Key Takeaway
Court ruling on no-fault insurance coverage denial due to provider's failure to cooperate at examination under oath and unlicensed practice violations.
Country-Wide Ins. Co. v Gotham Med., P.C., 2017 NY Slip Op 07538 (1st Dept. 2017)
(1) “The refusal by defendant’s principal, Dr. Alexandre Scheer, to answer questions at an examination under oath (EUO) about his compliance with a consent agreement and order he had entered into with the Office of Professional Medical Conduct (OPMC) constituted a failure to comply with the request for an EUO, a condition precedent to coverage under the insurance policy (see Hertz Corp. v Active Care Med. Supply Corp., 124 AD3d 411 ).”
This is the second time the Appellate Division opined on the issue of not answering questions at the EUO. The intentional refusal to comply “voided” coverage.
(2) “Defendant also argues that plaintiffs had no independent right to determine whether Scheer was in compliance with the consent agreement and order and that any determination by them of noncompliance would not render him “unlicensed” to practice medicine. This argument is unavailing. The consent agreement and order provides that any medical practice in violation of the term permitting Scheer to practice only when monitored “shall constitute the unauthorized practice of medicine.” An unlicensed health care provider is ineligible to receive no-fault reimbursement (11 NYCRR 65-3.16), and an insurer may make a good faith determination that a medical provider assignee seeking no-fault benefits is ineligible to receive such benefits (State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313, 322 ).”
The facts on this one were highly advantageous to the insurance carrier. You had a wounded warrior, tried to put the dagger into him and he refused to allow that to occur.
(3) “Defendant waived the defenses of res judicata and award and arbitration (CPLR 3211; see Mayers v D’Agostino, 58 NY2d 696 ). While the arbitral awards in its favor were not issued until after it had filed its answer in this action, there is no indication on the record before us that defendant ever moved to amend its answer to assert either of those defenses.”
I think this is the most important point to take from this case. It is the danger of being forced to allow these matters to proceed to arbitration.
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Legal Update (February 2026): Since this 2017 post, 11 NYCRR Part 65 regulations governing no-fault insurance have undergone several amendments, including potential modifications to section 65-3.16 regarding unlicensed provider eligibility and related procedural requirements. Additionally, examination under oath procedures and failure to cooperate standards may have evolved through subsequent regulatory updates and case law developments. Practitioners should verify current provisions of 11 NYCRR 65-3.16 and related cooperation requirements before relying on the specific regulatory framework discussed in this analysis.
