Trial court, Fourth Department
Jun 13, 2011
2011 NY Slip Op 51194(U)
Split result
The insurer's orthopedic IME report failed to rebut medical necessity because its conclusion lacked a factual basis and medical rationale. At a nonjury trial conducted on stipulated documents and argument, the City Court of Buffalo dismissed the first, sixty-seventh, and 159th causes of action because the provider offered no proof of claim transmission. For the remaining claims, the parties stipulated to the provider's prima facie case and timely denials, and the court awarded the provider judgment. The orthopedic surgeon was qualified to evaluate chiropractic necessity, but the statement that chiropractic treatment would have no value did not address generally accepted professional standards. Despite a physical examination and extensive report, the opinion was conclusory and insufficient to rebut the presumption of medical necessity.
Trial court, Fourth Department
Sep 24, 2009
2009 NY Slip Op 29438
Provider prevailed
Service on the Superintendent of Insurance in Albany confers personal jurisdiction over consenting insurers in Buffalo City Court. Two providers served their assigned no-fault complaints through the Superintendent under Insurance Law § 1212. The insurers argued that service outside Erie County and adjoining counties violated the territorial limits of New York Constitution, article VI, § 1 (c). The County Court, Erie County, held that the insurers' required powers of attorney constituted advance consent to that service and contractually waived the territorial restriction. Insurance Law § 1212 (b) deems such service made within any state court's territorial jurisdiction. The court reversed both dismissal orders and remanded the actions, allowing the providers to proceed.
Trial court, Fourth Department
Jan 21, 2009
2009 NY Slip Op 29066
Provider prevailed
The insurers' express consent validated service on the Superintendent of Insurance beyond Buffalo City Court's territorial limits. The City Court, Buffalo, denied the insurers' CPLR 3211 (a) (8) motions to dismiss seven assigned no-fault actions. The providers served the Superintendent in Albany or New York City under Insurance Law § 1212. Although New York Constitution, article VI, § 1 (c) limits city-court process geographically, the foreign insurers expressly agreed to service on the Superintendent as a condition of doing business in New York. Following Pohlers v Exeter Mfg. Co. and applying Uniform City Court Act §§ 403 and 404, the court found that consent sufficient to confer personal jurisdiction.
Trial court, Second Department
Oct 31, 2008
2008 NY Slip Op 28434
Provider prevailed
A provider may obtain relevant medical records from an insurer upon supplying a valid assignment or authorization for disclosure. The radiology provider moved under CPLR 3124 to compel records concerning the scanned body parts and IME and peer-review reports. The insurer had produced its peer review and the materials reviewed, arguing that additional records could not prove the provider's prima facie case or be used by the insurer at trial. Applying CPLR 3101 (a), the City Court, Poughkeepsie, found the requested material could rebut the medical-necessity defense or assist cross-examination. Because no assignment was on file, it granted the motion conditioned on the insurer's receipt of the assignor's valid authorization.
Trial court, Third Department
Feb 11, 2008
2008 NY Slip Op 50729(U)
Provider prevailed
The insurer was denied summary judgment on a claim filed two days late, as the excuse for the delay was not unreasonable as a matter of law. The injured claimant filed the no-fault claim 32 days after the accident, following a meeting with counsel on the 30th day. Counsel attributed the additional two days to a work backlog. The City Court, Kingston, denied the insurer's motion to dismiss the action. It considered the brief delay and proffered excuse in light of the No-Fault Law's purpose and the justification provision in 11 NYCRR 65-1.1. The insurer's denial also failed to advise the claimant of the right to provide written justification, as required by 11 NYCRR 65-3.3 (e).
Trial court, Fourth Department
Jun 27, 2006
2006 NY Slip Op 51242(U)
Split result
The insurer's untimely denial precluded medical-necessity and fee-schedule defenses, but an unlicensed billing entity remained ineligible. The City Court, Buffalo, granted the treating physician summary judgment and granted the insurer summary judgment against the facility entity, which proved no claim submission, and the billing entity, whose lack of licensing was established through official website records under 11 NYCRR 65-3.16 (a) (12). Assignment objections were waived. The insurer proved neither timely denial nor verification tolling, and its peer review also lacked adequate rationale. Although fee limits under Insurance Law § 5108 (a) could not reduce recovery, charges exceeding the schedule without unique circumstances barred attorney's fees under 11 NYCRR 65-4.6 (i). The physician recovered unpaid benefits with statutory interest; possible cure of the entity's licensing defect remained unaddressed.
