December 2, 2022

NGM Acupuncture, P.C. v Nationwide Ins. Co. (2022 NY Slip Op 51271(U))

https://www.beynensonlaw.com/case-law/ngm-acupuncture-p-c-v-nationwide-ins-co-2022-ny-slip-op51271u/

Court: Appellate Term, Second Department
Decided: December 2, 2022
Citation: 2022 NY Slip Op 51271(U)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: EUO no-show Timeliness and preclusion Verification requests
Legal questions: No-show: coverage defense or precludable? (see the maps)

Cite as

NGM Acupuncture, P.C. v Nationwide Ins. Co., 2022 NY Slip Op 51271(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2022)

Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.

Summary

Editorial summary by Beynenson Law, not part of the court’s decision.

The insurer timely denied three claims based on the provider's EUO nonappearances, with tolling preserving the deadline for one claim. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, granting summary judgment dismissing the first, fifth and seventh causes of action. The fifth and seventh claims were denied within 30 days of receipt. An initial EUO had been scheduled before receipt of the first claim, so the time to pay or deny that claim was tolled upon receipt. The insurer timely scheduled a follow-up EUO after the initial nonappearance, continuing the toll under 11 NYCRR 65-3.6 (b). Its denial within 30 days of the second nonappearance was therefore timely.

Reported in New York Official Reports at NGM Acupuncture, P.C. v Nationwide Ins. Co. (2022 NY Slip Op 51271(U))

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

NGM Acupuncture, P.C., as Assignee of Paulette Blake, Appellant,
against
Nationwide Insurance Company, Respondent.

Law Offices of Gabriel & Moroff, P.C. (Jason Moroff and Matthew Sledzinsky of counsel), for appellant. Hollander Legal Group, P.C. (Allan S. Hollander of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Claudia Lanzetta, J.), dated June 15, 2021. The order, insofar as appealed from, granted the branches of defendant’s motion seeking summary judgment dismissing the first, fifth, and seventh causes of action.

ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from so much of an order of the Civil Court as granted the branches of defendant’s motion seeking summary judgment dismissing the first, fifth, and seventh causes of action on the ground that plaintiff had failed to appear for duly scheduled examinations under oath (EUOs).

Contrary to plaintiff’s contention, the claims underlying the fifth and seventh causes of action were timely denied, as these claims were denied within 30 days of defendant’s receipt thereof (see Island Life Chiropractic Pain Care, PLLC v 21st Century Ins. Co., 74 Misc 3d 17 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2021]). Plaintiff also asserts that the claim underlying the first cause of action was not timely denied. However, an initial EUO had been [*2]scheduled before defendant received this claim; therefore, defendant’s time to pay or deny this claim was tolled when this claim was received (see ARCO Med. NY, P.C. v Lancer Ins. Co., 34 Misc 3d 134[A], 2011 NY Slip Op 52382[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]). Further, as defendant timely scheduled a follow-up EUO after plaintiff failed to appear for the initial EUO, defendant’s time to pay or deny the claim remained tolled (see 11 NYCRR 65-3.6 [b]). Consequently, defendant’s subsequent denial of this claim, which was issued within 30 days of the second nonappearance, was timely (see Island Life Chiropractic Pain Care, PLLC, 74 Misc 3d 17; Quality Health Supply Corp. v Nationwide Ins., 69 Misc 3d 133[A], 2020 NY Slip Op 51226[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2020]).

Accordingly, the order, insofar as appealed from, is affirmed.

ALIOTTA, P.J., TOUSSAINT and BUGGS, JJ., concur.

ENTER:
Paul Kenny
Chief Clerk
Decision Date: December 2, 2022

Legal questions

A question of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.

No-show: coverage defense or precludable?

Open the full map

Is an IME/EUO no-show defense precluded if the insurer did not timely deny the claim on that ground?

This decision: Timely denial required as part of the no-show defense, and the insurer showed it

Held the EUO no-show denials timely: two claims were denied within 30 days of receipt, and the third, received after an initial EUO was scheduled, stayed tolled through a timely follow-up and was denied within 30 days of the second nonappearance.

Coverage defensePrecludable: denial lackingPrecludable: denial timelyThis decisionCites it or cited by itCited or followed

Of the 500 decisions on this question in the Second Department courts and the Court of Appeals, 334 (this one included) are in the same category.

Cited in this decision

A label shows how this decision treated the case it cites.

Island Life Chiropractic Pain Care, PLLC v 21st Century Ins. Co. (2021 NY Slip Op 21340) FollowedAn untimely EUO no-show denial of one claim does not waive the defense against later claims that are individually timely denied.
ARCO Med. N.Y., P.C. v Lancer Ins. Co. (2011 NY Slip Op 52382(U)) FollowedA follow-up EUO request is not premature when sent within 10 days after failure to appear for the initial scheduled examination.
Quality Health Supply Corp. v Nationwide Ins. (2020 NY Slip Op 51226(U))The 30-day pay-or-deny period for EUO nonappearance begins with the second missed EUO when no other verification is outstanding.

Cited by

A label shows how the later decision treated this one.

Precision Acupuncture P.C. v State Farm Mut. Auto. Ins. Co. (2025 NY Slip Op 50021(U)) FollowedA pending EUO request tolls the time to pay or deny later claims from the same provider for the same assignor before two EUO no-shows.

Similar decisions

Wellness Plaza Acupuncture, P.C. v Nationwide Ins. (2022 NY Slip Op 50934(U))The insurer established timely mailing of EUO notices and denials, and the provider raised no factual issue concerning mailing timeliness.
Northern Med. Care, P.C. v Nationwide Affinity Ins. Co. of Am. (2024 NY Slip Op 51822(U))An insurer may timely schedule more than two EUOs and deny a claim within the required period after the last scheduled EUO. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, granting the insurer summary judgment dismissing the complaint.
Arcadia Acupuncture, P.C. v Nationwide Ins. Co. (2021 NY Slip Op 51258(U))The provider obtained partial judgment for untimely denials, but disputed EUO convenience barred judgment on later claims.
GPLW Acupuncture, P.C. v Nationwide Mut. Ins. Co. (2024 NY Slip Op 50397(U))The provider raised no triable issue on the EUO nonappearance defense where the scheduling letters offered virtual attendance.
Hands On Physical Therapy Care v Nationwide Ins. (2022 NY Slip Op 50797(U))The insurer failed to establish timely EUO nonappearance denials for the provider's first three causes of action.