[*1]

Goldberg, Miller & Rubin, P.C., New York (Harlan R. Schreiber of counsel), for appellant.

Slotnick & Ashkenazy, LLP, Rockville Centre (Howard J. Stern of counsel), for respondent.

Order, Supreme Court, New York County (Lynn R. Kotler, J.), entered on or about August 1, 2019, which, in this action pursuant to Insurance Law § 5106 (c) for de novo review of a master arbitrator’s award, denied plaintiff insurer’s motion for summary judgment declaring it has no obligation to pay no-fault benefits to defendant medical provider, and granted defendant’s cross motion for summary judgment confirming the arbitration award, unanimously reversed, on the law, without costs, to grant plaintiff’s motion and to deny defendant’s cross motion. The Clerk is directed to enter judgment declaring in plaintiff’s favor.

Plaintiff insurer’s evidence, including affidavits attesting in detail to the regular business procedures and practices in the handling of its no-fault claims, including providing notice of scheduled IME exams to claimants, together with the mailing ledgers, which were signed and date-stamped by U.S. Postal Service employees, and listed therein IME notices received for mailing to the claimant here at his resident address, provided sufficient proof of proper mailing to support a presumption that the IME notices were received by the claimant (see Badio v Liberty Mut. Fire Ins. Co., 12 AD3d 229 [1st Dept 2004]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2d Dept 2001]). Although the notices incorrectly added the designation “1st Floor” to the address, there is no dispute that the address was otherwise correct and that claimant resided at that building (see Cadle Co. v Tri-Angle Assoc., 18 AD3d 100 [1st Dept 2005]).

The burden on the motion having shifted, defendant failed to offer any evidence in opposition, such as an affidavit from the claimant disavowing receipt of the IME notices or even describing the building composition in a manner that would support an inference that the inclusion of a floor in the address would result in nonreceipt. Plaintiff thus established that the injured claimant failed to appear for three properly scheduled IMEs, constituting breach of a condition precedent to no-fault coverage, warranting the denial of defendant’s claims to no-fault benefits for its medical services rendered to the claimant (see 11 NYCRR 65-1.1; Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559 [1st Dept 2011], lv denied 17 NY3d 705 [2011]). Concur—Kapnick, J.P., Mazzarelli, Moulton, Mendez, JJ.

[*1]

Goldberg, Miller & Rubin, P.C., New York (Eli Shmulik of counsel), for appellant.

The Rybak Firm, PLLC, Brooklyn (Maksim Leyvi of counsel), for respondents.

Order, Supreme Court, New York County (Lynn R. Kotler, J.), entered on or about December 10, 2019, which denied as premature plaintiff’s motion for summary judgment declaring that it is not obligated to reimburse defendants-respondents for no-fault claims submitted in connection with a motor vehicle accident, unanimously affirmed, without costs.

Plaintiff no-fault insurer failed to provide the injured claimant’s assignees with the “specific objective justification” for its request that the injured claimant submit to an examination under oath (EUO) to establish proof of claim (11 NYCRR 65-3.5 [e]; see American Tr. Ins. Co. v Jaga Med. Servs., P.C., 128 AD3d 441 [1st Dept 2015]). As the criteria by which plaintiff determined that an EUO was required constitute facts unavailable to defendants for use in opposing plaintiff’s motion, the motion was premature (CPLR 3212 [f]). Moreover, as the court noted, plaintiff moved for summary judgment before any depositions had been conducted (see e.g. Blech v West Park Presbyt. Church, 97 AD3d 443 [1st Dept 2012]).

We have considered plaintiff’s remaining contentions and find them unavailing. Concur—Renwick, J.P., Gesmer, Kern, Singh, JJ.

[*1]

The Law Office Jason Tenenbaum, P.C., Garden City (Jason Tenenbaum of counsel), for appellant.

The Law Office of Melissa Betancourt, P.C., Brooklyn (Jamin Koo of counsel), for Longevity Medical Supply Inc., respondent.

Kopelevich & Feldsherova, P.C., Brooklyn (David Landfair of counsel), for Jamaica Wellness Medical, P.C., and LVOV Acupuncture, P.C., respondents.

Order, Supreme Court, Bronx County (Wilma Guzman, J.), entered on or about September 30, 2019, which, to the extent appealed from as limited by the briefs, denied plaintiff’s motion to renew its motion for summary judgment declaring in its favor against defendants Longevity Medical Supply, Inc., Jamaica Wellness Medical, P.C., United Wellness Chiropractic, P.C., and Lvov Acupuncture, P.C., unanimously reversed, on the law, without costs, the motion for renewal granted and, upon renewal, the motion for summary judgment granted. The Clerk is directed to enter judgment declaring that plaintiff owes no coverage to said defendants.

Plaintiff provided a policy of insurance to VIP Limousine & Tuxedo, Inc. (VIP) that included a no-fault endorsement to an insured or eligible person for necessary expenses resulting from a motor vehicle accident. In April 2014, one of VIP’s limousines was hit in the rear by another car. Thereafter, the driver and passengers of the limousine (the individual defendants) filed claims as eligible persons under the policy issued by plaintiff, and later assigned their rights to the no-fault benefits to various medical providers (medical provider defendants).

Plaintiff moved for summary judgment, asserting that the accident was staged and therefore, none of the individual defendants or the medical provider defendants were entitled to benefits under the policy. Supreme Court denied the motion, finding that plaintiff failed to demonstrate as a matter of law that the accident was fraudulently or intentionally procured.

Plaintiff moved to renew its prior motion for summary judgment. In support of its motion to renew, plaintiff submitted additional evidence that the accident was staged in the form of a videotape confession by one of the passengers, which it had procured, after extensive motion practice, from the Police Department, Department of Financial Services, Insurance Fraud Bureau (DFS), and Kings County District Attorney’s Office. Supreme Court denied renewal on the grounds that plaintiff failed to offer any reasonable explanation as to why the videotape could not have been attached to its prior motion, and that the videotape was not properly authenticated for purposes of summary judgment.

Plaintiff appealed. We now reverse finding that renewal should have been granted in the interests of justice and substantive fairness (see Ross v Lewis, 181 AD3d 423, 424 [1st Dept 2020]; Cruz v Bronx Lebanon Hosp. Ctr., 73 AD3d 597, 598 [1st Dept 2010]; Rancho Santa Fe Assn. v Dolan-King, 36 AD3d 460, 461 [1st Dept 2007]). “Although it is true that a motion to renew should generally be based upon newly-discovered facts, this rule is not inflexible, and the court has discretion to grant renewal in the interest of justice even upon facts that were known to the movant at the time the original motion was made” (Kaszar v Cho, 160 AD3d 501, 502 [1st Dept 2018]).

Here, plaintiff demonstrated that the additional evidence it submitted in support of its motion to renew would change the prior determination and that it was required to engage in extensive motion practice to obtain the material. Plaintiff also established that it was unaware of the nature and extent of the information held by those agencies before then (CPLR 2221 [e] [2], [3]). The material, which included statements by the passengers who assigned their claims to defendants, proves that the motor vehicle accident was staged (see Matter of Global Liberty Ins. Co. of N.Y. v Eveillard, 171 AD3d 749, 750-751 [2d Dept 2019]; CPLR 2221 [e]).

Contrary to defendants’ contentions, the videotape of the confession of one of the defendants who participated in the scheme and the statements others provided to the police and DFS are admissible as party admissions (see People v Soto, 26 NY3d 455, 461 [2015]; People v Caban, 5 NY3d 143, 150-151 n [2005]). Plaintiff demonstrated the authenticity of this material by proof of the complete chain of custody (see People v Price, 29 NY3d 472, 481-482 [2017]).

Defendants failed to submit any evidence controverting plaintiff’s proof that the accident was staged. Concur—Kapnick, J.P., Singh, Kennedy, Mendez, JJ.

[*1]

Goldberg, Miller & Rubin, P.C., New York (Timothy R. Bishop of counsel), for appellant.

Order, Supreme Court, New York County (Barbara Jaffe, J.), entered December 20, 2018, which denied plaintiff’s motion for summary judgment declaring that defendants JS Medical, P.C. and Wert Specialty Orthopedics, P.C. (together, defendants) have no right to collect no-fault benefits from plaintiff with respect to the subject accident, and granted defendants’ cross motion for summary judgment to the extent of dismissing the complaint as against JS, unanimously reversed, on the law, without costs, plaintiff’s motion granted and defendants’ motion denied, and it is declared that defendants have no right to collect said no-fault benefits.

The claimants’ failure to subscribe and return the transcripts of their examinations under oath (EUOs) violated a condition precedent to coverage and warranted denial of the claims (see Hereford Ins. Co. v Forest Hills Med., P.C., 172 AD3d 567 [1st Dept 2019]). This is so notwithstanding plaintiff’s failure to present proof of proper delivery of the denials (see Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559, 560 [1st Dept 2011], lv denied 17 NY3d 705 [2011]). Plaintiff is entitled to summary judgment on the additional ground that defendants failed to appear at two scheduled EUOs (see Hertz Vehs. LLC v Significant Care, PT, P.C., 157 AD3d 600 [1st Dept 2018]; Mapfre Ins. Co. of N.Y. v Manoo, 140 AD3d 468 [1st Dept 2016], appeal withdrawn 29 NY3d 995 [2017]). Considering the brevity of the delay and JS’s ultimate failure to appear, we find that plaintiff’s “one-day tardiness in issuing its follow-up request for the EUO scheduled for” JS was “a technical defect excusable under 11 NYCRR 65-3.5 (p)” (Z.M.S. & Y. Acupuncture, P.C. v Geico Gen. Ins. Co., 56 Misc 3d 926, 930 [Civ Ct, Kings County 2017]). Concur—Friedman, J.P., Renwick, Gische, Mazzarelli, Moulton, JJ.

Plaintiff appeals from an order of the Civil Court of the City of New York, New York County (Judy H. Kim. J.), entered April 18, 2019, which granted defendant’s motion to vacate so much of the judgment as awarded plaintiff attorneys’ fees pursuant to 11 NYCRR § 65-4.6(c).

Per Curiam.

Order (Judy H. Kim, J.), entered April 18, 2019, affirmed, with $10 costs.

Upon the trial of this action, the court determined that plaintiff-provider established its entitlement to no-fault benefits in the amount of $4,590.72 and that defendant-insurer failed to establish its independent medical examination (IME) no-show defense. This determination is not challenged on appeal. The issue before us is whether plaintiff, who is entitled to attorneys’ fees pursuant to the governing Insurance Department Regulations (see 11 NYCRR § 65-4.6), is entitled to said fees pursuant to the standard fee provision contained 11 NYCRR § 65-4.6(d), which limits attorneys’ fees to 20% of the amount recovered, subject to a then-maximum fee of $850 (now $1,360), or pursuant to the hourly rate fee provision contained in 11 NYCRR § 65-4.6(c). Civil Court held that the standard fee provision contained in section 65-4.6(d) applies in this case. We agree, and therefore affirm.

The hourly rate fee provision contained in 11 NYCRR § 65-4.6(c) governs disputes where “one of the issues involves a policy issue as enumerated on the prescribed denial of claim form(NYS form NF-10)” (emphasis added). However, the “policy issues” enumerated on the denial of claim form at bar are clearly limited to include only: (1) the policy was not in force on the date of the accident (box 3); (2) the injured person is excluded under policy conditions or exclusion (box 4); (3) the policy conditions were violated, which is limited to two categories involving late submission of a notice of claim (box 5); (4) the injured person is not an eligible injured person (box 6); (5) and the injuries did not arise out of use or operation of a motor vehicle (box 7).

The language of 11 NYCRR § 65-4.6(c) and the specifically enumerated policy issues on the denial of claim form are clear and unambiguous; patently they do not include the assignor’s [*2]failure to attend an IME. Therefore, plaintiff was not entitled to hourly attorneys’ fees pursuant to 11 NYCRR 65-4.6(c). Since the standard fee provision applies to “all other disputes” (11 NYCRR § 65-4.6[d]), it was properly applied in this case.

Plaintiff’s arguments to the contrary do not warrant a different result. While the failure to attend an IME “is a breach of a condition precedent to coverage under the no-fault policy” (Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559, 560 [2011], lv denied 17 NY3d 705 [2011]), it is not a “policy issue as enumerated on the prescribed denial of claim form” (11 NYCRR § 65-4.6[c]). Nor is defendant’s characterization of its defense as a policy issue dispositive. Construing the regulation strictly, as we must since it is in derogation of the common law rule that parties to a controversy pay their own counsel fees (see McKinney’s Cons Laws of NY, Book 1, Statutes, § 301[a]; Matter of A.G. Ship Maintenance Corp. v Lezak, 69 NY2d 1, 5 [1986]), hourly attorneys’ fees are allowable where one of the specifically enumerated policy issues is involved, not whether one party designates a particular defense as a policy issue.

The opinion letters issued by Department of Financial Services (DFS) relied upon by plaintiff do not interpret the counsel fees regulation at issue. Nor did DFS explicitly state, in interpreting its own regulations, that the failure of the assignor to appear for an IME constitutes a “policy violation” so as to trigger additional attorneys’ fees under Insurance Department Regulations (11 NYCRR § 65-4.6[c]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.

[*1]

Law Office of Jason Tenenbaum, P.C., Garden City (Jason Tenenbaum of counsel), for appellant.

Fazio, Rynsky & Associates, LLP, Syosset (Svetlana Sobel of counsel), for respondent.

Order, Supreme Court, Bronx County (Donna Mills, J.), entered April 16, 2019, which denied the petition to vacate a master arbitrator’s award, unanimously reversed, on the law, without costs, and the petition granted.

The master arbitrator’s award was arbitrary in that it irrationally ignored well-established precedent that “the no-fault policy issued by petitioner was void ab initio due to respondent’s assignor’s failure to attend duly scheduled independent medical exams” (Matter of Global Liberty Ins. Co. of N.Y. v Top Q. Inc., 175 AD3d 1131, 1131 [1st Dept 2019]; see Matter of Global Liberty Ins. Co. v Professional Chiropractic Care, P.C., 139 AD3d 645, 646 [1st Dept 2016]; Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559, 560 [1st Dept 2011], lv denied 17 NY3d 705 [2011]). Concur—Renwick, J.P., Gische, Kern, Singh, JJ.

Defendant appeals from so much of an order of the Civil Court of the City of New York, Bronx County (Naita A. Semaj, J.), entered April 2, 2019, that denied, in part, its motion for summary judgment dismissing the complaint.

Per Curiam.

Order (Naita A. Semaj, J.), entered April 2, 2019, insofar as appealed from, reversed, without costs, motion granted, and the complaint dismissed. The Clerk is directed to enter judgment accordingly.

The defendant insurer made a prima facie showing of entitlement to judgment as a matter of law dismissing the underlying first-party no-fault action. The proof submitted by defendant, including the affirmed peer review report of its physician, set forth a factual basis and medical rationale for the conclusion that the medical supplies plaintiff provided to its assignor, including a portable whirlpool, heat lamp and massager, were not medically necessary (see Triangle R Inc. v New York Cent. Mut. Fire Ins. Co., 32 Misc 3d 143[A], 2011 NY Slip Op 51663[U] [App Term, 1st Dept 2011]). The report explained that the assignor was already receiving physical, acupuncture and chiropractic therapy for her injuries and that the equipment at issue was either unnecessary or redundant (see Enko Enters. Intl., Inc. v Clarendon Natl. Ins. Co., 30 Misc 3d 127[A], 2010 NY Slip Op 52267[U] [App Term, 1st Dept 2010]).

Plaintiff’s opposition, consisting of an attorney’s affirmation, prescription and various claim forms, was unaccompanied by any medical evidence or other competent proof of medical necessity, and failed to raise a triable issue (see TC Acupuncture, P.C. v Tri-State Consumer Ins. Co., 52 Misc 3d 131[A], 2016 NY Slip Op 50978[U] [App Term, 1st Dept 2016]; Karina K. Acupuncture, P.C. v AIG Centennial Ins. Co., 51 Misc 3d 132[A], 2016 NY Slip Op 50415[U] [App Term, 1st Dept 2016]; Cortland Med. Supply, Inc. v 21st Century Centennial Ins. Co., 46 Misc 3d 136[A], 2014 NY Slip Op 51886[U] [App Term, 1st Dept 2014]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.

[*1]

Gary Tsirelman, P.C., Brooklyn (Stefan M. Belinfanti of counsel), for appellant.

Bruno, Gerbino & Soriano, LLP, Melville (Nathan M. Shapiro of counsel), for respondent.

Rivkin Radler, LLP, Uniondale (Barry I Levy of counsel), for amici curiae.

Order, Appellate Term, First Department, entered January 2, 2018, which reversed an order of the Civil Court, New York County (Erika M. Edwards, J.), entered on or about November 30, 2016, denying the petition to vacate a master arbitrator’s award and confirming the award, and remanded the matter to Civil Court for a framed issue hearing on whether the policy limit was exhausted before petitioner became obligated to pay respondent’s claims, unanimously affirmed, without costs.

Generally, courts will not set aside an award where “there is a rational view to support it” (Country-Wide Ins. Co. v May, 282 AD2d 298, 298 [1st Dept 2001]; see also Matter of Carty v Nationwide Ins. Co., 212 AD2d 462 [1st Dept 1995]). However, in addition to irrationality, an award may be vacated if the arbitrator exceeds his or her power (see CPLR 7511 [b] [1] [iii]). An arbitrator exceeds his/her power if the award is “beyond the policy limits” (Matter of Brijmohan v State Farm Ins. Co., 92 NY2d 821, 823 [1998]; see also e.g. Countrywide Ins. Co. v Sawh, 272 AD2d 245 [1st Dept 2000]).

Respondent contends that its claims were complete before the policy issued by petitioner was exhausted. This argument is unavailing. The Court of Appeals has interpreted the word “claims” in 11 NYCRR 65-3.15 to mean “verified claims” (Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294, 300 [2007]), i.e., claims as to which the healthcare provider has submitted additional information requested by the insurer (see id. at 297-298, 300-301). Petitioner requested verification in the form of an examination under oath (EUO). Since respondent never appeared for an EUO, its claims were never verified. The defense that an award exceeds an arbitrator’s power is so important that a party may introduce evidence for the first time when the other party tries to confirm the award (see Brijmohan, 92 NY2d at 822-823).

Respondent may also raise on appeal the purely legal argument that Appellate Term lacked the power to remand to Civil Court for a framed issue hearing (see generally Branham v Loews Orpheum Cinemas, Inc., 31 AD3d 319, 323 n 2 [1st Dept 2006], affd 8 NY3d 931 [2007]). On the merits, however, this argument is unavailing (see Allstate Prop. & Cas. Ins. Co. v Northeast Anesthesia & Pain Mgt., 51 Misc 3d 149[A], 2016 NY Slip Op 50828[U] [App Term, 1st Dept 2016]; Allstate Ins. Co. v DeMoura, 30 Misc 3d 145[A], 2011 NY Slip Op 50430[U] [App Term, 1st Dept 2011]).

In view of the foregoing, respondent is not entitled to the attorneys’ fees it requested. Concur—Gische, J.P., Mazzarelli, Webber, Gesmer, JJ. [Prior Case History: 58 Misc 3d 144(A), 2017 NY Slip Op 51911(U).]

[*1]

Gary Tsirelman, P.C., Brooklyn (Gary Tsirelman of counsel), for appellant.

Jaffe & Velazquez, LLP, New York (Jean H. Kang of counsel), for respondent.

Judgment, Supreme Court, New York County (Lynn R. Kotler, J.), entered November 30, 2018, awarding respondent attorney’s fees in the sum total of $980 in connection with a no-fault arbitration award, unanimously modified, on the law, to remand the matter to Supreme Court for a determination of respondent’s reasonable attorney’s fees incurred in the CPLR article 75 proceeding brought by petitioner to vacate the arbitration award and on this appeal, and otherwise affirmed, without costs.

“The attorney’s fee for services rendered . . . in a court appeal from a master arbitration award and any further appeals, shall be fixed by the court adjudicating the matter” (11 NYCRR 65-4.10 [j] [4]). The term “court appeal” applies to a proceeding taken pursuant to CPLR article 75 to vacate or confirm a master arbitration award (see Matter of GEICO Ins. Co. v AAAMG Leasing Corp., 148 AD3d 703, 705 [2d Dept 2017]). Accordingly, respondent TC Acupuncture, as a prevailing applicant for payment by petitioner insurer of attorney’s fees in an article 75 proceeding reviewing an arbitration award, is entitled to an additional award of attorney’s fees, as fixed by the court, for its motion to modify the order, in a 2015 article 75 proceeding denying Countrywide’s petition to vacate the arbitration award, to include a ruling confirming the arbitration and its opposition to Countrywide’s motion to reargue that order. Supreme Court erred in failing to award these additional fees.

Respondent is also entitled to the attorney’s fees incurred in this appeal to this Court of the order issued in the article 75 proceeding, to be fixed by the court, upon remand, pursuant to 11 NYCRR 65-4.10 (j) (4) (see Matter of Country-Wide Ins. Co. v Bay Needle Care Acupuncture, P.C., 162 AD3d 407, 408 [1st Dept 2018]). Concur—Richter, J.P., Gische, Mazzarelli, Gesmer, JJ.

[*1]

The Law Office of Jason Tenenbaum, P.C., Garden City (Talia Beard of counsel), for appellant-respondent.

Gary Tsirelman, P.C., Brooklyn (Gary Tsirelman of counsel), for respondents-appellants.

Order, Supreme Court, Bronx County (Donna Mills, J.), entered February 1, 2019, which granted respondents’ motion to vacate, pursuant to stipulation, an order entered on default vacating an arbitration award, deny the petition to vacate the award, and grant statutory attorneys’ fees, to the extent of dismissing the petition, unanimously modified, on the law, to remand for a determination of respondents’ attorneys’ fees pursuant to 11 NYCRR 65-4.10 (j) (4), and otherwise affirmed, without costs.

Petitioner failed to establish that respondents’ assignor was injured in the course of his employment, and therefore that it properly denied his claim because workers’ compensation benefits were available to him (see Westchester Med. Ctr. v American Tr. Ins. Co., 60 AD3d 848, 849 [2d Dept 2009]). Although the assignor was allegedly injured while driving a livery car, his license from the New York Taxi and Limousine Commission was issued that day. Further, petitioner submitted no evidence that the assignor was on duty or carrying a paying passenger at the time of the incident (cf. Matter of Aminov v New York Black Car Operators Injury Compensation Fund, 2 AD3d 1007, 1007-1008 [3d Dept 2003], lv denied 4 NY3d 709 [2005]).

Supreme Court had the authority to award attorneys’ fees in connection with a “court appeal from a master arbitration award and any further appeals” (11 NYCRR 65-4.10 [j] [4]). Because the court failed to address respondents’ request for attorneys’ fees, the matter is remanded for a determination of the amount of fees to which respondents are entitled (see Matter of GEICO Ins. Co. v AAAMG Leasing Corp., 148 AD3d 703 [2d Dept 2017]), including fees for the instant appeal (see Matter of Country-Wide Ins. Co. v Bay Needle Acupuncture, P.C., 167 AD3d 404, 405 [1st Dept 2018]). Concur—Richter, J.P., Manzanet-Daniels, Webber, Gesmer, JJ.