Simple addition is insufficient

Jodi Jacobs, D.C., PLLC v Global Liberty Ins. Co. of NY, 2021 NY Slip Op 50445(U)(App. Term 2d Dept. 2021)

Since when was taking out the abacus insufficient to prove that you properly added and multiplied?

“Contrary to defendant’s contention, defendant was not entitled to the dismissal of so much of the complaint as sought to recover upon the unpaid portion of the $380.73 claim for services rendered June 1, 2016 through June 13, 2016 because defendant failed to conclusively establish its defense that the fees charged exceeded the amounts set forth in the workers’ compensation fee schedule (see Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]). Indeed, “the fee schedule does not, in and of itself, establish that defendant properly utilized the codes set forth within the workers’ compensation fee schedule to calculate the amount which plaintiff was entitled to recover for each service rendered (see Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co., 61 AD3d 13 [2009]; Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009])” (Acupuncture Healthcare Plaza I, P.C. v Metlife Auto & Home, 54 Misc 3d 142[A], 2017 NY Slip Op 50207[U], *1-2 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017]).”

The one good think about no-fault is the stakes are relatively low, so I can give attorneys who want the experience an opportunity to draft an appeal or to try a case.

NF-3 is the operative document

Unitrin Direct Ins. Co. v Beckles, 2020 NY Slip Op 06974 (1st Dept. 2020)

“Where, as here, the insurer submits evidence of a medical provider claim (NF-3), the timely request for an independent medical examination (IME) of the injured claimant within 15 days of the receipt of that claim, and the injured claimant is a no-show at two duly noticed IMEs, the basis for disclaimer of coverage is established, as a matter of law, and summary judgment is properly awarded to the insurer with respect to further coverage obligations and reimbursement of outstanding medical bills with respect to all treating providers (see Kemper Independence Ins. Co. v Adelaida Physical Therapy, P.C., 147 AD3d 437 [1st Dept 2017]; National Liab. & Fire Ins. Co. v Tam Med. Supply Corp., 131 AD3d 851 [1st Dept 2015]). “

It is the bill, not the NF-2

City Anesthesia Healthcare, P.C. v Erie Ins. Co. of N.Y., 2021 NY Slip Op 50135(U)(App. Term 2d Dept. 2020)

“Contrary to the determination of the Civil Court, defendant demonstrated that, before it had received the claim at issue, it properly scheduled independent medical examinations (IMEs) of plaintiff’s assignor, and that the assignor failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Defendant also demonstrated that it timely denied the claim (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), based upon the assignor’s failure to appear for the IMEs. An assignor’s appearance at an IME “is a condition precedent to the insurer’s liability on the policy” (Stephen Fogel Psychological, P.C., 35 AD3d at 722). Plaintiff’s contention that the pre-claim IME scheduling letter was required to be mailed within 30 days of defendant’s receipt of the NF-2 lacks merit (see 11 NYCRR 65-3.5 [a], [d]; Appendix 13).”

It is the bill, not the NF-2

Post claim IME

Total Chiropractic, P.C. v Hereford Ins. Co., 2020 NY Slip Op 51362(U)(App. Term 2d Dept. 2020)

“However, contrary to defendant’s further argument, defendant did not demonstrate that it is entitled to summary judgment dismissing the complaint based on plaintiff’s assignor’s failure to appear for IMEs, as the initial IME had not been scheduled to be held within 30 calendar days after defendant’s receipt of plaintiff’s claims (see 11 NYCRR 65-3.5 [d]).”

Post claim action.

Verification, EUO and IME

Avalon Radiology, P.C. v Global Liberty Ins., 2020 NY Slip Op 51374(U)(App. Term 2d Dept. 2020)

As this court has held, where an insurer timely requests verification, its time to pay or deny a claim does not begin to run until it has received all of the requested verification, including the conducting of an EUO, and the insurer need not deny a claim while it is waiting for requested verification even if it already has a basis to deny such claim (see Parisien v Citiwide Auto Leasing, 64 Misc 3d 132[A], 2019 NY Slip Op 51050[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2019]; Active Care Med. Supply Corp. v American Tr. Ins. Co., 61 Misc 3d 138[A], 2018 NY Slip Op 51584[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2018]; Alev Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co., 38 Misc 3d 143[A], 2013 NY Slip Op 50258[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]). As a result, the Civil Court’s holding that defendant was precluded from denying the claims based upon the assignor’s failure to appear for IMEs was erroneous. As no testimony was taken, the matter must be remitted to the Civil Court for a new trial.”

The NF-2

Colin v Global Liberty Ins. Co. of N.Y., 2020 NY Slip Op 51002(U)(App. Term 2d Dept. 2020)

“The record demonstrates conclusively that the address to which the IME scheduling letters had been mailed to plaintiff’s assignor matched the one provided by plaintiff’s assignor on the assignor’s sworn application for no-fault benefits (NF-2) and on plaintiff’s NF-3 forms, all of which were submitted to defendant. To the extent plaintiff contends that defendant was required to also send the IME scheduling letters to the same address but with a zip code which differed by one digit simply because the police report set forth that zip code, that contention lacks merit. Not only did plaintiff’s assignor swear under penalty of perjury that the zip code which defendant used was the correct zip code, plaintiff’s opposition papers did not contain an affidavit from plaintiff’s assignor which asserted that the zip code to which defendant mailed the IME scheduling letters was incorrect.”

IME excuse without personal knowledge

Medcare Supply, Inc. v Global Liberty Ins., 2020 NY Slip Op 50231(U) (1st Dept. 2020)

” Defendant’s moving papers demonstrated, prima facie, that defendant had timely mailed both the IME scheduling letters and the denial of claim form (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 IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). In opposition, plaintiff proffered an affirmation by its assignor’s counsel, who did not assert that she possessed personal knowledge of the facts. Consequently, plaintiff failed to raise a triable issue of fact in opposition to defendant’s motion (see Zuckerman v City of New York, 49 NY2d 557 [1980]). “

In this case, the attorney for the Assignor signed an affirmation explaining why her client failed to attend the IMEs. The court found this insufficient. Perhaps, Plaintiff would have had better luck in arbitration where the rules of evidence do not apply?

It’s the 30-day rule

Success Rehab, PT, P.C. v Hereford Ins. Co., 2019 NY Slip Op 52031(U) (App. Term 2d Dept. 2019)

“Contrary to defendant’s contention, defendant did not establish its entitlement to summary judgment. Defendant acknowledged that it had received 9 of the 12 claims at issue between May 13, 2015 and June 19, 2015 and that plaintiff’s assignor’s first IME was scheduled for August 3, 2015. As that IME had not been scheduled to be held within 30 calendar days after defendant had received those claims, defendant did not demonstrate its entitlement to summary judgment dismissing so much of the complaint as sought to recover upon those claims based upon the assignor’s failure to appear for IMEs (see 11 NYCRR 65-3.5 [d] “

IME no-shows sustained

Valdan Acupuncture, P.C. v Global Liberty Ins. Co. of NY, 2019 NY Slip Op 51705(U)(App. Term 2d Dept. 2019)

” Defendant established that initial and follow-up letters scheduling IMEs had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]); that plaintiff’s assignor had failed to appear on either date (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]); and that the claim seeking to recover the sum of $1,224.22 had been timely denied on that ground (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123). As plaintiff failed to raise a triable issue of fact in opposition to the branch of defendant’s cross motion seeking summary judgment dismissing, on the ground that plaintiff’s assignor had failed to appear for duly scheduled IME “

Tyorkin v Global Liberty Ins., 2019 NY Slip Op 51689(U)(App. Term 2d Dept. 2019)

“[d]efendant submitted an affidavit by a supervisor employed by Omnimed Evaluation Services, which had been retained by defendant to schedule IMEs, which affidavit sufficiently established that the IME scheduling letters had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Defendant also established that the assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Thus, defendant demonstrated that plaintiff had failed to comply with a condition precedent to [*2]coverage (id. at 722). As defendant’s cross motion further established that defendant had timely denied (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123) the claims on that ground…”

Compare to: Satya Drug Corp. v Global Liberty Ins. Co. of N.Y., 2019 NY Slip Op 51505(U)(App. Term 1st Dept. 2019)

It should be noted that the Appellate Division, First Department as I have seen does not follow the “Metro 8” contemporaneous rule. Thus, while I am biased here, the Second Department got it right.

Lidas Med. Supply, Inc. v Global Liberty Ins., 2019 NY Slip Op 51688(U)(App. Term 2d Dept. 2019)

” The record demonstrates conclusively that while the address to which defendant mailed the letters did not include an apartment number, the address matched the one provided by plaintiff’s assignor on the assignor’s sworn application for no-fault benefits (NF-2) and on the assignor’s sworn notice of intention to make claim form which was submitted to defendant. Consequently, defendant established that the address to which the IME scheduling letters were mailed was proper”

We have seen recent cases where the Appellate Term, Second Department has followed the Appellate Division First Department rule requiring the provider to show the address is wrong in the first instance. The safer route is always to provide corroboration of the address and the attorney rep. letter. The IME letters should always have the name and address of the EIP and the attorney on all letters.

Article 75 lay-up

Matter of Global Liberty Ins. Co. of N.Y. v Top Q. Inc., 2019 NY Slip Op 06445 (1st Dept. 2019)

I know AAA will not like this decision. But as we told the master arbitrator in our brief, this is the law. The master refused to listen.

The above thought actually traces back to a recent snarky post on the No-fault group on Facebook One poster I think hailed a AAA decision about the inability to delay for recorded statements as gospel. Another poster found a Civil Court case saying the same thing. I then found an App Term case from 12 years prior that was contrary. What is my point? Do not trust AAA (or the App. Term) on the law if you think you are right.

Truth be told, the App. Div First Department will grant you leave if you can show them that an App Term decision is inconsistent with precedent, common sense or of significant import. While I do not agree with every decision from that Court, you know that your applications are getting attention at that tribunal. Again, the First Department only hears cases from two counties and has significant resources to give cases the attention they deserve.

The Second Department, however, is a lot more sparring with their grants of leave. They will only grant leave if the issue is hot button and involves millions of dollars, if not addressed. For proof, ask yourself why that court heard a pre-LMK interest case and will hear the Alleviation case. That said, leave will almost never be granted in mundane cases.

In fact, if you were to track First and Second Department CPL 440 leave applications, you would see the same trend. I do not blame the Second Department for its stinginess in granting leave application, despite being the victim of perfunctory leave denials. That Court is the busiest appellate court in the country.

Time for a Fifth Appellate Division anyone?

As to this case:

“Order, Supreme Court, Bronx County (Julia I. Rodriguez, J.), entered August 31, 2018, which denied the petition to vacate a master arbitrator’s award, unanimously reversed, on the law, without costs, and the petition granted.

The master arbitrator’s award was arbitrary because it irrationally ignored the controlling law that the no-fault policy issued by petitioner was void ab initio due to respondent’s assignor’s failure to attend duly scheduled independent medical exams (see Hereford Ins. Co. v Lida’s Med. Supply, Inc., 161 AD3d 442, 443 [1st Dept 2018]; Matter of Global Liberty Ins. Co. v Professional Chiropractic Care, P.C., 139 AD3d 645, 646 [1st Dept 2016]; American Tr. Ins. Co. v Lucas, 111 AD3d 423, 424 [1st Dept 2013]).”