More Objective standards?

Understanding Objective Standards for No-Fault Insurance Examinations Under Oath

In a recent decision that has significant implications for no-fault insurance claims on Long Island, the Appellate Term addressed whether insurance companies need objective reasons to request Examinations Under Oath (EUOs) from healthcare providers. The case, MUA Chiropractic Healthcare, PLLC v Nationwide Mut. Ins. Co., 2022 NY Slip Op 51384(U)(App. Term 2d Dept. 2023), raises important questions about the balance of power between insurers and medical providers in no-fault disputes.

What Are Examinations Under Oath in No-Fault Cases?

An Examination Under Oath (EUO) is a formal proceeding where an insurance company can compel an injured person or medical provider to answer questions under oath about a claim. Think of it as a sworn statement, similar to a deposition, but conducted by the insurance company as part of their investigation process.

For injured parties, EUOs typically focus on:

• The circumstances of the accident
• The extent and nature of injuries
• Treatment received and its necessity
• Previous medical history
• Employment and lost wage claims

For healthcare providers, EUOs usually examine:

• The medical treatment provided
• Billing practices and procedures
• Patient records and documentation
• The provider’s relationship with the patient
• Compliance with no-fault regulations

The Legal Issue: Objective Standards for Provider EUOs

The central question in the MUA Chiropractic Healthcare case was whether insurance companies must demonstrate objective reasons before requesting an EUO from a medical provider. This is a critical distinction that affects the rights of both providers and patients in the personal injury and no-fault insurance system.

The Court’s Ruling

The court stated: “Plaintiff does not argue that defendant did not demonstrate its prima facie entitlement to summary judgment. Rather, plaintiff argues that defendant did not have an objective basis for requesting the EUOs. However, contrary to plaintiff’s contention, defendant was not required to set forth objective reasons for requesting EUOs in order to establish its prima facie entitlement to summary judgment.”

The court cited several cases supporting this position, including Interboro Ins. Co. v Clennon, NY Wellness Med., P.C. v Nationwide Mut. Ins. Co., and others. However, as our analysis reveals, this ruling may not reflect the complete legal landscape.

A Critical Analysis of the Decision

Attorney Jason Tenenbaum notes a significant issue with the court’s reasoning: “The Court cites to Clennon, but Clennon never decided the issue of objective standards.” This observation highlights a potential flaw in the court’s legal analysis and suggests that the precedent may not be as clear-cut as the decision implies.

The distinction between injured persons and medical providers is crucial here. While it may be reasonable for insurance companies to examine injured parties about their claims and treatment—especially when there’s significant treatment involved—the standards for compelling provider EUOs should arguably be higher.

What This Means for You

If You’re an Injured Party

Understanding your rights regarding EUOs is essential if you’ve been injured in a motor vehicle accident on Long Island. Insurance companies generally have broad authority to examine you under oath, particularly when:

• You’ve received extensive medical treatment
• There are questions about the accident circumstances
• You’re claiming significant lost wages
• There are discrepancies in your medical records

However, these examinations must be conducted fairly and within legal bounds. You have the right to legal representation during an EUO, and your attorney can object to improper questions or procedures.

If You’re a Medical Provider

The MUA Chiropractic Healthcare decision suggests that insurance companies may not need to demonstrate objective reasons before requesting your EUO. However, this area of law remains complex, and the standards may vary depending on the jurisdiction and specific circumstances.

Traditional grounds for provider EUOs include:

• Discrepancies between the patient’s testimony and treatment records
• Evidence suggesting potential fraud or abuse
• Questions about the necessity or appropriateness of treatment
• Billing irregularities or patterns

The Broader Legal Landscape

Jurisdictional Differences

Attorney Tenenbaum observes: “I think the Second Department if forced to confront the issue would probably side with the First Department on the objective basis issue.” This suggests that different appellate courts may have varying approaches to the objective standard requirement, creating potential inconsistencies in how these cases are handled across New York State.

This jurisdictional variation means that the outcome of your case may depend significantly on where it’s filed and which court ultimately decides the matter. This underscores the importance of having experienced legal representation familiar with local court practices and precedents.

The Mallela Defense

One commonly accepted ground for requesting provider EUOs is when there’s evidence supporting a Mallela defense. This refers to situations where the insurance company believes the provider may have engaged in fraudulent billing practices or provided unnecessary treatment. When a “bona fide investigation shows a Mallela defense,” courts have generally found this to constitute sufficient objective grounds for an EUO.

Protecting Your Rights in No-Fault Disputes

Whether you’re an injured party dealing with insurance company demands or a medical provider facing an EUO request, understanding your rights is crucial. The evolving legal landscape around objective standards makes it essential to have knowledgeable legal representation.

Key steps to protect yourself include:

• Respond promptly to insurance company requests
• Maintain detailed records of all communications
• Seek legal advice before agreeing to an EUO
• Understand your rights and obligations under no-fault law
• Don’t face the insurance company alone

Frequently Asked Questions About EUOs

Can I refuse to attend an Examination Under Oath?

Generally, no. If properly requested, EUOs are mandatory under no-fault insurance regulations. However, you have the right to legal representation during the examination, and your attorney can challenge improper or abusive EUO requests.

What happens if I don’t cooperate with an EUO?

Failure to cooperate with a properly requested EUO can result in the denial of your no-fault benefits or the dismissal of your provider’s claim for payment. Insurance companies can use non-cooperation as grounds to stop paying benefits.

Do I need a lawyer for an EUO?

While not legally required, having an attorney present during an EUO is highly recommended. Your lawyer can protect your rights, object to improper questions, and ensure the examination stays within proper bounds.

How long does an EUO typically last?

EUOs can last anywhere from one to several hours, depending on the complexity of the case and the issues being examined. Your attorney can help ensure the examination doesn’t become unnecessarily prolonged or abusive.

Can the insurance company ask about my personal medical history?

The scope of questioning in an EUO is generally limited to matters relevant to the claim. While some personal medical history may be relevant, your attorney can object to overly broad or intrusive questions that don’t relate to your current claim.

The Importance of Experienced Legal Representation

The MUA Chiropractic Healthcare decision and the ongoing evolution of objective standards in EUO cases demonstrate why experienced legal representation is essential in no-fault insurance matters. These cases involve complex legal issues that can significantly impact your rights and financial recovery.

At the Law Office of Jason Tenenbaum, we stay current with the latest developments in no-fault law and work tirelessly to protect our clients’ interests. Whether you’re facing an EUO demand or dealing with other no-fault insurance disputes, we have the experience and knowledge to guide you through the process.

Don’t let insurance companies take advantage of unclear legal standards or procedural complexities. Your rights matter, and you deserve representation that understands both the law and the practical realities of no-fault insurance disputes.

If you’re facing an Examination Under Oath or other no-fault insurance issues on Long Island, don’t navigate this complex legal landscape alone. Call 516-750-0595 for a free consultation with an experienced no-fault insurance attorney who will fight for your rights and ensure you receive the benefits you deserve.