Fogel again-

National Med. & Surgical Supply, Inc. v ELRAC, Inc., 2017 NY Slip Op 50028(U) (App. Term 2d Dept. 2017)

“Contrary to plaintiff’s assertion, there is no basis for a distinction between defendant’s contractual remedies when “the failure to appear for [EUOs] occurs before the submission of the claim form or after its submission” (id. at 722).”

This line of reasoning has its force from the Manoo debacle at the First Department.

Another EUO bonanza

J.K.M. Med. Care, P.C. v Ameriprise Ins. Co., 2016 NY Slip Op 26424 (App. Term 2d Dept. 2016)

(1)  “Plaintiff herein was neither named nor served in the Supreme Court proceeding, nor, at the time, was plaintiff in privity with its assignor, who was a named party in that proceeding, as the assignment of benefits had been executed before defendant had commenced the Supreme Court proceeding to compel the assignor’s appearance at an EUO or for declaratory relief upon the assignor’s failure to appear. As plaintiff had no full and fair opportunity to appear and defend its interests in the Supreme Court proceeding, the present action in the Civil Court is not subject to summary judgment dismissing the complaint by virtue of the Supreme Court declaration”

(2) “Defendant argues that, even in the absence of a judicial declaration, the order granting defendant’s motion for summary judgment dismissing the complaint should be affirmed on the alternative ground that plaintiff’s assignor had failed to appear for duly scheduled EUOs. However, contrary to defendant’s assertion, defendant failed to establish that it had timely and properly mailed its EUO scheduling letters”

(3)  “Furthermore, plaintiff properly argues that the scheduling letters failed to advise the assignor, in accordance with 11 NYCRR 65-3.5 (e), that she would be reimbursed for any loss of earnings and reasonable transportation costs incurred in complying with the request for an EUO.”

When do the malpractice insurance carriers get called?  This is not going to be a “U” or “A” citation, so names will appear on this order in the report.  Yikes.

A feckless appeal by Ameriprise

A.C. Med., P.C. v Ameriprise Ins. Co., 2016 NY Slip Op 51787(U) (App. Term 2d Dept. 2016)

“Pursuant to the no-fault regulations, “any additional verification required by the insurer to establish proof of claim shall be requested within 15 business days of receipt of the prescribed verification forms” (11 NYCRR 65-3.5 [b]). Since defendant received the claim in the amount of $403.58 on August 28, 2012 and mailed an EUO scheduling letter to plaintiff on September 26, 2012, defendant’s time to pay or deny that claim was reduced by the number of days that the EUO request was late (see 11 NYCRR 65-3.8 [l]). However, defendant did not timely deny that claim after plaintiff had failed to appear for the second scheduled EUO (see 11 NYCRR 65-3.8 [a] [1]). With respect to the remaining claims, because defendant did not mail its first EUO scheduling letter to plaintiff within 30 calendar days of receiving those claims, the scheduling letter was rendered a nullity by its untimeliness”

I almost ask myself – are you sometimes better off not showing up for the EUO?

Timely EUO letters

Fontanella v Allstate Ins. Co., 2016 NY Slip Op 51679(U)(App. Term 2d Dept. 2016)

“As to the remaining claims, defendant failed to establish that the denials were timely. The EUO scheduling letters were not sent within 30 days of the insurer’s receipt of each of the claims (see O & M Med., P.C. v Travelers Indem. Co., 47 Misc 3d 134[A], 2015 NY Slip Op [*2]50476[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]), and we note that delay letters, which request no verification, do not toll the 30-day statutory time period within which a claim must be paid or denied”

Beating a dead horse.  I think this may be the first time I saw a direction that said “EUO scheduling letters needed to be sent within 30-days of receipt of the claim.” This has been implied in light of 65-3.5(b); 3.5(l); 3.8 and Ins Law 5106 and the Neptune-Ameriprise case.

I actually get shutters when I see “Ameriprise” or “Allstate” listed in a no-fault appeal, because I know my life has just gotten that much more difficult than the night before.

EUO no show is unconditional

Integrative Pain Medicine, P.C. v Allstate Ins. Co., 2016 NY Slip Op 51525(U)

“Appearance at an EUO is a condition precedent to coverage (see 11 NYCRR 65—1.1; Interboro Ins. Co. v Clennon, 113 AD3d 596 [2014]; Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Upon finding that defendant demonstrated that it had timely and properly denied the claims at issue on the ground that plaintiff’s assignor had failed to appear for duly scheduled EUOs, the Civil Court should not have given plaintiff’s assignor an opportunity to cure its failure to act during claims processing (see IDS Prop. Cas. Ins. Co. v Stracar Med. Services, P.C., 116 AD3d 1005 [2014]). Under the circumstances, the court should have granted defendant’s cross motion for summary judgment unconditionally.”

It is interesting that the Civil Court found that the EIP should have another opportunity to attend EUO, which is what happened in IDS.  The Appellate Term, similar to the Appellate Division in IDS, said no more chances and dismissed the complaint.  Interesting.

EUO loss (again)

TAM Med. Supply Corp. v Ameriprise Auto & Home, 2016 NY Slip Op 51407(U)(App. Term 2d Dept. 2016)

“Plaintiff correctly argues that, because defendant failed to submit proof by someone with personal knowledge of the nonappearance of plaintiff for the examinations under oath in question, defendant’s cross motion for summary judgment should have been denied”

Oleg, is this the famous “would’ve, could’ve, should’ve but didn’t” affidavit that always loses?

The dates of the EUO’s do not need to be placed in the letters

Actual Chiropractic, P.C. v Mercury Cas. Co., 2016 NY Slip Op 51435(U)(App. Term 2d Dept. 2016)

“The proof submitted by defendant established that it had timely mailed both the EUO scheduling letters and the denial of claim forms at issue (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), and that plaintiff’s assignor had failed to appear for the duly scheduled EUOs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]; Ortho Prods. & Equip., Inc. v Interboro Ins. Co., 41 Misc 3d 143[A], 2013 NY Slip Op 52054[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]). We note that, contrary to the conclusion of the Civil Court, “the failure to set forth the dates of the scheduled examinations in the denial of claim form[s] did not render the denial[s] conclusory, vague, or without merit as a matter of law” (Quality Psychological Servs., P.C. v Avis Rent-A-Car Sys., LLC, 47 Misc 3d 129[A], 2015 NY Slip Op 50378[U], *1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]).”

This is posted for three reasons.  One, it is my case so I am biased.  Second, the no-show was proved through  what I call a business record foundation.  Third, we see that the level of specificity that is required on the disclaimer (again) is that of notice.

False statement about prior injuries warrants further discovery

Jones v Seta, 2016 NY Slip Op 06556 (1st Dept. 2016)

“Defendants’ discovery, after the filing of the note of issue, that Jones had been involved in prior accidents involving the same body parts alleged to have been injured in the subject accident, constitutes “unusual or unanticipated circumstances” warranting further discovery (22 NYCRR 202.21[d]; see Bermel v Dagostino, 50 AD3d 303 [1st Dept 2008]). However, defendants have not articulated a need for a supplemental physical examination, as the IME doctor has already examined Jones, documented his or her findings, and can supplement the same upon receipt of the records relating to Jones’ prior injuries and treatment”

By analogy, false statements at an EUO regarding prior injuries would then warrant a subsequent EUO.  Assuming the false statements at the second EUO are not remediable, is this a ground for disclaimer?

EUO no-show substantiated

AVM Chiropractic, P.C. v 21st Century Ins. Co., 2016 NY Slip Op 51354(U)(App, Term 2d Dept. 2016)

“Contrary to plaintiff’s only arguments on appeal, the proof submitted by defendant in support of its motion was sufficient to give rise to a presumption that the denial of claim forms at issue had been properly mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]), and to demonstrate that plaintiff’s assignor had failed to appear for the EUOs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]; Active Chiropractic, P.C. v Praetorian Ins. Co., 43 Misc 3d 134[A], 2014 NY Slip Op 50634[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]).”

I like this case because it cites the Active Chiro case which discussed certified transcripts of no-show.  That issue played out at the First Department in Liberty v. KO

Proof insufficient to comply with 65-3.5(b), 65-3.6(b)

Liberty Mut. Insurance Co. v K.O. Med., P.C., 2016 NY Slip Op 06166 (1st Dept. 2016)

Violation of 3.5(b); 3.6(b)

(1)  Plaintiffs seek, inter alia, a declaration that defendant is not entitled to no-fault insurance benefits because it failed to appear for examinations under oath (EUOs). However, plaintiffs failed to demonstrate that the EUOs were properly noticed (see e.g. Interboro Ins. Co. v Perez, 112 AD3d 483 [1st Dept 2013]). Counsel’s affirmation may be sufficient proof that the requests for EUO were mailed (see Liberty Mut. Ins. Co. v Five Boro Med. Equip., Inc., 130 AD3d 465 [1st Dept 2015]), but neither the affirmation nor anything else in the record establishes that the requests were mailed in accordance with the time frames set forth in the no-fault implementing regulations. Under the circumstances, the timeliness of plaintiffs’ claim denials is immaterial (see Interboro Ins. Co., 112 AD3d 483).

In this case, the insurance carrier sought to EUO the provider regarding  various bills that were received from numerous Assignors  If you read the papers, there is no mention of when the billing was received.  There was proof of mailing of the EUO letters and uncertain bust statements.  The court in light of the recent holdings correctly found that there was no evidence that the EUO’s were timely scheduled relative to the receipt of the bills

Failure to prove the no-show

(2) “Plaintiffs also failed to establish prima facie defendant’s failure to appear for the EUOs. The transcripts submitted to show defendant’s failure to appear on certain dates were uncertified and unsworn (see Rue v Stokes, 191 AD2d 245, 246-247 [1st Dept 1993]), and no evidence was submitted with respect to the other dates.”

This struck me as odd since the proofs in this case were neither better nor worse than the proofs in Allstate v. Pierre.  The carrier should have put a business record foundation paragraph for the EUO bust statements in the affidavit.  Of course, Pierre would have been decided differently under the current standard of law.

This could be chronicled under the headline: the perils of DJs when people answer.