EUO Summary Judgment Requirements New York – What Insurers Must Prove

EUO Summary Judgment Requirements: What Insurance Companies Must Prove in New York

Understanding Prima Facie Requirements in EUO No-Show Cases

When healthcare providers fail to appear for scheduled Examinations Under Oath (EUOs), insurance companies often seek summary judgment to deny no-fault benefits claims. The decision in Actual Chiropractic, P.C. v State Farm Insurance clarifies what insurers must demonstrate to establish their prima facie entitlement to judgment, and notably, what they are not required to prove.

The Actual Chiropractic Decision: Key Legal Framework

In Actual Chiropractic, P.C. v State Farm Insurance, 2019 NY Slip Op 50421(U)(App. Term 2d Dept. 2019), the court addressed a crucial procedural question: must insurance companies provide objective reasons for requesting EUOs when seeking summary judgment for benefits denials?

The Court’s Clear Answer

The court definitively answered this question: No, insurance companies are not required to set forth objective reasons for requesting EUOs when establishing their prima facie entitlement to summary judgment. This ruling aligns with established precedent and simplifies the requirements for insurers seeking judgment in EUO no-show cases.

Prima Facie Requirements for EUO Summary Judgment

What Insurance Companies Must Prove

According to the Actual Chiropractic decision, citing Interboro Insurance Co. v Clennon, 113 AD3d 596, 597 (2014), insurers need only demonstrate “as a matter of law” three essential elements:

1. Proper EUO Demand: That they “twice duly demanded an from the ”
2. Provider’s Failure to Appear: That “the provider failed to appear” for the scheduled examinations
3. Timely Denial: That “the issued a timely denial of the claims”

What Insurance Companies Are NOT Required to Prove

Importantly, the decision makes clear that insurers do not need to:

• Provide objective reasons or justification for the EUO request
• Demonstrate good cause for the examination
• Show suspicious circumstances warranting investigation
• Prove the reasonableness of the EUO demand

Supporting Case Law and Legal Authority

Consistent Precedent Across Departments

The Actual Chiropractic decision cites several supporting cases that establish this framework:

• Parisien v Metlife Auto & Home, 54 Misc 3d 143, 2017 NY Slip Op 50208
• Palafox PT, P.C. v State Farm Mutual Auto Insurance Co., 49 Misc 3d 144, 2015 NY Slip Op 51653

The Interesting “Compare” Citation

The decision includes an intriguing “cf.” (compare) citation to American Trust Insurance Co. v Jaga Medical Services, P.C., 128 AD3d 441 (2015). This reference subtly acknowledges that the First Department’s analysis in Jaga took a different approach, suggesting some judicial disagreement on these issues.

Practical Implications for Legal Practice

For Insurance Companies and Defense Counsel

This decision provides clear guidance for insurers seeking summary judgment in EUO no-show cases:

• Streamlined Requirements: Focus on proving the three essential elements without needing to justify the EUO request
• Burden Reduction: No need to develop extensive records showing suspicious circumstances
• Efficient Litigation: Faster path to summary judgment when providers fail to appear

For Healthcare Providers and Plaintiff’s Counsel

While this decision favors insurers, it clarifies the battlefield for healthcare providers:

• Challenge Procedure, Not Justification: Focus defenses on procedural compliance rather than reasonableness of EUO demands
• Attend EUOs: The best defense against summary judgment is compliance with EUO demands
• Documentation is Critical: Ensure all correspondence and scheduling issues are properly documented

Strategic Considerations in EUO Litigation

Beyond the Prima Facie Case

While insurers may not need to justify EUO demands initially, other legal theories remain available to challenge unreasonable examination requests:

• Claims of harassment through excessive EUO demands
• Procedural defects in EUO scheduling
• Constitutional due process challenges in extreme cases
• Bad faith claims where patterns of abuse emerge

The Broader No-Fault Context

EUO issues frequently intersect with other areas of no-fault practice, including car accident injury claims and broader personal injury litigation. Understanding EUO requirements helps attorneys navigate the complex interplay between no-fault benefits and tort recovery.

Connection to Other Legal Practice Areas

Personal Injury Cases and No-Fault Benefits

EUO compliance affects not only healthcare providers but also injured parties pursuing compensation. Clients involved in motor vehicle accidents often need to understand both their no-fault benefits and their right to pursue car accident injury claims against at-fault parties.

Healthcare Provider Representation

Medical practices, especially those treating accident victims, need skilled legal representation to navigate no-fault requirements while maintaining their right to compensation. This includes understanding EUO obligations and protecting against improper benefit denials.

Future Developments in EUO Law

Potential Legislative Changes

While current law clearly favors insurers in EUO summary judgment motions, ongoing discussions about no-fault reform may affect these requirements. Healthcare providers and legal practitioners should monitor potential changes to No-Fault Regulations 68.

Appellate Court Harmonization

The “cf.” citation to Jaga suggests some tension between different appellate departments. Future decisions may need to address any inconsistencies in how courts approach EUO justification requirements.

Frequently Asked Questions About EUO Summary Judgment

What must insurance companies prove to get summary judgment when providers miss EUOs?

Insurance companies must prove three elements: (1) they twice properly demanded EUOs from the provider, (2) the provider failed to appear, and (3) they issued timely denials of the claims. They do not need to justify why they requested the EUOs.

Can healthcare providers challenge EUO demands as unreasonable?

While providers cannot challenge the lack of objective justification for EUO demands in summary judgment proceedings, they may still challenge EUOs on other grounds such as procedural defects, harassment, or bad faith patterns of conduct.

What happens if a provider partially complies with EUO demands?

Partial compliance may not satisfy the insurer’s requirements. Providers should attend all scheduled EUOs and comply fully with reasonable requests to avoid potential benefits denials.

How does this decision affect ongoing no-fault litigation?

The decision clarifies that insurers have a relatively low burden for establishing prima facie entitlement to summary judgment in EUO no-show cases. This may encourage more aggressive summary judgment motions by insurers.

Should healthcare providers always attend EUOs?

Generally, yes. The best protection against summary judgment and benefits denial is compliance with properly scheduled EUO demands. Providers should consult with experienced counsel if they believe an EUO demand is improper or harassing.

Conclusion

The Actual Chiropractic decision provides valuable clarity for both insurers and healthcare providers navigating New York’s no-fault system. By establishing clear, limited requirements for EUO summary judgment motions, the court has streamlined the process for insurers while clarifying the legal landscape for providers and their counsel.

Understanding these requirements is crucial for effective legal representation in no-fault disputes. While the decision favors insurers in many respects, it also provides a clear roadmap for both sides to understand their rights and obligations in EUO proceedings.

Whether you’re a healthcare provider dealing with EUO demands, an injured party navigating no-fault benefits, or an attorney handling insurance disputes, experienced legal guidance can help protect your rights and interests in these complex proceedings.

Call 516-750-0595 for a free consultation with an experienced New York no-fault insurance attorney who can help you understand your rights and develop effective strategies for EUO compliance and insurance claim disputes.