Key Takeaway
Court finds insufficient proof of IME mailing in no-fault case, highlighting importance of proper documentation when claiming patient no-show for scheduled examinations.
When Insurance Companies Fail to Prove IME Notice Was Properly Mailed
In New York no-fault insurance law, Independent Medical Examinations (IMEs) are a critical tool for insurers to evaluate claims. However, when a patient doesn’t appear for an IME, the insurance company must prove they provided proper notice. A recent Appellate Term decision demonstrates what happens when that proof falls short.
The case K.O. Med., P.C. v Mercury Cas. Co. involved a provider seeking payment for services that were denied based on the patient’s failure to appear for scheduled IMEs. The insurance company moved for summary judgment, arguing they had properly scheduled the examinations and the patient simply didn’t show up. However, the court found their documentation insufficient to establish that the IME scheduling letters were actually mailed.
This decision underscores a common issue in no-fault litigation: the burden of proving proper mailing procedures. Unlike situations where IME letters do not need to be sent to provider, insurers must still demonstrate they followed correct protocols when notifying patients. Cases involving no-show substantiated claims often turn on these procedural details.
Jason Tenenbaum’s Analysis:
K.O. Med., P.C. v Mercury Cas. Co., 2017 NY Slip Op 51158(U)(App. Term 2d Dept. 2017)
I reviewed the papers. The IME vendor changed the affidavit that was sent and inter-changed the defunct “Crosslands” with “Examworks” (the successor) entity. There was no discussion regarding the jural relationship between the two entities. I only realized that when I reviewed the papers after receiving the decision. Ironically, I was not the only one to miss that salient point. The Appellate Time signed an OSC granting us a stay of trial and granted the application motion to stay. Neither of these are easy feats. More finely tuned eyes saw the mistake. I will say this: they have a good set of proof-readers at that court. They find things all the time I never find.
“The Civil Court properly denied the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover on claims that had been denied based upon plaintiff’s assignor’s failure to appear for the IMEs, as the proof submitted by defendant was not sufficient to give rise to a presumption that the IME scheduling letters at issue had been properly mailed”
Key Takeaway
Insurance companies must provide adequate proof of proper mailing procedures when denying claims based on IME no-shows. This case highlights how even seemingly minor documentation issues, such as entity name changes without establishing corporate relationships, can undermine an insurer’s defense and prevent summary judgment.
