Appellate Division, First Department
Feb 29, 2024
2024 NY Slip Op 01114
Insurer prevailed
The pharmacy's arbitration loss was upheld because non-electronic prescriptions failed to satisfy statutory requirements. The Appellate Division, First Department, affirmed denial of the pharmacy's petition to vacate the master arbitrator's award favoring the insurer. Evidence supported noncompliance with Public Health Law § 281 (3) and Education Law § 6810; the award was neither irrational nor contrary to settled law. Under Mallela, omission of a defense from the mandatory endorsement in 11 NYCRR 65-1.1 (d) did not itself invalidate it. The pharmacy's oral-prescription arguments were rejected, with no indication they had been presented to either arbitrator. Default relief was also rejected because it had not been sought and the service affidavit failed to recite service of the documents required by CPLR 312-a (a).
Appellate Division, Second Department
Feb 7, 2024
2024 NY Slip Op 00646
The Workers' Compensation Board has primary jurisdiction over coverage issues concerning accident-related medical expenses and compensability. The no-fault insurer sought reimbursement from the workers' compensation carrier through an unjust-enrichment subrogation action. The Board had directed the carrier to pay for necessary treatment. Having sought neither review nor reopening of the compensation hearing, the no-fault insurer failed to establish that it lacked recourse before the Board under Workers' Compensation Law § 142 (7), 12 NYCRR 300.13 (a) (4), 12 NYCRR 300.13 (b) (2) (iv) and 12 NYCRR 300.14 (a). The Appellate Division, Second Department, reversed dismissal under CPLR 3211 (a) (2) and remitted to Supreme Court, Queens County, for redetermination after final resolution of a prompt Board application; the carrier's remaining contention was not properly before the appellate court.
Appellate Division, First Department
Feb 6, 2024
2024 NY Slip Op 00599
Insurer prevailed
The provider's petitions failed because policy-exhaustion awards were rational and its wage-offset argument was unavailing. The Appellate Division, First Department, affirmed denial of two CPLR article 75 petitions challenging master arbitration awards denying benefits. Following First Department rather than contrary Second Department precedent did not warrant vacatur, because an insurer's obligations cease upon payment of the contractual policy limit. The provider could first raise in its petitions the argument that the insurers twice took the 20 percent wage offset, against gross wages and policy limits. That argument failed because Insurance Law § 5102 (b) permits deducting 20 percent of lost earnings and specified other setoffs from first-party benefits. As the provider did not prevail, attorney fees under 11 NYCRR 65-4.10 (j) (4) were denied.
Appellate Term, Second Department
Feb 16, 2024
2024 NY Slip Op 50202(U)
Split result
MVAIC failed to establish coverage exhaustion because it omitted the dates claims were received and fully verified. In the provider's assigned no-fault action, the Appellate Term, Second Department, modified the order to deny MVAIC's summary judgment motion while affirming denial of the provider's cross motion. MVAIC had to prove that its payments exhausted the available coverage in accordance with 11 NYCRR 65-3.15; the missing dates prevented that showing. The provider also failed to establish that its claims were not timely denied or that timely denials were conclusory, vague, or legally meritless. Neither party obtained summary judgment.
Appellate Term, Second Department
Feb 16, 2024
2024 NY Slip Op 50203(U)
Split result
The insurer failed to prove policy exhaustion because its claim specialist did not lay a sufficient foundation for the payment log. In the provider's assigned-benefits action, the insurer had to show that it paid the policy limits in accordance with 11 NYCRR 65-3.15. Its payment log lacked a sufficient foundation under CPLR 4518 (a), leaving it unable to establish that any listed payments had been made. The provider also failed to establish that its claim had not been timely denied or that a timely denial was conclusory, vague or legally without merit. The Appellate Term, Second Department, modified the order to deny the insurer's summary judgment motion and affirmed denial of the provider's cross motion.
Appellate Term, Second Department
Feb 16, 2024
2024 NY Slip Op 50205(U)
Insurer prevailed
The insurer's delay in answering was excused based on the particular circumstances, lack of willfulness and absence of prejudice. In the provider's assigned-benefits action, the insurer sought to compel acceptance of its late answer under CPLR 3012 (d). Its employee attributed the delay to difficulty connecting the summons and complaint to an inactive policy and claim file, followed by a request that the provider voluntarily discontinue for lack of coverage. The provider rejected the answer as untimely and disputed the excuse. Finding no improvident exercise of discretion in accepting the excuse, the Appellate Term, Second Department, affirmed the order, insofar as appealed from, granting the insurer's motion.
Appellate Term, Second Department
Feb 16, 2024
2024 NY Slip Op 50204(U)
Split result
The insurer's summary judgment motion based on policy exhaustion was denied on appeal. The Appellate Term, Second Department, modified the order and affirmed denial of the provider's cross motion. It relied on the reasons stated in JSJ Anesthesia Pain Mgt., PLLC v Nationwide Ins. Co., the companion appeal decided the same day, No. 2023-655 K C.
