ins. Co., 66 AD3d 996, 996, quoting Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 11 AD3d 664, 664). A timely denial of a no-fault insurance medical claim alone does not, however, avoid preclusion where the “denial is factually insufficient, conclusory, vague or otherwise involves a defense which has no merit as a matter of law” (Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 11 AD3d at 665).
Here, the hospital established its prima facie entitlement to judgment as a matter of law based on the untimeliness of the denial of claim….
In opposition to the motion, however, Esurance raised a triable issue of fact as to whether the denial of claim was timely issued by submitting the affidavit of an employee with knowledge of its “standard office practices or procedures designed to ensure that items were properly addressed and mailed” (St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d at 1124), wherein he attested that a denial of claim was timely issued to the hospital. We note that while the denial of claim contained errors, they were not significant by themselves, and did not pose any possibility of confusion or prejudice to the hospital under the circumstances; thus, the denial was not rendered a nullity
Further, Esurance raised a triable issue of fact as to whether Cancian was “injured as a result of operating a motor vehicle while in an intoxicated condition” (Insurance Law § 5103[b]). Contrary to the hospital’s contention, the personal observations of the police officer present at the scene of the accident as recorded in the police accident report were properly considered by the Supreme Court under the business record exception to the hearsay rule (see CPLR 4518[a]; Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co., 44 AD3d at 753).”
Very good work on the part of defense counsel. Defense counsel tore apart the ridiculous “how was I supposed to know what was denied, I only spend my life doing medical collections work.” He also tore apart “the police report was uncertified” even though the whole world knows it says what it says. Lastly, defense counsel beat back the untimely denial argument, but I am not sure how or what the facts were regarding this argument. I have an email into defense counsel to find out what actually happened.
“We agree with the defendant that the Supreme Court erred in precluding it from introducing into evidence two accident reports. The accident reports were made in the regular course of business and were admissible under CPLR 4518(a). A business record is admissible even though the person who prepared it is available to testify to the acts or transactions recorded.”
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 2011 NY Slip Op 21039 (App. Term 2d Dept. 2011)
When Carothers was decided, people on here commented that a third-party biller would now be able to establish a prima facie case provided certain prerequisites were met. This was based upon the following language in Carothers:
“Further, although a proper foundation can be established by a recipient of records who does not have personal knowledge of the maker’s business practices and procedures, there must still be a showing that the recipient either incorporated the records into its own records or relied upon the records in its day-to-day operations”. Andrew Carothers, M.D., P.C. v. Geico Indem. Co., 79 A.D.3d 864, 865 (2d Dept. 2010).
Admittedly, I tended to agree with the comments. But like many, I failed to look at the cases Carothers cited, particularly Plymouth Rock Fuel Corp. And, I of all people should have known better because when I wrote the losing appellant’s brief in Pine Hollow v. Progressive many years ago, my main argument was consistent with Plymouth Rock: the owner or other custodian employed at the medical facility can incorporate the records of the biller, not the other way around. I lost at that time, and perhaps that is why I acquiesced to the comments that were posted here.
In any event, the Etienne case proves that I was actually correct 7 years ago. Perhaps now, I can sleep better at night. The pertinent quote of Etienne is as follows:
“In each of those cases, an entity sought to admit a third party’s records into evidence, pursuant to the business records exception to the hearsay rule, through the testimony of the entity’s own employee. In the case at bar, however, it was plaintiff that sought to admit its own claim forms, pursuant to the business records exception to the hearsay rule, through the testimony of an employee of its third-party biller. Further, it appears that, in DiSalvo and Plymouth Rock Fuel Corp., the third party had a business duty to report accurate information to the entity seeking to use those records. In this case, although plaintiff’s biller asserted that plaintiff had a contractual duty to provide accurate information to its billing company, plaintiff did not submit any evidence of such a duty”.
Aside from making it almost impossible for medical practices that are not in business anymore to satisfy a prima facie case, there was something really interesting in the opinion that I have to put in here:
“Finally, the fact that the claim forms are prescribed by regulation does not render them inherently [*4]trustworthy or reliable. As recognized by the Court of Appeals, incidents of no-fault fraud are prevalent in New York, including instances where corrupt medical clinics “generate stacks of medical bills for each passenger, detailing treatments and tests that were unnecessary or never performed” (see Matter of Medical Socy. of State of NY v Serio, 100 NY2d 854 ).”
This should be contrasted to what the Appellate Term, First Department said on the exact issue, while also construing Matter of Medical Socy. of State of NY v Serio:
“Our conclusion that a plaintiff provider can use admissions obtained through a notice to admit to establish its entitlement to recover overdue assigned first-party no-fault benefits is consonant with the purposes underlying the No-Fault Law, which “were to ensure prompt compensation for losses incurred by accident victims without regard to fault or negligence, to reduce the burden on the courts and to provide substantial premium savings to New York motorists” (Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854, 860 )”
Really interesting stuff.
Yellow Book of N.Y., L.P. v Cataldo, 2011 NY Slip Op 00678 (2d Dept. 2011):
- Affiant could work for successor entity and lay a proper business record foundation for the documents.
“Additionally, Cataldo contends that the plaintiff’s documents should not have been admitted into evidence pursuant to the business records exception to the hearsay rule because the plaintiff’s witness was employed by the plaintiff’s successor-in-interest and because she lacked personal knowledge of the information contained in the documents. As the witness at issue was fully familiar with the plaintiff’s record-keeping procedures and practices, this contention is without merit (see CPLR 4518[a])”
- A representative to a party may not be kicked out of the courtroom –
“Cataldo’s contention that the Supreme Court erred in denying his request to exclude a witness from the courtroom is without merit. The record supports the Supreme Court’s determination that the witness at issue was employed by the plaintiff’s successor-in-interest and was, therefore, a party representative. As such, and in the absence of extenuating circumstances, the witness was entitled to remain in the courtroom throughout the trial (see Auger v State of New York, 263 AD2d 929, 932; Liquori v Barrow, 160 AD2d 843, 844; Carlisle v County of Nassau, 64 AD2d 15, 18). Further, Cataldo failed to establish that he suffered any prejudice due to the continued presence of the witness (see People v Scheck, 24 AD3d 574).”
– Thanks to DG for picking up on the “kicking out the witness” portion of the opinion.
Short and sweet from the Appellate Division.
J.D.M. Imports Co., Inc. v Hartstein, 2010 NY Slip Op 09186 (1st Dept. 2010)
“The court correctly found that plaintiff’s computer database was a business record (see Ed Guth Realty v Gingold, 34 NY2d 440, 451 ), and then properly admitted a print-out from the database (see People v Weinberg, 183 AD2d 932, 933 , lv denied 80 NY2d 977 ; see also Guth, 34 NY2d at 452).”
Carothers v GEICO Indem. Co., 2010 NY Slip Op 51718(U)(App. Term 2d Dept. 2010).
We just saw this from the Fourth Department this week. Compare – Velocity Invs., LLC v Cocina, 2010 NY Slip Op 06854 (4th Dept. 2010).
Velocity Invs., LLC v Cocina, 2010 NY Slip Op 06854 (4th Dept. 2010)
“We agree with defendant that Supreme Court erred in granting the motion inasmuch as plaintiff failed to submit nonhearsay evidence to support the cause of action for an account stated. We therefore modify the judgment accordingly. Although plaintiff submitted copies of credit card statements allegedly sent to defendant, who failed to pay or to object to them, plaintiff failed to lay a proper foundation for the admission of those documents as business records pursuant to CPLR 4518 (a) (see West Val. Fire Dist. No. 1 v Village of Springville, 294 AD2d 949), which was the only basis proffered by plaintiff for their admissibility.”
Those who analogize a no-fault action to an account stated cause of action should take a minute to lament at what this case says.
People v Batjer, 2010 NY Slip Op 06825 (4th Dept. 2010)
“We agree with defendant, however, that the court erred in admitting in evidence certain records of BTS inasmuch as the People failed to establish that the records fall within the business records exception to the hearsay rule (see CPLR 4518 [a]; CPL 60.10). An employee of Regeneration Technologies, Inc. (RTI), a human tissue processing company that contracts with BTS, testified that RTI relied on the records submitted by BTS, which were incorporated into RTI’s records following a reconciliation process. The employee also testified that RTI was required to maintain those records, that the records were made in the regular course of RTI’s business, and that RTI maintained those records in the regular course of business. However, the RTI employee was not familiar with the record-keeping procedures of BTS and thus was unable to testify whether BTS made the records contemporaneously with the events being recorded, whether the records in question were made in the regular course of the business of BTS, or whether it was in fact the regular course of the business of BTS to make such records.”
This is a pretty exacting standard.
Total Family Chiropractic v Mercury Cas. Co., 2010 NY Slip Op 51470(U)(App. Term 2d Dept. 2010)
This was another one that did not necessarily go my way. By way of explanation, this was a complicated case, where the defense was whether plaintiff assignors made or conspired to make material misrepresentations in the procurement of the insurance policy.
The bills were delayed pending EUO’s of the assignors. The assignors were coy about admitting that Karoy Brown resided with his soon to be bride, Crystal Franklin Brown. There were four vehicles that were registered and owned by Crystal Franklin. Evidence was adduced that a trailer was parked in front of the Franklin residence, which contained lawn mowers and other equipment. Karoy alleged that he commuted from New Jersey to Patchogue to perform landscaping for a man whose name and number he could not remember. He worked between 3-5 days per week, for 12 hours per day. He would always go back home to New Jersey at the end of the day. Both assignors denied using the vehicles for any commercial purposes. Karoy had a suspended driver’s license during the relevant time period. Also, Karoy made a pass at the court reporter after the EUO. Thank goodness Crystal did not see that.
Evidence was also adduced that Crystal kept logs of the jobs that were performed. Both Assignors had cellphones. Crystal had a lease for her place, and had a landlord. Other material information was in existence.
The bills were delayed following the EUO in order to obtain this information. Once obtained, a further investigation would be done, which would shed more light on this case.
Nobody ever complied with the verification requests.
Had the supplied information demonstrated that the vehicles were used for commercial purposes or that Karoy was a resident and used the vehicle, then the claims would have most likely been denied due to the making of material misrepresentations in the procurment of the insurance policy.
Dueling motions for summary judgment were made following commencement of this action. A spreadsheet was used to log all of the pertinent dates for each bill. This case was pre-LMK so there were tons of bills for $33.70 and $67.40 flying around out there.
The Court said the following: “In an attempt to establish that the time period in which it had to pay or deny the claims was tolled due to outstanding verification requests, defendant relied upon spreadsheets annexed to the affidavit of its claim representative. However, because the claim representative did not establish that the spreadsheets constituted evidence in admissible form (see CPLR 4518 [a]; People v Kennedy, 68 NY2d 569, 579-580 ; Palisades Collection, LLC v Kedik, 67 AD3d 1329, 1330-1331 ; Speirs v Not Fade Away Tie Dye Co., 236 AD2d 531 ), defendant has not shown that it made timely verification requests.”
The information annexed to the spreadsheets were the dates the bills were received, verifications sent, etc. All of this information was annexed to the motion itself. In fact, the motion was about 1000 pages. The spreadsheet was more or less illustrative. I mean, I usually put a chart in my motion and put the information in the said chart. Since there was so much information for each bill, I used a spreadsheet instead of one of my charts in this case.
The affidavit of the claims representative had the standard language that this court previously found to be sufficient to allow the entry of all of the documents into evidence. The information in the spreadsheet was incorporated by reference. The case the court cites, Pallisades Collection, involved an assigned credit card debt that Pallisades purchased from Discover. Pallisades had to establish a business record foundation involving Discover’s business practices, in order to allow the entry of Discover’s data into evidence.
Here, the information was always stored and processed by Mercury. The affidavit, after laying a foundation for the dates and form of the documents, said that the spreadhseets annexed to the affidavit memorialized the information pertinent to the claim. I have to disagree with the court on this one.
Anyway, the moral of the story is this. If you have information that requires a spreadsheet, make sure you somehow incorporate the actual spreadsheet as part of the affidavit.
“3. The following represents the claims handling in this matter:
4. blah blah.
5. Facsimiles shall be deemed originals.”
On the bright side, the notice of trial was stricken so that Mercury can now search this state to find the Brown family and invite them to come in for an EBT.