8 decisions · 1 Appellate Division · 7 trial courts
Issues this month: Medical necessity 3 MVAIC 2 Discovery and procedure 2 Defaults and vacatur 1 Fraudulent incorporation (Mallela) 1 Provider's prima facie case 1
MVAIC's motion to vacate a default order compelling judgment payment was granted upon a sufficient excuse and meritorious defense. The Appellate Division, Second Department, reversed and vacated the order granting the claimant's petition under Insurance Law § 5210. It found counsel's explanation substantiated under CPLR 2005 and a meritorious defense under Insurance Law § 5208 (a) (3), satisfying CPLR 5015 (a) (1).
The insurer's timely medical-necessity denial was ineffective because it rested on a nurse's opinion. The provider sought summary judgment for unpaid MRI services and established submission of its claim. Applying 11 NYCRR 65-3.8 (b) (4) and Abraham v Country-Wide Insurance Company, the court treated a nurse's medical opinions as incompetent and inadmissible. The insurer failed to establish lack of medical necessity through a medical examination or peer review and was precluded from asserting that defense despite its timely denial. The District Court, Nassau County, granted the provider summary judgment with statutory interest and attorney fees; it did not reach the insurer's other issues.
The provider's assignment did not authorize disclosure of the insurer's entire no-fault file under HIPAA. The District Court, Nassau County, granted the insurer's CPLR 3103 (a) protective-order motion in part. Finding the insurer a covered entity under 45 CFR 160.103, the court required a valid authorization under 45 CFR 164.508 (a) (1) and (c) for full-file review, subject to privileged and protected material. The assignment and NF-2 did not suffice. Under CPLR 3121 (a), however, the assignor placed the condition in controversy as to the billed services. The provider therefore obtained disclosure of all materials concerning the alleged concurrent treatment. The insurer was directed to produce those materials within 30 days or face preclusion of their use at trial, including through expert testimony.
An insurer cannot recoup payments solely for an alleged violation of Business Corporation Law § 1503 (a) without a private right of action. The Supreme Court, Otsego County, granted the providers' dismissal and summary judgment motions against fraud and unjust enrichment claims concerning medical corporations' employment of licensed acupuncturists. The fraud allegations satisfied CPLR 3016 (b), but the insurer alleged no substantive injury apart from the statutory violation. The services were performed, and equity did not require repayment. The court left open whether the employment arrangement was unlawful. It also granted the insurer summary judgment dismissing one provider's counterclaim because it failed to specify when services were provided, whether they were billed, or their reasonable value.
A provider's substantive challenge to an unsworn peer review permits the insurer to rely on that report in opposition to summary judgment. The Civil Court, Kings County, granted the insurer reargument and denied the provider's summary judgment motion. Applying evidentiary principles from serious-injury motions under Insurance Law § 5102 (d), the court distinguished affirmative reliance from merely mentioning or submitting a document. The provider challenged the review's conclusions through another peer review, even though it omitted the disputed report itself. Reliance for refutation opened the door to the insurer's use of the report. Although the insurer's business-record foundation was insufficient, the report was properly before the court and supplied a factual basis and medical rationale raising a triable medical-necessity issue.
The insurer's timely denials failed to preserve a medical-necessity defense because they lacked a sufficient factual basis and medical rationale. The denials stated that the provider had failed to substantiate necessity and relied on a peer review identifying missing clinical information. The insurer never requested additional verification. Applying Insurance Law § 5106 (a) and 11 NYCRR 65-3.5 (a), the Civil Court, Kings County, found that the report could support a verification request but did not establish lack of medical necessity. The denial language improperly shifted the initial burden to the provider and failed to fully explain the denial reasons. The court precluded the defense and awarded the provider judgment with statutory interest and attorney's fees.
MVAIC is not entitled to offset a settlement paid on behalf of insured parties exonerated from responsibility for the accident. The Supreme Court, New York County, granted the injured claimant's motion determining that MVAIC could not reduce its statutory liability limits by a $25,000 settlement. A jury had found that the insured vehicle's owner and operator were not involved in the hit-and-run accident; the settlement agreement provided payment even if they prevailed. Following White v Ramirez, the court applied Insurance Law § 5210 (b) (2) to payments from parties adjudged jointly or severally liable, rather than merely alleged to be liable. Although the court acknowledged MVAIC's public-policy objection, it concluded that any change belonged to the Legislature.
A provider may join multiple claims against one insurer under CPLR 601 (a), even if the claims are unrelated. The provider sought unpaid benefits assigned by 36 accident victims, alleging breaches of no-fault insurance contracts under Insurance Law § 5106 (a). The insurer sought severance under CPLR 603 and dismissal. The Supreme Court, Kings County, denied the motion, finding common legal questions under the insurance contracts and no persuasive showing of logistical prejudice or jury confusion. Following Hempstead General Hospital v Liberty Mutual, the court upheld joinder despite separate accidents and assignors. It also rejected dismissal based on the amounts of individual claims because Supreme Court has no minimum monetary threshold for subject matter jurisdiction.
Headnotes, outcome labels and monthly summaries are our own summaries, not the courts’ words; the decision itself is the authority. Months follow the date a decision was handed down; new decisions are added monthly, so a recent month can still grow.