December 18, 2015
Alfa Med. Supplies, Inc. v Praetorian Ins. Co. (2015 NY Slip Op 51847(U))
https://www.beynensonlaw.com/case-law/alfa-med-supplies-inc-v-praetorian-ins-co-2015-ny-slip-op51847u/
- Decided
- December 18, 2015
- Citation
- 2015 NY Slip Op 51847(U)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Later treatment
- Followed in 1 later decision (see Cited by)
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.
Reported in New York Official Reports at Alfa Med. Supplies, Inc. v Praetorian Ins. Co. (2015 NY Slip Op 51847(U))
against
Praetorian Insurance Company, Defendant-Respondent.
Plaintiff appeals from an order the Civil Court of the City of New York, New York County (Tanya R. Kennedy, J.), entered February 3, 2015, which granted defendant’s motion for summary judgment dismissing the complaint.
Per Curiam.
Order (Tanya R. Kennedy, J.), entered February 3, 2015, affirmed, with $10 costs.
Defendant-insurer made a prima facie showing of entitlement to summary judgment dismissing the plaintiff-provider’s claim for first-party no-fault benefits by establishing that it properly mailed the notices for independent medical examinations (IMEs) to plaintiff’s assignor and her attorney, and that the assignor failed to appear (see American Tr. Ins. Co. v Lucas, 111 AD3d 423 [2013]; American Tr. Ins. Co. v Solorzano, 108 AD3d 449 [2013]). Contrary to plaintiff’s contention, defendant was entitled to request the IMEs prior to its receipt of plaintiff’s claim forms (see 11 NYCRR 65-1.1; Steven Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720, 721 [2006]; Easy Care Acupuncture P.C. v Praetorian Ins. Co., 49 Misc 3d 137[A], 2015 NY Slip Op 51524[U][App Term, 1st Dept 2015]; see also Inwood Hill Med., P.C. v General Assur. Co., 10 Misc 3d 18, 19-20 [2005]). Moreover, defendant submitted competent evidence of the assignor’s nonappearance in the form of the sworn affidavits of the scheduled examining chiropractor/acupuncturist and defendant’s third-party IME scheduler, setting forth facts sufficient to demonstrate the affiants’ personal knowledge of the assignor’s repeated failures to appear for the IMEs and the office practices and policies when an assignor fails to appear for a schedule IME (see American Tr. Ins. Co. v Lucas, 111 AD3d at 424; Harmonic Physical Therapy v Encompass Home and Auto Ins. Co. 47 Misc 3d 146[A], 2015 NY Slip Op 50733[U][App Term, 1st Dept 2015]).
In opposition, plaintiff did not specifically deny the assignor’s nonappearance or otherwise raise a triable issue with respect thereto, or as to the mailing or reasonableness of the underlying notices (see Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559, 560 [2011], lv denied 17 NY3d 705 [2011]; see also Badio v Liberty Mut. Fire Ins. Co., 12 AD3d 229 [2004]). “Accordingly, when [plaintiff’s] assignor[] failed to appear for the [*2]requested medical exams, [defendant] had the right to deny all claims retroactively to the date of loss, regardless of whether the denials were timely issued” (American Tr. Ins. Co. v Lucas, 111 AD3d at 424), and even though defendant initially denied the claims on different grounds (see Unitrin, 82 AD3d at 560).
Plaintiff’s remaining contentions are unpreserved and/or without merit.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concur I concur
Decision Date: December 18, 2015
Legal questions (3)
Questions 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.
Did the insurer prove its IME/EUO no-show defense: mailed, compliant scheduling requests and the claimant’s nonappearance?
This decision: Insurer proved mailed, compliant requests and the nonappearance; claimant's answers rejected
Held the IME no-show defense established: notices were properly mailed, IMEs could be requested before the claim forms were received, and examiner and scheduler affidavits showed personal knowledge of the repeated nonappearances.
Of the 163 decisions on this question in the First Department courts and the Court of Appeals, 92 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on 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: No-show voids coverage; insurer need not show a timely denial (rules on the question, but another ground decided the case)
Held that once the assignor failed to appear for IMEs the insurer could deny all claims retroactively regardless of whether the denials were timely issued, even though it first denied them on different grounds.
Of the 36 decisions on this question in the First Department courts and the Court of Appeals, 29 (this one included) are in the same category.
Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?
This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)
Held the insurer established proper mailing of the IME notices to the assignor and her attorney, and the provider raised no triable issue as to their mailing.
Of the 151 decisions on this question in the First Department courts and the Court of Appeals, 104 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.
Cited in this decision
A label shows how this decision treated the case it cites.
- American Tr. Ins. Co. v Lucas (2013 NY Slip Op 07273) FollowedFailure to attend duly scheduled IMEs voids the policy ab initio and permits retroactive denial of claims regardless of denial timeliness.
- Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 09604)An insurer may deny benefits retroactively to the date of loss for failure to attend reasonably required IMEs under 11 NYCRR 65-1.1.
- Easy Care Acupuncture P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51524(U))An insurer may request IMEs before a provider submits claim forms under 11 NYCRR 65-1.1.
- Inwood Hill Med., P.C. v General Assur. Co. (2005 NY Slip Op 25437)An injured person's failure to attend reasonably requested IMEs breaches a condition precedent to no-fault coverage.
- Harmonic Physical Therapy v Encompass Home & Auto Ins. Co. (2015 NY Slip Op 50733(U))The insurer proved the assignor's IME nonappearance through sworn statements based on personal knowledge of office practices and policies.
- Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC (2011 NY Slip Op 01948) FollowedAn assignor's failure to attend required IMEs permits retroactive denial of no-fault claims regardless of denial timeliness.
Cited by
A label shows how the later decision treated this one.
- Alsaad Med., P.C. v State Farm Mut. Auto. Ins. Co. (2021 NY Slip Op50532(U)) FollowedA provider's failure to attend duly scheduled EUOs defeats coverage even when the insurer's denial is untimely.
- Mapfre Ins. Co. of N.Y. v Manoo (2016 NY Slip Op 04446)EUO requests made before receipt of a claim form are not subject to the verification notice requirements of 11 NYCRR 65-3.5 and 65-3.6.
Similar decisions
- S.A. Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50953(U))The insurer's examining professionals' affidavits established the assignor's IME nonappearances through personal knowledge of office practices.
- MRJA Radiology, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51381(U))The insurer established the assignor's IME nonappearance through the scheduled physician's affirmation and the scheduler employee's affidavit.
- Alpha Acupuncture, P.C. v Hertz Claim Mgt. Corp. (2014 NY Slip Op 51515(U))An assignor's failure to attend a duly scheduled IME permits denial of all claims from the date of loss despite late denials or earlier grounds.
- Park Slope Med. v Praetorian Ins. Co. (2011 NY Slip Op 52062(U))An assignor's appearance at a duly scheduled IME is a condition precedent to the insurer's liability under the policy.
- MDJ Med., P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50895(U))The insurer proved timely mailing of IME and EUO notices and the assignor's repeated nonappearances.