43537/15

For plaintiff:
Oleg Rybak, Esq.
The Rybak Firm PLLC
1810 Voorhies Ave., 3rd Fl, Suite 7
Brooklyn NY 11235

For defendant:
Matteo G. Sandusky, Esq.
Law Offices of Daniel J. Tucker
One Metro Tech Center, 7th Fl
Brooklyn, NY 11201

RECITATION, AS REQUIRED BY CPLR2219(A), OF THE PAPERS CONSIDERED IN THE REVIEW OF THIS MOTION:

Notice of Motion 1

Notice of Cross-Motion 2

Answering Affidavit 3

Reply Affidavit 4

In an action to recover assigned first-party no-fault insurance benefits, plaintiff moves for an order: 1) awarding summary judgment in favor of plaintiff pursuant to CPLR 3211(c) or CPLR 3212(a); 2) limiting the issues of fact for trial pursuant to CPLR 3212(g) that the statutory billing forms were mailed to and received by the insurance carrier and that payment of no-fault benefits was overdue; and 3) dismissing defendant’s affirmative defenses pursuant to CPLR 3211(b). Defendant cross-moves for summary judgment, seeking dismissal on the basis that the plaintiff’s assignor failed to appear for an EUO.

To prevail on its motion, plaintiff has the burden to demonstrate by admissible proof that [*2]the no-fault claim forms underlying the action were submitted to the defendant and that either that defendant had failed to deny the claims within the requisite 30-day period, or that defendant had issued timely denials of the claims that were conclusory, vague or without merit as a matter of law (see Insurance Law section 5106[a]; Westchester Med. Ctr. v. Nationwide Mut. Ins. Co., 78 AD3d 1168, 2010 NY Slip Op. 08933 [App. Div., 2d Dept., 2010]).

In the case at bar, plaintiff did not establish that defendant had failed to deny the claims within the requisite 30-day period, or that defendant had issued timely denials that were conclusory, vague or without merit as a matter of law. Plaintiff’s motion is accordingly, denied.

Defendant, in support of the cross-motion for summary judgement, submits affirmation of Netanel Bencheim, Esq. dated November 20, 2017 which states that the assignor did not appear for an EUO.

Failure to appear for an EUO violates a condition precedent to coverage, and the burden is on defendant to show that the requested party failed to appear (Five Boro Psychological Servs., P.C. v. State Farm Mut. Auto. Ins. Co., 39 Misc 3d 141(A), 2013 NY Slip Op. 50753(U) [App Term, 2d Dept, 2d & 11th Jud Dists, 2013]). Generally, a statement from an attorney alleging that he or she was present in the office on the relevant dates and that he or she would have been the one to conduct the EUO is sufficient to demonstrate personal knowledge of the no-show (T & J Chiropractic, P.C. v. State Farm Mut. Auto. Ins. Co., 47 Misc 3d 130[A], 2015 NY Slip Op. 50406(U) [App Term, 2d Dept, 2d 11th & 13th Jud Dists, 2015]).

In the case at bar, defendant failed to submit competent proof of assignor’s nonappearance. Mr. Bencheim, a shareholder of Bencheim and Associates states that defendant retained his law firm to conduct plaintiff’s EUO which was scheduled to be held on November 30, 2010, and rescheduled to December 29, 2010 due to plaintiff’s nonappearance. Mr. Bencheim states that he has personal knowledge that “the plaintiff did not attend the examination under oath on December 30, 2010″ which is a day after the scheduled date of the examination. As such, defendant failed to establish that plaintiff failed to appear for the examination on the scheduled date of December 29, 2010.

Moreover, Mr. Bencheim states that he has personal knowledge of plaintiff’s non-appearance for the EUO based on his review of the file. The affirmant does not specify or provide the documents he reviewed, or identify the creator(s) of the unspecified documents. Nor does Mr. Bencheim explain the basis of his detailed recollection of assignor’s non-appearance approximately seven years prior to his November 20, 2017 affirmation.

Accordingly, Mr. Bencheim’s affirmation is conclusory and lacks probative value (Utica Acupuncture P.C. v. Amica Mut. Ins. Co., 55 Misc 3d 126(A), 2017 NY Slip Op. 50331(U) [App. Term., 1st Dept., 2017]).

For the foregoing reasons, plaintiff’s motion and defendant’s cross motion are denied as both parties failed to establish entitlement as a matter of law.

Dated: May 17, 2018
ODESSA KENNEDY
Judge of the Civil Court

[*1]

Civil Court of the City of New York, Kings County, February 24, 2018

APPEARANCES OF COUNSEL

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

Jaffe & Koumourdas & Mohavicka, LLP, New York City (Thomas Torto of counsel), for defendant.

Background/History

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved, inter alia, after a final appellate decision in its favor, for additional attorney’s fees pursuant to 11 NYCRR 65-4.6 of “no less than $250,000.00.”

The original order of the Honorable Carolyn Wade, dated March 6, 2009 (2009 WL 10454195 [Civ Ct, Kings County, Mar. 6, 2009, index No. 1208322005]), denied plaintiff’s motion for summary judgment based upon its failure to establish its prima facie case. Subsequently, the decision and order was appealed to the Appellate Term, for the Second, Eleventh and Thirteenth Judicial Districts, which affirmed (31 Misc 3d 21 [2011]). Thereafter, the Appellate Division in Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (114 AD3d 33, 46 [2d Dept 2013]), with two dissenting Justices, reversed, holding,

“(T)he plaintiff established, prima facie, its entitlement to judgment as a matter of law by demonstrating that its prescribed statutory billing forms used to establish proof of claim (see 11 NYCRR 65-1.1) were mailed to and received by the defendant and that the defendant failed to either timely pay or deny the claims (see Insurance Law § 5106; 11 NYCRR 65-3.8 [a] [1]; Westchester Med. Ctr. v Progressive Cas. Ins. Co., 89 AD3d at [*2]1082; Westchester Med. Ctr. v GMAC Ins. Co. Online, Inc., 80 AD3d at 604).”^[FN1]

The Court of Appeals affirmed. (See Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015].){**59 Misc 3d at 581}

Arguments of the Parties Regarding Additional Attorney’s Fees

For context, the court incorporates by reference its prior interim decision and order dated June 2, 2017, and restates relevant portions summarizing the arguments of respective counsel.

Plaintiff argued, inter alia, that as the legal issue of a medical provider’s prima facie showing was an issue that was considered by the Court of Appeals, the same was novel and unique and therefore warrants additional legal fees.

In opposition, defendant contended, inter alia, that plaintiff’s application for attorney’s fees of “no less than $250,000” is beyond this court’s jurisdictional limit, and that nonetheless, plaintiff is not entitled to excess attorney’s fees because the issues in this no-fault action were not novel or complex. For example, in support of its appeal to the Appellate Term, plaintiff’s counsel served and filed a four-page appellant’s brief and when the matter reached the Court of Appeals upon defendant’s appeal of the order of the Appellate Division, the Court of Appeals decision began with established principles encompassing a plaintiff medical provider’s prima facie case and concluded by predicating its conclusion on the admissibility of an affidavit. In short, defendant argued that the issue of evidentiary proof on a summary judgment motion is not novel or unique and that even if plaintiff’s counsel “expended a great deal of ‘time, money and effort’ on this case . . . it is not enough by itself to warrant the award of additional attorney’s fees.”

As to additional attorney’s fees in matters involving a claim for first-party no-fault benefits, 11 NYCRR subpart 65-4, Regulation No. 68-D governs the limitations of the same. The applicable subdivisions read as follows:^[FN2]

“(e) . . . the attorney’s fee shall be limited as follows: 20 percent of the amount of first-party benefits, plus interest thereon, awarded by the arbitrator or court, subject to a maximum fee of $850.

“(f) Notwithstanding the limitations listed in this section, if the arbitrator or a court determines that the issues in dispute were of such a novel or unique{**59 Misc 3d at 582} nature as to require extraordinary skills or services, the arbitrator or court may award an attorney’s fee in excess of the limitations set forth in this section. An excess fee award shall detail the specific novel or unique nature of the dispute which justifies the award.” (11 NYCRR 65-4.6 [emphasis added].)

As was observed in Maxwell v State Farm Mut. Auto. Ins. Co. (115 AD2d 190, 192 [3d Dept 1985]):

“The focus on the excess award determination is not necessarily on the results achieved [*3]but on the issues presented, i.e., whether they are novel and/or unique and necessitate extraordinary efforts on the attorney’s behalf . . . . [In this case] the primary issues were settled on well-established rules of contract law and statutory construction. While counsel is to be commended for his efforts, the fact remains that the issues were not so novel or unique as to justify an excess fee award.”

In Dumlao v State Farm Ins. Co. (173 AD2d 517 [2d Dept 1991]), the Court held that the issue of whether the injury was caused by an accident covered under the policy or whether it resulted from a preexisting arthritic condition was not sufficiently unique to warrant departure from the maximum attorney’s fee provided for under the insurance regulation.

In the instant matter, the issue of whether an affidavit of service from a third-party billing company is sufficient to establish plaintiff medical provider’s prima facie case—i.e., entitlement to reimbursement for assigned first-party no-fault benefits—was ultimately certified by the Appellate Division to the Court of Appeals. Inasmuch as the Court of Appeals accepted the certified question, this court found that the issue presented is sufficiently novel so as to warrant consideration of additional attorney’s fees in accordance with 11 NYCRR 65-4.6.^[FN3]

{**59 Misc 3d at 583}As such, a hearing was warranted to determine additional attorney’s fees. Parenthetically, plaintiff’s counsel’s contention that a comparatively large attorney’s fee for a modest principal award is appropriate based upon Matter of Hempstead Gen. Hosp. v National Grange Mut. Ins. Co. (179 AD2d 645 [2d Dept 1992]) is misplaced. The appropriateness of an increased attorney’s fee in excess of $850 will be determined based upon applicable considerations of a reasonable attorney’s fee (see RMP Capital Corp. v Victory Jet, LLC, 139 AD3d 836, 839 [2016] [“the award of attorneys’ fees, whether pursuant to agreement or statute, must be reasonable and not excessive”]).

In Matter of Rahmey v Blum (95 AD2d 294, 300 [2d Dept 1983]), which is a seminal case on the calculation of a reasonable attorney’s fee, the Court laid out an “analytical framework . . . to aid the courts in computing a reasonable attorney’s fee.” (See also Law Off. of Thaniel J. Beinert v Litinskaya, 43 Misc 3d 1205[A], 2014 NY Slip Op 50504[U] [Civ Ct, Kings County 2014].)

The court in Ousmane v City of New York (22 Misc 3d 1136[A], 2009 NY Slip Op 50468[U], *9-10 [Sup Ct, NY County 2009]) utilized the lodestar method, as elaborated in Rahmey, of determining the reasonableness of awarding attorney’s fees and that methodology is expressed as follows:

“A. Hours Reasonably Expended

“The first step to be taken in arriving at a fair and appropriate award of attorneys’ fees [*4]under the lodestar method is to determine whether the number of hours claimed were reasonably ‘expended from contemporaneous time sheets.’ Becker v. Empire of America Federal Savings Bank, 177 AD2d 958 (4th Dept 1991); see also Rahmey, 95 AD2d at 300-301. The court need not automatically accept inadequately documented hours or those hours which reflect ‘padding, i.e., hours that are excessive or otherwise unnecessary.’ Rahmey, 95 AD2d at 301. The following factors are also to be considered in assessing the reasonable hours worked: the extent to which the hours reflect inefficiency or duplicative work; legal work versus non-legal work, investigations, and other work performed{**59 Misc 3d at 584} by non-lawyers; time spent in court differentiated from out-of-court efforts; and the court’s own knowledge, experience and expertise as to the time required to complete a similar task. Id.; see also Matter of Spingarn, 164 Misc 2d 891, 894 (Sup Ct, NY County 1995).” (Emphasis omitted.)

Regarding the hourly fee charged by counsel making the application for attorney’s fees, the court in Carroll v Weill (2008 NY Slip Op 32512[U], *8 [Sup Ct, NY County 2008, Ramos, J.]) stated,

“To determine the reasonable hourly billing rate, the ‘prevailing market rate’ or the rate ‘prevailing in the community for similar services by lawyers of reasonably comparable skill, experience, and reputation’ applies (Blum v Stenson, 465 US 886, 896 [1984]); Farbotko v Clinton County of N.Y., 433 F3d 204 [2d Cir 2005]).”

While it is well established that “[t]he focus on the excess award determination is not necessarily on the results achieved but on the issues presented, i.e., whether they are novel and/or unique and necessitate extraordinary efforts on the attorney’s behalf” (Maxwell, 115 AD2d at 192), there is scarcely any case law on the determination of an appropriate attorney’s fee award in this specialized field of no-fault law.

In Liebman v New Jersey Mfrs. Ins. Co. (123 Misc 2d 697 [Civ Ct, Bronx County 1984]), the court granted an excess fee award based upon the court granting an hourly rate that was found within the regulations while allowing the jury to determine the number of hours. At the time, the court held that the attorney’s compensation should be $75 per hour for “out of court time” and $150 per hour for “in court time” (Liebman, 123 Misc 2d at 701). Prior to the repealing of the original Regulation No. 68, which implemented New York’s No-Fault Law, in 2001, the provision pertaining to an attorney’s fee, former 11 NYCRR 65.17 (b) (6) (iv) dictated that

“(a) for preparatory services relating to the arbitration forum or court, the attorney shall be entitled to receive a fee of up to $70 per hour . . . and . . .

“(b) in addition, an attorney shall be entitled to receive a fee of up to $80 per hour for each personal appearance before the arbitration forum or court.”

The revised Regulation No. 68-D, effective post April 5, 2002, incredibly, did not change the hourly compensation (former 11{**59 Misc 3d at 585} NYCRR 65-4.6 [d] [1], [2]). Lastly, the sixth amendment to Regulation No. 68, which is not applicable to the services at issue, which revised certain aspects of attorney’s fees, likewise, did not change an hourly compensation rate for the practice of no-fault law (11 NYCRR 65-4.6 [c]). It appears that the hourly compensation rate was largely unchanged albeit modestly increased from $35 per hour for out of court services and $50 per hour for in court services in the late 1970s (11 NYCRR 65.16 [c] [7] [iii] [a], [b]).

However, the statute in effect at the time services were rendered, 11 NYCRR 65-4.6 (f) (the most recent amendment on Feb. 4, 2015, contains virtually the same language found but under subdivision [e] of 11 NYCRR 65-4.6), is clear and unambiguous, and the words “[n]otwithstanding the limitations listed” and “court may award an attorney’s fee in excess of the limitations,” will be given their plain meaning (State of New York v Patricia II., 6 NY3d 160[*5][2006]) and a legal fee based on the usual and customary hourly fees charged by attorneys practicing no-fault law, taking into consideration reasonably comparable skill, experience, and reputation, under a lodestar or quantum meruit standard, will be awarded if at least one of those standards is met.

Although this court in its interim order dated June 2, 2017, determined that it would award “reasonable” attorney’s fees based on the lodestar standard, the court may also make an award under quantum meruit through its inherent authority to do so. (See Beacon Fed. Sav. & Loan Assn. v Marks, 97 AD2d 451 [2d Dept 1983].)

Even where the attorney rate is found to be reasonable, the court may reduce the fee if it finds the amount of time spent rendering legal services was excessive. See Metropolitan Lofts of NY, LLC v Metroeb Realty 1, LLC (46 Misc 3d 1222[A], 2015 NY Slip Op 50251[U], *12 [Sup Ct, Kings County 2015, Demarest, J.]):

“The Court has further determined, however, that a 10% discount is necessitated by the duplication apparent in some of the billing. Although the hourly billing rates are reasonable, the number of hours is found to be excessive (see NYCTL 1996-1 Trust v Stavrinos Realty Corp., 113 AD3d 602, 604-605 [2d Dept 2014]; Kaygreen Realty Co., LLC v IG Second Generation Partners, L.P., 78 AD3d 1008, 1010 [2d Dept 2010]; Friedman v Miale, 69 AD3d 789, 791 [2d Dept 2010]).”

{**59 Misc 3d at 586}Lastly, the court noted that as the attorney’s fees sought are statutory and are not a part and parcel of the principal award, the jurisdictional limit of $25,000 is not applicable (see NY City Civ Ct Act § 201; Metrotran Adv. Trust Fund v Cado Trans., 156 Misc 2d 725 [Civ Ct, Kings County 1993]).

The Court in DeGregorio v Bender (52 AD3d 645, 646 [2d Dept 2008]) summarized the standards:

“In fixing an award of legal fees in quantum meruit, the court should consider ‘evidence of the time and skill required in that case, the complexity of the matter, the attorney’s experience, ability, and reputation, the client’s benefit from the services, and the fee usually charged by other attorneys for similar services’ ” (citing Rosenzweig v Gomez, 250 AD2d 664 [1998]).

The Attorney’s Fee Hearing

The court held an attorney’s fee hearing on September 26, 2017, September 27, 2017, September 28, 2017, and October 3, 2017, pursuant to 11 NYCRR 65-4.6.

Testimony of Max Valerio, Esq. (Plaintiff’s Witness)

The court heard testimony from Max Valerio, Esq., a subpoenaed witness, who testified on behalf of the plaintiff’s counsel that he is a former partner of the law firm and has worked on “hundreds of appeals.” Mr. Valerio estimated that he spent approximately 20 hours doing research and 20 hours writing the four-page brief which was submitted to the Appellate Term. Mr. Valerio had no independent recollection and no contemporaneous time records. Mr. Valerio estimated that he spent 5-10 hours preparing for the Appellate Term argument. Mr. Valerio testified that he also spent 10-20 hours preparing the motion for leave to appeal to the Appellate Division. After the motion was granted, he was involved in drafting the brief which was eventually submitted to the Appellate Division. No one else helped him in researching, writing or editing the brief. Mr. Valerio testified that he “probably” spent 80 hours working on the appellate brief, or a period of approximately two weeks. There was no record on appeal prepared by plaintiff’s counsel inasmuch as the appeal was based on the clerk’s return. Mr. [*6]Valerio testified that he read the opposition brief from the defendant and spent between 10-20 hours working on the reply and two to four hours preparing for oral argument in the Appellate{**59 Misc 3d at 587} Division. Mr. Valerio’s hourly rate in 2005 ranged from $300-$500 per hour depending on the nature of his legal services rendered. There was an argument he made in the Appellate Division which lasted one-half hour.

The court accepts Mr. Valerio’s testimony to the extent that he performed legal services regarding the appeal covering the period up to and including the argument before the Appellate Division, and that he alone worked on the briefs, and that the lowest rate utilized when billing at an hourly rate was $300 per hour, but otherwise finds his testimony generally not credible.

Testimony of David Gottlieb, Esq. (Plaintiff’s Witness)

The court heard testimony from David Gottlieb, Esq., who worked for plaintiff’s counsel in 2010 and has perfected hundreds of appeals in the Appellate Term, and the Appellate Division, First and Second Departments, as well as two appeals in the New York State Court of Appeals. Mr. Gottlieb was on Brooklyn Law School’s Law Review and was admitted in 2005. Mr. Gottlieb has conducted approximately 100 no-fault bench trials. Mr. Gottlieb prevailed in his law firm’s competition as to who would present the oral argument in the Court of Appeals. The draft of the Court of Appeals brief was circulated throughout the law firm for feedback from other members of the firm. Mr. Gottlieb testified that he spent approximately six hours reviewing the record, and eight hours reviewing and researching citations within the defendant’s brief. The first draft of the Court of Appeals brief took 10 hours, the second draft took 20 hours. The final draft took 10 hours. There were at least 43 emails involving feedback from other members of the firm. The reply brief (Court of Appeals) took six hours to get through (14 pages). Mr. Gottlieb checked all cites and quotes. After reviewing the reply in the Court of Appeals, Mr. Gottlieb prepared a motion to allow the filing of amicus briefs. The preparation for the argument in the Court of Appeals was 28 hours. Mr. Gottlieb reviewed videos of arguments made in the Court of Appeals in preparation and spent a total of 130 hours working on the appeal to the Court of Appeals including oral argument. There were costs from the appellate printers, but no bills for these costs were admitted into evidence. Mr. Gottlieb did not keep contemporaneous time records.

The court accepts Mr. Gottlieb’s testimony that he performed legal services regarding the appeal covering the period of time{**59 Misc 3d at 588} from the date of the Appellate Division decision through the decision in the Court of Appeals, but because there was inadequate testimony regarding hourly rate fees and no contemporaneous time records, the court otherwise finds his testimony insufficient for establishing a reasonable hourly rate or time spent providing legal services. Under cross-examination, regarding certain services performed, Mr. Gottlieb testified as follows, “from what I remember . . . (2 hours of watching videos)” and “cannot tell for sure.”

Stephan Belinfanti, Esq. (Plaintiff’s Witness)

Mr. Belinfanti was admitted to the bar in 2001, and worked for Country-Wide Insurance Co. as a staff attorney in mid-2004, as well as other insurance defense firms and eventually started working for plaintiff’s counsel in September 2010. Mr. Belinfanti has conducted hundreds of bench trials and six jury trials, three of which concluded with a verdict, and has perfected a number of appeals. This court has had Mr. Belinfanti appear before it at numerous bench trials and recognizes his talent and competence. However, Mr. Belinfanti likewise did not keep any contemporaneous time records and the court is unwilling to accept testimony regarding estimates of “minimum” time spent in performing certain legal tasks. The court did not find Mr. [*7]Belinfanti’s testimony regarding attorney rates, to the extent there was such testimony, to be sufficient.

Gary Tsirelman, Esq. (Plaintiff’s Witness)

Mr. Tsirelman is the principal of the plaintiff’s counsel’s firm and has been an attorney for 16 years. Mr. Tsirelman is well qualified in the area of no-fault law having an office of 40 employees with 16 lawyers with 95% of his cases involving no-fault. Mr. Tsirelman testified that he spent 10 hours working on the appeal in the Appellate Term, six hours researching and editing, three hours working up defendant’s brief, and one hour discussing the appeal with Mr. Valerio. Regarding the appeal to the Appellate Division, Mr. Tsirelman spent 40 hours working on the appeal as follows: 20 hours editing/researching, 10 hours reading and rereading defendant’s brief and 10 hours discussing procedure and strategy with Mr. Valerio. Mr. Tsirelman detailed how 10 attorneys participated in moot court in preparation for the argument in the Court of Appeals. Mr. Tsirelman spent 10 hours editing and researching the Court of Appeals brief, three hours considering anticipated opposition,{**59 Misc 3d at 589} and six hours helping to get Mr. Gottlieb ready for his oral argument in the Court of Appeals.

Mr. Tsirelman testified that senior attorneys are billed at $500/hour for Racketeer Influenced and Corrupt Organizations Act no-fault defenses, declaratory actions, and breach of contract cases. This rate is placed in all retainers except for no-fault cases. The court finds that certain of the tasks were duplicative and excessive.

Sedmund Resciniti (Defendant’s Witness)

Mr. Resciniti is an attorney with 57 years’ legal experience who has a significant background in insurance law and testified on behalf of the defendant as someone with specialized knowledge in the area of No-Fault Law. Mr. Resciniti testified that he was employed by Allstate Insurance Company in 1960 and since 1962 maintained his own practice with a specialty in insurance law and no-fault. Although Mr. Resciniti testified regarding his interpretation of the statute as to the maximum hourly rate that can be charged by an attorney in an excess fee application, such an interpretation is completely disregarded because such province resides exclusively with the court. (See Measom v Greenwich & Perry St. Hous. Corp., 268 AD2d 156, 159 [1st Dept 2000] [“(e)xpert testimony as to a legal conclusion is impermissible”], citing People v Kirsh, 176 AD2d 652, 653 [1991], lv denied 79 NY2d 949 [1992].) However, the court does consider Mr. Resciniti’s opinion that the hourly rate for no-fault legal services was $50 per hour between 2005 and 2015.^[FN4] Mr. Resciniti has perfected six to seven appeals in the Court of Appeals, 35-40 appeals in the Appellate Division, and argued in approximately 20 matters in the Appellate Division, First and Second Departments, but has never tried a no-fault case in civil court and has only appeared in arbitration proceedings. Mr. Resciniti testified as to the time it would take to accomplish certain tasks by the plaintiff and that any time above the following estimates is unreasonable: drafting Appellate Term brief (1.5-2 hours); preparation for and oral argument in the Appellate Term (1.5 hours); drafting motion for leave to appeal to the Appellate Division (duplicative of Appellate Term motion) (one hour); drafting Appellate Division brief (12 hours); drafting reply brief (four hours); oral argument in Appellate Division (and preparation, two hours); drafting brief in Court{**59 Misc 3d at 590} of Appeals (eight hours); and oral argument in Court of Appeals (and preparation, two hours). According to Mr. Resciniti, the total reasonable hours for the appeal could [*8]not exceed 32.5-33 hours and any hours in excess of these hours is duplicative or excessive.

The court finds that the testimony of Mr. Resciniti comes much closer to the reasonable hours expended in prosecuting the appeals than the evidence presented by plaintiff’s counsel and the estimates of defendant’s witness will be treated as a concession of the reasonable minimum number of hours that were required to prosecute the appeals. Where defendant presents an expert who renders an opinion regarding the reasonable hours expended, defendant concedes those hours. (Cf. Kuehne & Nagel v Baiden, 36 NY2d 539, 544 [1975] [“in the absence of either party challenging the verity of the alleged facts, as is true in the instant case, there is, in effect, a concession that no question of fact exists”]; cf. Schifter v Commercial Travelers Mut. Acc. Assn. of Am., 183 Misc 74 [1944], affd 269 App Div 706 [1945]; see also Annotation, Proper Procedure and Course of Action by Trial Court, Where Both Parties Move for Summary Judgment, 36 ALR2d 881.)

Legal Analysis

The court is unable to utilize the lodestar method to determine reasonable attorney’s fees because plaintiff’s counsel’s firm did not keep any contemporaneous billing records and did not provide the court with proof of a “reasonable hourly billing rate,” by showing the “prevailing market rate” or the rate “prevailing in the community for similar services by lawyers of reasonably comparable skill, experience, and reputation” (Carroll v Weill, 2008 NY Slip Op 32512[U], *8; Matter of Rahmey v Blum, 95 AD2d 294 [2d Dept 1983]). However, the court may accept, at a minimum, the 33 hours conceded by the defendant (cf. Kuehne & Nagel v Baiden) and the statutory rate of $70 for legal services rendered out of court or $80 for legal services rendered in court. (See former 11 NYCRR 65-4.6 [d] [1], [2].)

The court rejects all testimony regarding an hourly rate of plaintiff’s counsel’s attorneys of between $500 to $1,000 per hour because such testimony only pertained to hourly rates charged by plaintiff’s firm having to do with matters other than the type of litigation or appeal ultimately argued in the Court of Appeals. The court accepts plaintiff’s counsel’s respective testimony regarding the experience of its attorneys which included years of practice and areas of expertise.{**59 Misc 3d at 591}

Unlike federal courts which strictly apply only a lodestar analysis (New York State Assn. for Retarded Children, Inc. v Carey, 711 F2d 1136 [2d Cir 1983]), state courts frequently determine reasonable attorney’s fees on a quantum meruit basis in a multitude of contexts under its inherent authority. (See Matter of First Natl. Bank of E. Islip v Brower, 42 NY2d 471 [1977] [where court refused to accept contractual provision mechanically applying a rate of 15% for attorney’s fees upon default judgment and only accepted such percentage as a limitation of such “reasonable fees” up to such percentage based on a “quantum meruit” basis]; see Matter of Greenfield, 127 AD3d 1189, 1192 [2d Dept 2015] [involving an estate matter, where an appellate court affirmed the trial court’s quantum meruit award of attorney’s fees in the absence of the law firm keeping contemporaneous time records]; see Padilla v Sansivieri, 31 AD3d 64, 67 [2d Dept 2006] [a matter involving a personal injury case where a disbarred attorney is claiming a fee prior to his disbarment, “there is case law expressly recognizing that the calculation of an award of legal fees as a portion of a contingent fee and based on an hourly rate are both properly fixed as quantum meruit determinations”], citing Lai Ling Cheng v Modansky Leasing Co., 73 NY2d 454, 459 [1989].)

As Justice Rivera determined in Nawaz v Boryczka (34 Misc 3d 1234[A], 2012 NY Slip Op 50367[U], *2 [Sup Ct, Kings County 2012]), “quantum meruit” is defined to be “as much as he [or she] deserve[s].” (Black’s Law Dictionary 1119 [5th ed 1979], quantum meruit.) Making that [*9]determination requires an assessment of the value of the services rendered. (See Ruggiero v Gross Plumbing & Heating, 226 AD2d 984, 986 [3d Dept 1996] [where appellate court reversed trial court in making quantum meruit determination on papers because, “the affidavit submitted by the (law) firm in support of its fee request lacked evidence of other significant factors generally considered when determining fee requests under quantum meruit, namely, the total time spent, the hourly rate charged, the amounts customarily charged for similar services in the same locality and the difficulty of the case”].)

The time spent by plaintiff’s counsel in attending the attorney’s fee hearing is not compensable as a “fee on a fee.” (See Matter of Hempstead Gen. Hosp. v National Grange Mut. Ins. Co., 179 AD2d 645, 646 [2d Dept 1992]; Kumble v Windsor Plaza Co., 161 AD2d 259, 261 [1st Dept 1990].){**59 Misc 3d at 592}

Issue: Is there enough evidence in the record to award plaintiff’s counsel’s fees under a theory of quantum meruit?

At the hearing, numerous documents were admitted into evidence but these documents alone are insufficient to make a quantum meruit attorney’s fee award. (See Neals v Cox, 240 AD2d 380, 380-381 [2d Dept 1997] [“(a)ssuming, arguendo, that the case file was admissible in evidence, no evidence was submitted of the hours worked on the case and the respondent’s hourly rate. Accordingly, the respondent failed to prove the value of her services on a quantum meruit basis (see, Glickson v Eli Lilly & Co., 234 AD2d 416; Sparks v Barry’s Plumbing & Heating Corp., 230 AD2d 606; Ruggiero v Gross Plumbing & Heating, 226 AD2d 984)”].) Here, there is no doubt that time was spent in the preparation of the numerous documents that were placed into evidence, but the court would engage in pure speculation regarding establishing the actual time involved in preparing those documents.

Given that legal fees in no-fault cases are determined on an hourly rate or a percentage of the recovery (11 NYCRR 65-4.6 under current subdivision [c] [$70/$80 per hour] with a maximum of $1,400 for in/out of court services or under current subdivision [b] up to 20% of recovery not to exceed $1,360), and that plaintiff’s counsel’s firm practices virtually all no-fault law, some explanation should have been offered as to why no time records were kept.

The court is being asked to use its own experience and expertise (Matter of Rahmey v Blum, 95 AD2d 294, 300 [2d Dept 1983]) to determine the reasonable hours, if any, above the hours conceded by the defendant and to further determine the reasonable hourly rates, if determined, above those specified in the statute (11 NYCRR 65-4.6). The plaintiff’s counsel in its posttrial memorandum of law is asking the court to consider the case of Matter of Hempstead Gen. Hosp. v National Grange Mut. Ins. Co. (179 AD2d 645 [2d Dept 1992]) where the Appellate Court affirmed the trial court’s setting of the attorney hourly rate in a no-fault matter of $175 per hour in 1989 which adjusted by the Bureau of Labor Statistics inflation calculator is equivalent to $354 in 2017.

This court will apply a flat hourly rate of $250 as reasonable for the legal services provided and makes an award of a legal fee only to the following extent:{**59 Misc 3d at 593}

Therefore, based upon the foregoing, plaintiff’s motion for additional attorney’s fees pursuant to 11 NYCRR 65-4.6 is granted and defendant is directed to make payment of $12,325 to plaintiff’s counsel within 30 days of the court’s decision or plaintiff may enter judgment.

Footnotes

Footnote 1:The exception was plaintiff’s claim dated November 17, 2004, in the amount of $139, which was denied based on “results from [an] independent medical exam the claimant attended on [September 21, 2004].” (See Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d at 36.)

Footnote 2:Plaintiff commenced this action in September 2005, prior to the adoption of the sixth amendment to 11 NYCRR 65-4.6, and as such, the amendment is not applicable and the subdivision as cited is the text of the regulation prior to the amendment. However, it should be noted that amended subdivision (e) has the same language as found in former subdivision (f).

Footnote 3:Indeed, the acceptance of a certified question by the Court of Appeals is discretionary (see 22 NYCRR 500.27 [a]; see also 22 NYCRR 500.22 [b] [4] [requiring movants to submit, inter alia, “(a) concise statement of the questions presented for review and why the questions presented merit review by this Court, such as that the issues are novel or of public importance, present a conflict with prior decisions of this Court, or involve a conflict among the departments of the Appellate Division”]; Liriano v Hobart Corp., 92 NY2d 232, 243 [1998] [the Court of Appeals declined to accept a certified question where “(t)he Second Circuit’s opinion does not indicate that there is an unsettled or open question of New York substantive law”]; Tunick v Safir, 94 NY2d 709, 711-712 [2000] [the Court of Appeals noting that “the certification procedure can provide the requesting court with timely, authoritative answers to open questions of New York law, facilitating the orderly development and fair application of the law and preventing the need for speculation”]).

Footnote 4:In 2005 11 NYCRR 65-4.6 (d) (1) and (2) reflected an hourly rate of $70/$80 depending on in court or out of court work with a cap of $1,400.

[*1]

Civil Court of the City of New York, Kings County, December 18, 2017

APPEARANCES OF COUNSEL

The Rybak Firm, PLLC, Brooklyn, for plaintiff.

Peter C. Merani, P.C., New York City, for defendant.

Plaintiff’s motion to reargue its motion for summary judgment is decided as follows:

In this action to recover assigned first-party no-fault benefits, plaintiff submitted a claim form and invoice to defendant for services rendered to Cosby Reavis on October 8, 2013. According to plaintiff’s claim, these services related to various codes promulgated under the Official New York Workers’ Compensation Medical Fee Schedule (the fee schedule), including code 20999, which is a “By Report” code. Defendant denied plaintiff’s claim in part because plaintiff did not bill its services in accordance with the applicable fee schedule. Plaintiff filed the instant action and both parties moved for summary judgment.

With specific regard to plaintiff’s motion to reargue, this court denied plaintiff’s motion for summary judgment with respect to plaintiff’s claim for payment under code 20999 (52 Misc 3d 491 [2016]). The court reasoned that, because code 20999 is a “By Report” code, plaintiff was required to submit certain information about the services provided in order to establish a proper billing rate as part of its prima facie case. Plaintiff did not provide this information, and consequently, plaintiff did not meet its initial burden of proof on summary judgment.

Plaintiff now moves to renew and reargue its motion for summary judgment. A motion for leave to renew is addressed to the court’s sound discretion and can be granted only if it is shown that there are new facts, although in existence at the time the original motion was made, that were unknown to the movant and therefore were not brought to the court’s attention (Semenov v Semenov, 98 AD3d 962, 963 [2d Dept 2012]). To the extent the facts are new, plaintiff must offer a reasonable justification for its failure to present such facts on the prior motion (id.).

A motion to reargue must show that there was a point of law or fact that was overlooked in the prior motion, and cannot be based on arguments different from those originally stated in the prior motion (NYCTL 1998-1 Trust v Rodriguez, 154 AD3d 865, 865 [2d Dept 2017]; Rodriguez v Gutierrez, 138 AD3d 964, 966-967 [2d Dept 2016]).

Plaintiff argues that “academic literature” dictates that dry needling is commonly billed under code 20999, and attaches this “literature” to its motion to renew and reargue. As an{**60 Misc 3d at 683} initial matter, plaintiff does not explain why it did not offer this “literature” in support of its underlying motion for summary judgment, and so it cannot be considered for the motion to renew (Semenov, 98 AD3d at 963). Likewise, the court cannot consider this “literature” as part of the motion to reargue, as it is a new theory not advanced in the underlying motion (NYCTL 1998-1, 154 AD3d at 865; Rodriguez, 138 AD3d at 966-967).

Even if this court were to consider this “literature,” plaintiff provides no reason why the court should give it any weight or deference. The referenced document is titled “Local Coverage Determination (LCD): Pain Management (L33622).” Plaintiff offers no explanation about who authored the document, who uses this document, how it is used, or the weight, if any, the medical community gives the document. All this said, the document makes a passing statement that dry needling should be billed under code 20999. Even assuming this were true, it would not change the “By Report” designation in the fee schedule, which requires a medical provider to submit a report with its bill to establish the proper billing rate.

Additionally, plaintiff argues that this court incorrectly interpreted plaintiff’s prima facie burden as established by Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (25 NY3d 498, 507 [2015]). Plaintiff argues that Viviane Etienne holds that plaintiff’s prima facie burden is limited only to proving timely submission of a claim form, and that payment is overdue. In its underlying decision in this action, this court explained that, in order to determine the appropriate monetary value of services designated “By Report,” the Official New York Workers’ Compensation Medical Fee Schedule directs the medical provider to provide certain information to justify its billing. These documents and information (i.e., the “report”) are part of the “completed claim form” (see Viviane Etienne, 25 NY3d at 507), and thus part of plaintiff’s prima facie burden, so that defendant has sufficient notice of the services being billed in order to make a proper decision on the claim. Plaintiff does not argue that the court [*3]overlooked or misunderstood a point of law. Instead, plaintiff simply disagrees with the court’s reasoning.

After plaintiff filed the instant motion, the Appellate Term issued its decision in Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (57 Misc 3d 145[A], 2017 NY Slip Op 51452[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017]). {**60 Misc 3d at 684}In Bronx Acupuncture, the plaintiff medical provider sought payment for services submitted under a “By Report” code. The defendant insurance company denied the claim because the plaintiff did not provide certain documentation. The appellate court treated the documentation as a request for additional documentation, and held that defendant’s denial was not proper because it did not request the documentation in accordance with 11 NYCRR 65-3.5 (b) (Bronx Acupuncture, 57 Misc 3d 145[A], 2017 NY Slip Op 51452[U], *1).

That said, the specific legal issue confronted in this action is whether the “report” in a “By Report” claim is an additional form of documentation or verification, as is generally the case when a carrier requests copies of medical records, or subsequent letters of medical necessity, or rather, in this unique circumstance, whether the “report” in a claim billed “By Report” is actually an integral part of the bill or claim form, and so whether it must be included in order to constitute a “completed claim form.” If it is the latter, then it would be an element of plaintiff’s prima facie burden to produce such a “completed claim form,” under Viviane Etienne. It would not constitute a separate, new element of the prima facie burden.

I acknowledge, support, and endeavor to follow the principles laid out in Viviane Etienne. Further, I am mindful of the Appellate Term’s decision in Bronx Acupuncture and its potential implication in this case. That said, I find that it is definitional to the submission of any claim that the claim form must be complete, and that to satisfy the prima facie burden laid out in Viviane Etienne, completed claim forms must provide the necessary data to identify both the value of the claim and the basis for calculating that value. It is the satisfaction of this prima facie threshold that shifts the burden to the insurer to pay or deny the claim, or to demand further verification, within the times specified in the regulations. Alone in the applicable fee schedule, the “By Report” code provides no inherent value. The code is a wild card which invites the provider to name the value of the claim and to explain, in narrative form, the basis of calculation for that value. Without the report, the “By Report” code is not reduced to a defined service with a calculated value, and the insurer has no basis to either pay or deny the associated claim. For these reasons, I find that the report is a necessary component of the bill for a “By Report” claim. Its absence renders the claim form incomplete, fails to satisfy the prima facie requirements laid out in Viviane Etienne{**60 Misc 3d at 685}, and so fails to trigger the insurer’s obligation to timely pay or deny the claim.

For the foregoing reasons, plaintiff’s motion to renew and reargue is denied.

725730/2016

Attorney for Plaintiff:
Damin J. Toell Esq. from the Law Offices of Damin J. Toell, P.C.

Attorney for Defendant:
Jamila Shukry Esq. from McCormack & Mattei, P.C.

In this action by a provider to recover assigned first-party no-fault benefits, Plaintiffs seeks reimbursement for chiropractic manipulation under anesthesia of assignor Maria Baez’ cervical spine, thoracic spine, lumbar spine, pelvis and left shoulder on December 21, 2016, January 4, 2016 and January 8, 2016, arising out of an accident on October 13, 2015.

Both parties stipulated that Plaintiff established its prima facie case by timely submitting the bills at issue to Defendant and Defendant established timely mailing the denial. The sole issues remaining for trial were the defenses of medical necessity and whether Plaintiff was properly reimbursed by Defendant pursuant to the fee schedule and calculations applied.

A bench trial was commenced and completed on October 24, 2017. Defendant produced a chiropractor, Dr. Thomas McLaughlin who conducted a peer review of Ms. Baez’ records and testified that the series of manipulations under anesthesia performed on Ms. Baez were not medically necessary. Dr. McLaughlin testified that Ms. Baez did not have surgery, and generally, most patients who receive manipulation under anesthesia are people who recently underwent surgery and cannot move a joint because of the increase of scar tissue (tr at pp. 18-19). Furthermore, Dr. McLaughlin testified that Ms. Baez’ records indicate she had an upper neuron region disorder and manipulation under anesthesia would be inappropriate for a person with such a disorder (tr at p. 15 lines 3-14). Dr. McLaughlin also testified that, in this case, Ms. Baez’ medical records reflected that Ms. Baez’ condition since the accident remained consistent in many respects, but showed improvement in others, and Plaintiff did not allow Ms. Baez to proceed with physical therapy to its full potential before performing manipulation under anesthesia (tr at p. 32 lines 1-10). He testified that some of Ms. Baez’ other doctors recommended further physical therapy, and none of them recommended manipulation under anesthesia (tr at p. 24 lines 12-20). Dr. McLaughlin also testified on direct examination that Ms. [*2]Baez’ initial consultation for manipulation was performed on the same date as her first manipulation under anesthesia (tr at p. 14 lines 5-16), but, on cross-examination, Dr. McLaughlin admitted that his statement on direct examination was incorrect and that the initial consultation for manipulation under anesthesia was actually five days before the first procedure (tr at pp. 25-26).

Specifically, Dr. McLaughlin testified that, Dr. Alex Khait, the doctor who performed the procedures on Ms. Baez, used the National Academy of Manipulation Under Anesthesia guidelines in deciding to perform the procedure, and that under the guidelines the procedure should be used when it would be the “most efficacious care for the person.” He disagreed that manipulation under anesthesia was the “most efficacious care” for Ms. Baez at the time it was done (tr at p. 18 lines 7-24).

Defendant also produced Christine Madigan, a Senior Litigation Representative for Defendant who testified that Defendant was billed for $3,572.91, and should have been instead been billed $1,462.47, based on the correct fee schedule (tr at p. 37 lines 21-25). Ms. Madigan testified which codes and modifiers should have been used and how often they should have been billed in calculating its invoice. During her testimony, Ms. Madigan testified that Defendant was charged three times in one day for manipulation under anesthesia to the cervical, thoracic and lumbar spines, even though the code should have been billed only once per day under the multiple procedure rule (tr at p. 47 lines 3-11).

Plaintiff presented an additional witness, chiropractor Dr. Robert Luca, to rebut Dr. McLaughlin’s testimony regarding the medical necessity of the procedures. Dr. Luca testified twenty-five points of contention with Dr. McLaughlin’s analysis. He testified that manipulation under anesthesia served to “restore the proper joint both mechanical and physiological” with stretching to remobilize the joint and “re-establish the normal or near normal resting length of the muscles tendons and ligaments as well as reactivate something called collateral inhibition physiological response” (tr at p. 54 lines 7-24). He testified that the procedure is not only reserved for patients who have undergone surgery. Among his reasons that the procedure was necessary in Ms. Baez’ case was that “the patient has responded favorably to conservative chiropractic medical treatment, but continued to experience chronic pain or persistent pain”; Ms. Baez had two to six weeks of care at least before the procedure, but suffered continuing pain that interfered with her lifestyle, and Ms. Baez refused other options for treatment (tr at p. 56 lines 3-23). He stated that these reasons were listed in the criteria set by the National Academy of Manipulation Under Anesthesia for a patient who would be an appropriate candidate for manipulation under anesthesia (tr at pp. 55-56). He also disagreed with Dr. McLaughlin and stated that, from his review of the medical records and the peer review, it appeared that Ms. Baez had “plateaued” and was “rebounding” into a “downward cycle,” even though her initial response to treatment was good (tr at p. 62 lines 10-25). He also thought that Ms. Baez received a sufficient course of treatment prior to manipulation under anesthesia (tr at p. 63 lines 6-13).

The issue here is whether Defendant, through the testimony of its expert witness, satisfied its burden of establishing a lack of medical necessity and, if it did so, whether Plaintiff proved, by a preponderance of the evidence, that the services rendered were medically necessary (see New Horizon Surgical Ctr, LLC v Allstate Ins. Co., 52 Misc 3d 139[A][App Term 2d Dept 2016]; see also Park Slope Med. & Surgical Supply v Travelers Ins. Co., 37 Misc 3d 19 [App Term, 2d Dept 2012]).

“A no-fault insurer defending a denial based on lack of ‘medical necessity’ must at least show that the services were inconsistent with generally accepted medical/professional practice (Citywide Soc. Work & Psy. Serv., PLLC v Travelers Indem. Co., 3 Misc 3d 608, 609 [Civ Ct, Kings County 2004]). “Generally accepted practice is that range of practice that the profession will follow in the diagnosis and treatment of patients in light of the standards and values that define its calling” (Id. at 616). Unless there is reference to “generally accepted” medical/professional practice, conflicting expert testimony will only show a difference in professional medical judgment between two doctors (Id. at 612).

In this trial, the conflicting opinions of Dr. McLaughlin and Dr. Luca demonstrate a difference in professional medical judgment regarding whether manipulation under anesthesia was appropriate for the assignor in this case, in light of the standards set forth by the National Academy of Manipulation Under Anesthesia.

Defendant did not present sufficient evidence to establish that the manipulation under anesthesia was inconsistent with generally accepted professional practice considering Ms. Baez’ medical treatment and condition at the time. Therefore, the evidence was insufficient to carry defendant’s burden of proving that the services were not medically necessary.

However, based on the credible and uncontroverted testimony of Ms. Madigan, this court finds that Defendant has met its burden of showing that the appropriate amount for the invoices at issue was $1,462.47 instead of $3,572.91. Plaintiff submitted no evidence or testimony to rebut Ms. Madigan’s testimony.

Therefore, judgment is awarded in favor of Plaintiff. The Clerk is directed to enter judgment in favor of Plaintiff in the amount of $1,462.47, together with applicable statutory interest, attorney fees and costs.

This constitutes the Decision and Order of the Court.

Dated: December 13, 2017
Kings, New York
____________________
Mary V. Rosado, J.C.C.

Decided on July 31, 2017

Civil Court of the City of New York, Kings County

[*1]

Civil Court of the City of New York, Kings County, July 20, 2017

APPEARANCES OF COUNSEL

Rivkin Radler LLP, Uniondale (Vincent P. Valente of counsel), for defendant.

Zara Javakov, Esq., P.C., Brooklyn (Adam Waknine of counsel), for plaintiff.

The issue as to which reargument is granted, as to which we find no controlling appellate authority, is whether a no-fault insurer which notices an examination under oath (EUO) of a medical professional provider, as to which the provider timely objects and requests explanation as to the reason for the EUO, is obligated to provide such a reason as a prerequisite to the EUO.

Defendant GEICO Insurance (GEICO) moves for reargument of this court’s decision and order dated March 20, 2017 (March 20 decision), which denied GEICO’s motions for summary judgment in eight cases consolidated for decision.^[FN1] The March 20 decision found that plaintiffs had established their prima facie cases as to timely mailing of bills, receipt thereof by GEICO, and nonpayment of the bills, and that GEICO had made its prima facie case as to timely mailing of requests for examinations under oath and plaintiff provider’s nonappearance for examination. The court held, in relevant part, that “in view of Plaintiff’s request in response to Defendant’s demand for EUO of a reason therefore, and Defendant’s response denying necessity to provide any reason, triable issues exist as to whether Defendant had any legally valid reason for seeking EUOs of Plaintiff provider.” (Mar. 20 decision para 2 thereof.) It is primarily this holding that is challenged by GEICO on reargument.

The Relevant Facts

The relevant facts in each of these cases are similar. In each case, upon receipt of bills from plaintiff, GEICO timely notified plaintiff American Chiropractic Care P.C. (American) to appear for an EUO, and plaintiff’s counsel, upon receipt of that notification, expeditiously wrote to GEICO’s counsel, prior to the date scheduled for the EUO, requesting that GEICO{**57 Misc 3d at 531} provide “good faith reasons, based upon the application of objective standards that serves as justification for demanding [plaintiff] to appear for an EUO.” (See e.g. Letter of Julie Lyumbimova, Esq., dated [*2]Aug. 14, 2014, annexed within exhibit 3 to GEICO’s motion.)

In response to the letters of plaintiff’s counsel requesting a good faith reason for the EUO of the provider, GEICO’s counsel declined to provide any reason, but instead asserted that “GEICO is not required to provide your Client with the objective basis and/or ‘good reasons’ for its request for an EUO,” citing 11 NYCRR 65-3.5 (c), and specifically so much thereof as provides, in relation to the requirement that EUOs to be supported by specific objective justification, that “insurer standards shall be available for review by [State Insurance] Department examiners.” (See Letter of Ryan Goldberg, dated Aug. 26, 2014, part of exhibit 3 to GEICO’s motion.) It is undisputed that following the exchange of such correspondence, plaintiff did not appear for examination.

The Legal Issue

After careful analysis of the case law cited by each party, and the applicable regulations, the court stands by its prior decision that upon receipt of a timely request (that is, sufficiently prior to the date for which the EUO is scheduled to allow for a response), the insurer is required to provide some good faith basis for the EUO, and the requirement that insurer standards for scheduling EUOs are available for review by the Insurance Department does not relieve the insurer from the need to respond, in the manner set forth below, to a timely request on behalf of the provider.

Analysis

The Comprehensive Motor Vehicle Insurance Reparations Act (Insurance Law § 5101 et seq.) and the no-fault regulations (11 NYCRR 65-1.1 et seq.) provide the no-fault insurer with the right to require an EUO of the assignor of the claim, as well as the provider of medical services or supplies. While the right to an EUO of an assignor, that is, an individual who suffered injury as the result of an automobile accident, is virtually automatic, the EUO of a provider stands on different grounds. The reason for this is that there is obvious potential to abuse the EUO of a provider, typically a medical doctor or chiropractor, although it may also be a provider of durable medical{**57 Misc 3d at 532} equipment. The claims at issue in no-fault cases are ordinarily no more than a few thousand dollars, and frequently less than even $1,000. To require a doctor to leave his or her practice for at least half a day, between the time to travel to and from an EUO, and the time actually spent under examination, will often result in a loss of income to the doctor disproportionate to, if not in excess of, the amount of the claim, although here GEICO specifically offered to reimburse American for lost earnings and transportation expenses, as required by the regulations. Equally important, an EUO takes the doctor away from time that would otherwise be spent providing health care to patients. (In this regard, there is no provision to reimburse the provider for the time spent in preparation for the examination, including that necessary to compile and review the numerous documents requested by GEICO in advance of the EUO.) The public interest requires that such disruption of medical professionals not be undertaken lightly or on the proverbial fishing expedition in the hope that some basis, perhaps the provider’s nonappearance, may be developed to deny an otherwise legitimate claim.

This court recognizes, and indeed endorses, the right of an insurer, acting in good faith, to require an EUO of a provider. Such EUOs are an important tool in rooting out fraud, which many believe to be all too prevalent in the medical treatment of no-fault patients. Thus, a balance must be struck between the policy of rooting out and preventing fraud, and not unnecessarily disrupting the practice of a medical professional without a good faith basis for so doing.

On reargument, both plaintiff and GEICO have provided case law supporting their respective [*3]positions. The court notes that virtually all of the cases cited emanate from trial courts or arbitrators, so that there is little, if any, appellate authority on this issue.

GEICO relies on the following cases: City Chiropractic v State Farm (Civ Ct, Kings County, Feb. 24, 2016, Thompson, J., index No. 37182/14 [relying on Department of Insurance opinion letters dated Oct. 15, 2002 and Dec. 22, 2006]); Gotham Massage Therapy v State Farm (Civ Ct, Bronx County, Dec. 20, 2010, Taylor, J., index No. 30502/09); and Karina K. Acupuncture v State Farm (Civ Ct, Kings County, Jan. 3, 2012, Garson, J., index No. 1702/11) as well as various arbitration awards and judgments entered thereon, all holding that the insurer has no obligation to state any reason for an EUO of the provider. (The{**57 Misc 3d at 533} court opinions and orders are annexed as exhibit 5 to GEICO’s moving papers, and the arbitration awards are annexed as exhibit 6.)

None of these cases emanate from an appellate court, so they are not binding on this court. Moreover, while City Chiropractic appears directly on point, as do some of the arbitration awards, both Gotham Massage and Karina K. are factually distinguishable. In Gotham Massage, there is no indication that the provider requested a justification for the EUO prior to its scheduled date. Karina K. refused to appear for its EUO unless the insurer agreed to a series of “non-negotiable” demands, a situation far different from the request of American for an explanation of its good faith basis for an EUO. Accordingly, the legal authority relied upon by GEICO may be distilled into one case directly on point, a second which may or may not be on point depending on facts not contained in the opinion, and arbitration awards, coupled with the opinion letters of the Insurance Department. In response, plaintiff relies on a number of cases which emanate from trial courts, and are as equally lacking in binding authority as those relied upon by GEICO, together with a number of arbitration awards. We note that the trial court cases relied upon by plaintiff, while not controlling, appear to be more closely on point than those cited by GEICO. For example, in Avalon Radiology, P.C. v Ameriprise Ins. Co. (52 Misc 3d 836 [Suffolk Dist Ct 2016]) the court held:

“Thus [provider’s] request for the objective reason in response to the first EUO request triggered an obligation on the part of the . . . insurer to respond by providing the specific objective justification for the EUO request. The insurer’s response in this case to the effect that it was not obligated to do so is plainly wrong.” (52 Misc 3d at 838.)

In Rutland Med., P.C. v State Farm Ins. Co. (45 Misc 3d 1033 [Civ Ct, Kings County 2014]), the court denied the insurer’s motion for summary judgment, finding triable issues where the provider timely objected to appearing for an EUO, as to whether if the insurer failed to respond, the provider’s failure to appear for the EUO was reasonable. In Dynamic Med. Imaging, P.C. v State Farm Fire & Cas. Co. (32 Misc 3d 600 [Nassau Dist Ct 2011]), the court noted, albeit in what is arguably dicta, that the insurer “would also have to establish it had an objective justification for requesting the EUO. Such proof requires affidavits.” (32 Misc 3d 600, 604.) In Victory{**57 Misc 3d at 534} Med. Diagnostics, P.C. v Nationwide Prop. & Cas. Ins. Co. (36 Misc 3d 568 [Nassau Dist Ct 2012]), the court held that “before a claimant provider should be required to produce Mallela^[FN2] material, the insurer must have and articulate a good faith and [*4]factual basis for seeking the information.” (36 Misc 3d 568, 574.) Plaintiff cites other trial court cases and arbitration awards with similar holdings.

While plaintiff cites several Appellate Term cases, they are not controlling, as they dealt with the situation where the respective plaintiff providers, unlike American, did not timely object to the EUO request, but sought to raise objections only in response to the insurer’s subsequent summary judgment motion, following the provider’s nonappearance. While American asserts that those cases provide authority that the Appellate Term would have upheld a timely objection lacking an explanatory response by the insurer, we decline to so read those cases. (See Natural Therapy Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 42 Misc 3d 137[A], 2014 NY Slip Op 50134[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]; Natural Therapy Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 44 Misc 3d 141[A], 2014 NY Slip Op 51310[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]; Metro Health Prods., Inc. v State Farm Mut. Auto. Ins. Co., 47 Misc 3d 127[A], 2015 NY Slip Op 50402[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015].)

GEICO asserts that the requirement that its standards for scheduling EUOs of providers be made available to the Insurance Department precludes any request by the provider for a preexamination explanation for an EUO. The court disagrees. First, that requirement neither explicitly nor implicitly provides that Insurance Department oversight is in lieu of or preempts the provider’s right to timely seek an explanation for the EUO. We note that even were the Insurance Department to find an insurer to have abused the EUO process, that would be of little solace to a provider who duly appeared for examination. Moreover, the Insurance Department’s oversight of the standards employed by an insurer is necessarily a different analysis than whether those standards were properly applied with regard to a particular provider.

In balancing the need for insurers to conduct EUOs of providers to root out and prevent fraud against the burden on the{**57 Misc 3d at 535} insurer to respond to a timely request for explanation from the provider as to the reason for an EUO, and the burden on a medical professional to appear for examination, we find the burden on the insurer to respond to be slight. In support of GEICO’s underlying motion, GEICO submitted the affidavit of its special investigator, Victor Hernandez, who set forth in great detail the matters supporting GEICO’s need for an EUO of American. From a review of the Hernandez affidavit, it appears that all of these matters were known to GEICO at the time it noticed the EUO of American. This court sees no reason why GEICO could not have easily responded to American’s request for explanation by setting forth some of the matters now contained in the Hernandez affidavit, rather than by stonewalling and asserting that it did not have to provide any explanation to American.

We do not mean to suggest that GEICO should have responded by setting forth all of the information at its disposal with regard to American, or that it needed to set forth anything under oath. But, in this court’s view, GEICO needed to set forth some explanation, even in the form of a letter from counsel, which might have contained a highly-edited version of the matters set forth in Mr. Hernandez’s subsequent affidavit, to demonstrate a good faith basis for the EUO. The burden on the insurer to make some prima facie showing of good faith is far less than the burden that would be imposed on a provider to appear for examination when there is no good faith basis to request an EUO.

There is another benefit to a rule requiring the insurer to provide a substantive response to a timely objection by a provider to an EUO. A substantive response will allow the provider, with the advice of counsel, to make an intelligent decision whether to appear for the EUO and to be adequately prepared so that the examination may be expeditiously concluded. The good faith, or lack thereof, would be established by the insurer’s substantive response. A provider who fails to appear [*5]for its properly noticed EUO, as to which a substantive response was made to any timely objection, would be subject to summary dismissal of its case. And, as the statute and regulations only require a good faith application of objective standards, it would be extremely difficult, at the least, for the provider to challenge a substantive explanation by the insurer for the EUO, so long as that explanation was made in good faith.{**57 Misc 3d at 536}

Conclusion

Accordingly, while the court has granted reargument, upon reargument, we hold that no controlling facts or applicable law was overlooked in the March 20 decision and order. The court stands by the March 20 decision, and particularly paragraph “2” thereof, holding it to be a triable issue as to whether GEICO had a good faith basis, under objective standards, to seek the EUO of American,^[FN3] given American’s timely objection to the EUO, and GEICO’s refusal to set forth any basis for the examination.

Footnotes

Footnote 1:We similarly consolidated for decision GEICO’s eight motions for reargument.

Footnote 2:State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313 (2005).

Footnote 3:American and GEICO dispute whether American attached to its papers in the underlying motion sufficient documents to show that it raised timely objection to EUOs with regard to assignments from certain assignors, namely Jesus and Bella Gutierrez. In reviewing American’s papers, it appears that its counsel’s letter included these claims in a list annexed to that letter referencing these assignors. Nevertheless, as to these assignors, the issues for trial shall include whether American’s counsel timely objects to the EUOs prior to the scheduled date.

[*1]

Civil Court of the City of New York, Kings County, May 25, 2017

APPEARANCES OF COUNSEL

The Rybak Firm, PLLC, Brooklyn (Mikhail Kopelevich of counsel), for plaintiff.

Richard T. Lau & Associates, Jericho (Jeremy Maline of counsel), for defendant.

In this action by a provider to recover assigned first-party no-fault benefits, a bench trial commenced and concluded on May 4, 2017. The parties made no pretrial stipulations. Pursuant to the order of the Honorable Steven Z. Mostofsky, dated February 3, 2016, plaintiff “establishe[d] [its] prima facie case” and the amount in dispute is $2,389.76. The order goes on to indicate, “[t]he sole issue for trial shall be whether the verification requests remain[ ] outstanding.” There were no witnesses appearing on behalf of either party.

The court left the record open solely to address the legal issue of which party bears the burden of establishing whether the verification requests remain outstanding. In support, defendant submitted a posttrial memorandum by Jeremy Maline, Esq., dated May 18, 2017, and in reply, plaintiff submitted a posttrial memorandum by Oleg Rybak, Esq., dated May 22, 2017. In brief, plaintiff’s counsel argued that as the issue of outstanding verification is an affirmative defense, it is the defendant’s burden to establish that verification remains outstanding. Defense counsel argued, inter alia, that the order dated February 3, 2016, should be read to indicate that defendant has met its burden of establishing its defense as defendant has proved “timely and proper mailing of the verification requests and mailing of the 120 day denial.”

It is well settled that an insurer may toll the 30-day period to pay or deny a claim by [*2]properly requesting verification within 15 business days from its receipt of the proof of claim form or bill. (11 NYCRR 65-3.5 [b]; Psych. & Massage Therapy Assoc., PLLC v Progressive Cas. Ins. Co., 5 Misc 3d 723 [Civ Ct, Queens County 2004].) If the

“requested verifications has not been supplied to the insurer 30 calendar days after the original request, the insurer shall, within 10 calendar days, follow up with the party from whom the verification was requested, either by telephone call . . . or by mail. At the same time the insurer shall inform the applicant and such person’s attorney of the reason(s) why the claim is delayed by identifying in{**56 Misc 3d at 683} writing the missing verification and the party from whom it was requested.” (11 NYCRR 65-3.6 [b].)

“A claim need not be paid or denied until all demanded verification is provided.” (New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [2d Dept 2004]; Prime Psychological Servs., P.C. v ELRAC, Inc., 25 Misc 3d 1244[A], 2009 NY Slip Op 52579[U] [Civ Ct, Richmond County 2009]; see also Insurance Law § 5106 [a]; 11 NYCRR 65-3.5 [c]; 65-3.8 [a] [1].) As for services rendered on or after April 1, 2013, if the applicant does not provide within 120 calendar days from the date of the initial request either all such verification under the applicant’s control or possession or written proof providing reasonable justification for the failure to comply, the insurer may deny the claim. (11 NYCRR 65-3.5 [o].)

In the court’s view, defendant’s argument that defendant established mailing of the 120-day denial obviates defendant’s burden to demonstrate prima facie that it had not received the requested verification is unpersuasive as the sole issue for trial is whether the verification requests remain outstanding. Defendant generally bears the burden of proving its affirmative defense (Manion v Pan Am. World Airways, 55 NY2d 398 [1982]). Defendant failed to present any witnesses at trial to prove that it, in fact, did not receive any response to its verification requests.

Lastly, defense counsel has not cited any case law that would convince this court to find otherwise. To the extent that defense counsel discusses any outstanding discovery in its memorandum, such issue is not before the court and therefore was not considered.

Based on the foregoing, the court finds that the defendant has failed to meet its burden of establishing its affirmative defense of outstanding verification and as the order of the Honorable Steven Mostofsky found that plaintiff established its prima facie case, the Clerk is directed to enter judgment in favor of the plaintiff in the amount of $2,389.76 with applicable statutory attorney’s fees, interest, costs and disbursements.

[*1]

Civil Court of the City of New York, Kings County, May 26, 2017

APPEARANCES OF COUNSEL

Law Offices of Emilia Rutigliano, P.C., Brooklyn (Michael Tsugel of counsel), for plaintiff.

Rivkin Radler, LLP, Uniondale (John J. Vobis Jr. of counsel), for defendant.

In this action by a provider to recover assigned first party no-fault benefits, plaintiff moves for summary judgment arguing that it established its prima facie entitlement to recovery of its unpaid no-fault bills and defendant cross-moves for summary judgment based upon plaintiff’s purported failure to appear for four examinations under oath (EUO).

Plaintiff argues, inter alia, the denials issued in this matter were untimely as defendant’s EUO scheduling letters were untimely. Specifically, defendant’s letter dated May 19, 2015 which rescheduled plaintiff’s missed EUO on May 8, 2015 is late as the regulations require that the follow-up requests be issued within 10 calendar days of the missed EUO date. Lastly, plaintiff contends that the affidavits proffered by defendant are conclusory and insufficient to establish that the EUO scheduling letters and subsequent denials were timely and properly mailed and that defendant’s affiant fails to demonstrate personal knowledge of plaintiff’s nonappearances.

In reply, defendant contends that the mailing of the EUO notice 11 days after the third missed EUO does not negate plaintiff’s obligation to appear based upon 11 NYCRR 65-3.5 (p). Further, defendant contends that its affiant sufficiently established its standard office procedures as to the issuance of the letters and denials at issue and that plaintiff’s nonappearances for the four EUOs were, likewise, adequately demonstrated.

An insurer may toll the 30-day period to pay or deny a claim by properly requesting verification within 15 business days from its receipt of the proof of claim form or bill. (11 NYCRR 65-3.5 [b]; Psych. & Massage Therapy Assoc., PLLC v Progressive Cas. Ins. Co., 5 Misc 3d 723 [Civ Ct, Queens County 2004].) If the

“requested verification[ ] has not been supplied to the insurer 30 calendar days after the original [receipt], the insurer shall, within 10 calendar days, follow up with the party from whom the verification was requested, either by [a] telephone call . . . or by mail. At the same time the insurer shall inform the applicant and such person’s attorney of the reason(s) why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested.” (11 NYCRR 65-3.6 {**56 Misc 3d at 928}[b].)

“For the purposes of counting the 30 calendar days after proof of claim, wherein the claim becomes overdue pursuant to section 5106 of the Insurance Law, with the exception of section 65-3.6 of this Subpart, any deviation from the rules set out in this section shall reduce the 30 calendar days allowed.” (11 NYCRR 65-3.8 [l].)

Plaintiff also relies upon Presbyterian Hosp. in City of N.Y. v Aetna Cas. & Sur. Co. (233 AD2d 431 [2d Dept 1996]), where the Court found that the follow-up requirements for verification requests are to be “strictly construed.” In Presbyterian, the insurer, after not receiving a response to its initial request for additional verification, did not issue a follow-up request and after receiving the requested records three months later, issued a denial shortly thereafter. As such, the 30-day period within which the carrier should have either paid or denied the claim had run “ ’even before verification [was] obtained’, due to the carrier’s ‘lack of diligence in obtaining the verification’ ” (Presbyterian, 233 AD2d at 433, citing Keith v Liberty Mut. Fire Ins. Co., 118 AD2d 151, 154 [2d Dept 1986]). In Concourse Chiropractic, PLLC v Fiduciary Ins. Co. of Am. (35 Misc 3d 146[A], 2012 NY Slip Op 51058[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]), the court found that the insurer’s follow-up request was untimely when its follow-up request was issued more than a month after the nonappearance at the first scheduled EUO. However, the foregoing cases and their progeny were decided on a set of facts and circumstances prior to the promulgation and application of the fourth amendment of 11 NYCRR subpart 65-3. The fourth amendment of 11 NYCRR subpart 65-3, subdivision 65-3.5 (p) (fourth amendment), was enacted on January 30, 2013 and reads as follows:

“(p) With respect to a verification request and notice, an insurer’s nonsubstantive technical or immaterial defect or omission, as well as an insurer’s failure to comply with a prescribed time frame, shall not negate an applicant’s obligation to comply with the request or notice. This subdivision shall apply to medical services rendered, and to lost earnings and other reasonable and necessary expenses incurred, on or after April 1, 2013.”

There appears to be no higher court analysis of the phrase: “as well as an insurer’s failure to comply with a prescribed time frame, shall not negate an applicant’s obligation to comply{**56 Misc 3d at 929} with the request or notice.” Nonetheless, and comparably, in Pine Hollow Med., P.C. v Global Liberty Ins. Co. of N.Y. (25 Misc 3d 244 [Civ Ct, Kings County 2009]), the court reasoned that “defendant should not be deprived entirely of the opportunity to review and obtain the needed proof by dint of its one-day tardiness in submitting its follow-up request” and that “[i]t would be patently absurd and contravene the meaning of 11 NYCRR 65-3.8 (j) to impose a more draconian punishment on an insurer who is one day late in requesting follow-up verification than on an insurer who is one day late in requesting additional verification” (id. at 250). It would appear that the fourth amendment addresses such deficiency and is in accord with the foregoing opinion. Thus, it is within this framework upon which the court evaluates the matter at hand.

As an initial matter, upon a review of defendant’s proffered affidavit, the court notes that the affidavit of Cerean Edwards lacks the name of the person whom it was sworn printed beneath the signature as required by CPLR 2101 (a). However, CPLR 2101 (f) states:

“(f) Defects in form; waiver. A defect in the form of a paper, if a substantial right of a party is not prejudiced, shall be disregarded by the court, and leave to correct shall be freely given. The party on whom a paper is served shall be deemed to have waived objection to any defect in form unless, within fifteen days after the receipt thereof, the party on whom the paper is served returns the paper to the party serving it with a statement of particular objections.”

To the extent that plaintiff’s counsel did not proffer any objection to the affidavit in its opposition papers and the same does not prejudice a substantial right of plaintiff, the court finds such defect to have been waived (see generally Devonshire Surgical Facility, LLC v Allstate Ins. Co., 38 Misc 3d 127[A], 2012 NY Slip Op 52351[U] [App Term, 1st Dept 2012]; Complete Orthopedic Supplies, Inc. v State Farm Mut. Auto. Ins. Co., 23 Misc 3d 5 [App Term, 2d Dept, 2d & 11th Jud Dists 2009]).

As to the facts of this case, defendant contends that upon receipt of the bills at issue, defendant issued an initial demand for EUO scheduled for March 23, 2015.^[FN1] When plaintiff failed to appear, defendant issued a request dated March 26, 2015 for{**56 Misc 3d at 930} EUO on April 14, 2015. Defendant contends that plaintiff failed to appear and thus issued another request dated April 20, 2015 for EUO on May 8, 2015. When plaintiff failed to appear, defendant issued a request dated May 19, 2015 for EUO on June 16, 2015. As plaintiff failed to appear for the fourth time, defendant issued a denial dated June 24, 2015.^[FN2]

In the instant matter, the court finds that defendant submitted sufficient proof in admissible form to demonstrate that the EUO scheduling letters were properly and timely mailed. Upon review of the affidavit of Cerean Edwards, defendant’s claims associate, the court finds that defendant, through its standard office policies and procedures, has established the timely and proper mailing of its letters scheduling plaintiff’s EUO and the denials at issue (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2d Dept 2008]; Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co., 36 Misc 3d 156[A], 2012 NY Slip Op 51767[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]; Hollis Med. Servs., P.C. v GEICO Ins. Co., 36 Misc 3d 156[A], 2012 NY Slip Op 51768[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]). Defendant also proffered the affirmation of Ryan Goldberg, Esq., who affirmed that he was present in the office to conduct the examination under oath of plaintiff on March 23, 2015, April 14, 2015, May 8, 2015 and June 16, 2015 and that plaintiff failed to appear for the same. The court finds that the affirmation sufficiently demonstrated plaintiff’s nonappearances (see Olmeur Med., P.C. v Nationwide Gen. Ins. Co., 41 Misc 3d 143[A], 2013 NY Slip Op 52031[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]).

Thus, in this instance, the court finds that the insurer’s one-day tardiness in issuing its follow-up request for the EUO scheduled for June 16, 2015 to be a technical defect excusable under 11 NYCRR 65-3.5 (p). Further, under 11 NYCRR 65-3.5 (p), plaintiff’s obligation to appear for an EUO was not negated{**56 Misc 3d at 931} based upon the one-day tardiness in light of the fact that there were three prior EUOs previously scheduled in a timely manner, where plaintiff failed to appear for all four scheduled EUOs and where plaintiff “failed to allege, much less prove, that it had responded in any way to the EUO requests at issue” (Professional Health Imaging, P.C. v. State Farm Mut. Auto. Ins. Co., 52 Misc 3d 134[A], 2016 NY Slip Op 51026[U], *1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]). Similarly, in Infinity Health Prods., Ltd. v Eveready Ins. Co. (67 AD3d 862 [2d Dept 2009]), the Appellate Division, in reversing the Appellate Term’s determination in favor of plaintiff where defendant’s follow-up request for additional verification was sent three days prior to the expiration of a full 30 calendar days as dictated by 11 NYCRR former 65-15 (e) (2) (now 11 NYCRR 65-3.6 [b]), stated the following:

“Indeed, in light of the particular factual circumstances herein, it would be incongruous to conclude that the Insurance regulation regarding follow-up verification, or any other statute or rule, warrants a result which would, in effect, penalize an insurer who diligently attempts to obtain the information necessary to make a determination of a claim, and concomitantly, rewards a plaintiff who makes no attempt to even comply with the insurer’s requests.” (Infinity Health Prods., Ltd. v Eveready Ins. Co., 67 AD3d 862, 865 [2d Dept 2009]; see also Triangle R Inc. v Praetorian Ins. Co., 30 Misc 3d 129[A], 2010 NY Slip Op 52294[U] [App Term, 1st Dept 2010].)

To the extent that this court finds 11 NYCRR 65-3.5 (p) applicable to the unique set of facts and circumstances before it, the court notes that this provision may invariably create additional litigation rather than serving the purpose of the no-fault legislation, which is to encourage expeditious resolution of claims (see New York Hosp. Med. Ctr. of Queens v Motor Veh. Acc. Indem. Corp., 12 AD3d 429, 430 [2004], quoting Dermatossian v New York City Tr. Auth., 67 NY2d 219, 225 [1986]). Thus, even in finding in favor of defendant in this matter, the court notes that such ruling is limited to the facts and circumstances of the instant case.

Therefore, based upon the foregoing, plaintiff’s motion for summary judgment is denied. Defendant’s cross motion for summary judgment is granted and plaintiff’s complaint is dismissed.

Footnotes

Footnote 1:The court notes that as to the two bills at issue, both demands were made one to two business days beyond the requisite 15 business days and as such, the number of days beyond 15 business days would only reduce the calendar days allowed for the issuance of a denial pursuant to 11 NYCRR 65-3.8 (l).

Footnote 2:The court notes that the affidavit of defendant’s affiant, Cerean Edwards, contained what appears to be a scrivener’s error in part II, paragraph 10, where Ms. Edwards states that plaintiff did not appear for the EUO on April 14, 2015. When read in whole, the date denoted by Ms. Edwards does not appear to be correct. However, the same is without any consequence as only an attorney affirmation adequately demonstrates plaintiff’s nonappearances for the scheduled EUOs.

[*1]

Civil Court of the City of New York, Kings County, December 8, 2016

APPEARANCES OF COUNSEL

Law Offices of Ilona Finkelshteyn, P.C., Brooklyn, for plaintiff.

Law Offices of Daniel J. Tucker, Brooklyn, for defendant.

Plaintiff Clear Water Psychological Services PC seeks to recover no-fault benefits assigned to it by Oshane Crooks (assignor) and moves for summary judgment on the grounds that the bills it submitted to American Transit Insurance Company remain unpaid. Defendant cross-moves for a 90-day stay of the action pending a determination by the Workers’ Compensation Board as to whether the assignor was acting as an employee at the time of the subject automobile accident which occurred on November 10, 2014, and whether he is entitled to workers’ compensation benefits.

At issue is the admissibility of the signed but uncertified police accident report dated November 10, 2014, which indicated that at the time of the accident, the assignor was driving a vehicle with a taxi license plate number and that there were two passengers in the vehicle, to establish that the assignor was acting in the course of his employment. Defendant submits that the report mandates that the 90-day stay be granted.

Facts stated in a police report are not admissible unless they constitute an exception to the hearsay rule (Memenza v Cole, 131 AD3d 1020, 1021-1022 [2d Dept 2015]). If the report is based upon the officer’s personal observations while carrying out police duties, it is admissible as a business record. (Id.; CPLR 4518 [a]; Wynn v Motor Veh. Acc. Indem. Corp., 137 AD3d 779, 780 [2d Dept 2016]; see also Bhowmik v Santana, 140 AD3d 460, 461 [1st Dept 2016] [police accident report, in which officer recorded his own observations that the plaintiff smelled of alcohol and appeared to be intoxicated, was not based on hearsay, and was therefore admissible].)

Pursuant to Vehicle and Traffic Law §§ 603-a and 604, whenever a motor vehicle accident results in serious physical injury, and such accident either is discovered by a police officer, or reported to an officer within five days after an accident, it is the duty of the police to immediately investigate the facts and complete a report on a form prescribed by the Commissioner of Motor Vehicles, a copy of which shall be sent to the Commissioner{**54 Misc 3d at 917} within five business days of the completion of such investigation report (People v Quackenbush, 88 NY2d 534, 539 [1996]; Bouet v City of New York, 125 AD3d 539, 540 [1st Dept 2015]). In New York City, the prescribed police accident report (PAR) is the MV-104AN. (See State of New York Department of Motor Vehicles, Police Accident Report Manual, https://dmv.ny.gov/forms/p33Part01.pdf.)

In the instant action, Police Officer (P.O.) Stephenson filled out this form. The fifth line on the PAR asks for the plate numbers of the vehicles involved in the accident, and the table following line 7 asks for a list of all involved in the accident. As P.O. Stephenson filled out the particulars of the license plate number and the names of the passengers, one can only conclude that his notations were based on his personal observations at the scene of the subject accident.

Although the MV-104AN is signed at the bottom by P.O. Stephenson, it is not certified, and defendant’s cross motion for summary judgment does not contain an affidavit or other sworn evidence from someone with personal knowledge establishing its authenticity or accuracy. CPLR 4518 (c) permits a police report to be admitted as proof of the facts recorded therein only if “[it] bear[s] a certification or authentication by the head of the . . . [police] department . . . or by an employee delegated for that purpose.” Since the MV-104AN is not certified, it does not qualify for admission under CPLR 4518 (c) (Nationwide Gen. Ins. Co. v Bates, 130 AD3d 795, 796 [2d Dept 2015]; Adobea v Junel, 114 AD3d 818 [2d Dept 2014]; Cheul Soo Kang v Violante, 60 AD3d 991 [2d Dept 2009]).

Although the PAR may not be admitted into evidence in its current form, defendant’s motion still presents factual questions regarding the assignor’s status as an employee of a taxi base, as plaintiff does not dispute the truthfulness of P.O. Stephenson’s observations that the vehicle involved in the subject accident had a taxi license plate. Pursuant to Workers’ Compensation Law § 2 (3) and (4), the term “employer” includes a person or entity who leases a taxicab, and concomitantly, the term “employee” includes “a driver, operator or lessee who contracts with an owner, operator or lessor for the purpose of operating a taxicab” (see Matter of Mihalaris v UTOG 2-Way Radio, 299 AD2d 677, 678 [3d Dept 2002]). The question of the assignor’s employment status and his entitlement to benefits under the Workers’ Compensation Law must be resolved at a hearing before the Board, which has primary jurisdiction over{**54 Misc 3d at 918} deciding these matters (Siekkeli v Mark Mariani, Inc., 119 AD3d 766, 768 [2d Dept 2014]; Dunn v American Tr. Ins. Co., 71 AD3d 629, 630 [2d Dept 2010]; Speroni v Mid-Island Hosp., 222 AD2d 497, 498 [2d Dept 1995]).

In light of the above, defendant’s motion is granted to the extent that this action shall be [*3]stayed for 90 days pending a prompt application to determine the applicability of the Workers’ Compensation Law to plaintiff’s claim.

[*1]

Civil Court of the City of New York, Kings County, December 8, 2016

APPEARANCES OF COUNSEL

Law Offices of Aloy O. Ibuzor, New York City, for defendant.

The Rybak Firm, PLLC, Brooklyn (Oleg Rybak of counsel), for plaintiff.

The novel issue presented is whether a no-fault insurer must request examinations under oath (EUOs) of all conceivable entities within 15 business days of receipt of a written notice of claim, as provided in 11 NYCRR 65-3.5 (b), or whether its 15 days in which to request an EUO starts anew after it completes one EUO and discovers the need for an additional EUO of another entity.

Plaintiff Sure Way NY, Inc. seeks to recover from defendant Travelers Insurance Co. no-fault benefits for services and medical equipment it provided to its assignor Rachel Constantino for alleged injuries she sustained in a motor vehicle accident which occurred on July 26, 2013.

Defendant received plaintiff’s two bills on September 16, 2013 (first bill), and October 2, 2013 (second bill), respectively, and made two successive verification requests for each bill seeking, inter alia, documentation describing the equipment provided, including wholesale invoices, information regarding the model number, manufacturer, and serial number, and cancelled checks used to pay the invoices. Defendant made verification requests on the two bills between September and November 2013. Petitioner does not challenge the timeliness of these requests.

On December 19, 2013, while the requested verification remained outstanding, defendant conducted an EUO of the assignor, which plaintiff also concedes was timely. The assignor’s testimony raised questions regarding the accuracy of the billing and coding associated with the claims submissions, and the legal relationship between the plaintiff’s corporation and the individuals who performed the services. As a result, on January 9, 2014, defendant sent a letter to plaintiff requesting that it appear for an EUO scheduled for January 29, 2014. After plaintiff failed to appear for the EUO, defendant sent a second{**56 Misc 3d at 291} scheduling letter to plaintiff dated January 31, 2014, requesting that plaintiff appear for an EUO on February 18, 2014. Plaintiff again failed to appear.

Based upon plaintiff’s failure to respond to the verification requests and failure to appear for the two scheduled EUOs, defendant issued a denial of plaintiff’s claims on February 20, 2014. Plaintiff does not dispute that it failed to respond to the verification requests or that it failed to appear for the EUOs. Defendant moves for summary judgment on the grounds that plaintiff breached a condition precedent to coverage by failing to attend the EUOs. Plaintiff cross-moves for summary judgment on the ground that defendant did not timely mail a request for an EUO within 15 days of its receipt of plaintiff’s claim.

In Prestige Med. P.C. v Travelers Home & Mar. Ins. Co. (56 Misc 3d 284 [Civ Ct, Kings County 2014]), this court held that before an insurance company can take advantage of denying a claim for failure to appear for an EUO beyond the 30-day period pursuant to Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC (82 AD3d 559 [1st Dept 2011]), it must first comply with the notification time lines contained in the verification procedures. This court reached this result because an EUO, as cogently noted by the Honorable Fred J. Hirsh in Tarnoff Chiropractic, P.C. v GEICO Ins. Co. (35 Misc 3d 1213[A], 2012 NY Slip Op 50670[U], *5 [Nassau Dist Ct 2012]), “is a hybrid between a condition precedent to coverage and verification.” Thus, most of the procedural time lines governing EUOs are contained in the regulations relating to verification. (Prestige at 286; see also Country-Wide Ins. Co. v Castro, 2016 NY Slip Op 31505[U] [Sup Ct, NY County 2016].)

11 NYCRR 65-3.5 details the verification procedures to be followed after the insurer receives the completed application for no-fault benefits (NYS form N-F 2). The injured party or that party’s assignee (medical services provider) must then submit written proof of claim (claim form—usually verification of treatment by attending physician or other health care provider—NYS form N-F 3) to the insurer within 45 days after the date the medical services are rendered (Prime Psychological Servs., P.C. v Nationwide Prop. & Cas. Ins. Co., 24 Misc 3d 230, 233 [Civ Ct, Richmond County 2009]). 11 NYCRR 65-3.5 (b) authorizes an insurer, upon [*2]receiving the written proof of claim or its substantial equivalent written notice, to request{**56 Misc 3d at 292} “any additional verification required . . . to establish proof of claim . . . within 15 business days of receipt of the prescribed verification forms.” (Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294, 299 [2007]; see A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co., 101 AD3d 53 [2d Dept 2012]; Prestige at 286.) By properly requesting additional verification within 15 days from the receipt of the proof of claim form, an insurer may toll the 30-day period in which it must deny the claim. (Prestige at 286, citing Prime Psychological Servs., 24 Misc 3d at 233.) If the requested verification has not been supplied to the insurer within 30 days after the original request, the insurer shall, within 10 days, follow up upon its request for verification either by a telephone call or by mail (11 NYCRR 65-3.6 [b]).

EUOs and independent medical examinations (IMEs) are considered to be part of an insurer’s “entitlement to ‘additional verification’ ” following receipt of a provider’s statutory claim forms (Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 18, 19 [App Term, 2d Dept, 2d & 11th Jud Dists 2004], affd in part 35 AD3d 720 [2d Dept 2006]; see 11 NYCRR 65-3.5 [d]; see also Prime Psychological, 24 Misc 3d at 233; All-Boro Med. Supplies, Inc. v Progressive Northeastern Ins. Co., 20 Misc 3d 554 [Civ Ct, Kings County 2008]). Therefore, the written request or demand letter for an EUO must be mailed by an insurer within 15 days of receipt of the proof of claim form (Allstate Ins. Co. v American Comprehensive Healthcare Med. Group, P.C., 2016 NY Slip Op 31175[U] [Sup Ct, NY County 2016]; see National Liab. & Fire Ins. Co. v Tam Med. Supply Corp., 131 AD3d 851, 851 [1st Dept 2015]; American Tr. Ins. Co. v Jaga Med. Servs., P.C., 128 AD3d 441, 441 [1st Dept 2015]; O & M Med., P.C. v Travelers Indem. Co., 47 Misc 3d 134[A], 2015 NY Slip Op 50476[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]; Prestige at 286; see also Unitrin Advantage Ins. Co. v Better Health Care Chiropractic, P.C., 2016 NY Slip Op 30837[U] [Sup Ct, NY County 2016] [an insurer must comply with the no-fault insurance regulations governing the claim procedure which prescribe specific time frames for requesting and scheduling EUOs and IMEs in order to satisfy its prima facie burden on a motion for summary judgment declaring that no coverage exists based on the failure of a claimant or medical provider to appear for an EUO or IME]).

In Prestige, this court ruled, in a case of first impression, that when an insurer obtains new information from an EUO of the assignor, which gives it reason to conduct an EUO of the{**56 Misc 3d at 293} assignee provider, the insurer must send the EUO request to the assignee within 15 business days of the date the EUO of the assignor was held. This court now provides the rationale for this ruling: that the decision to conduct the EUO of the assignee was based upon new information, causing this to be a new verification request, as opposed to a follow-up request upon a party who has not responded or did not respond in full to the initial request for information.

This court then addressed the ramifications that flow from a request for an additional EUO that was not made within the 15 days prescribed in the regulations. It applied precedent governing untimely requests for additional verification to untimely requests for EUOs. In Nyack Hosp. v General Motors Acceptance Corp. (27 AD3d 96 [2d Dept 2005]), the Second Department ruled that when an insurer is late in requesting additional verification beyond the 15-day time period, the insurer’s time to either pay or deny the claim is reduced. Therefore, inasmuch as the defendants mailed the request for additional verification two days beyond the 15-day period, the time within which the defendants had to either pay or deny the claim was reduced from 30 to 28 days. In so ruling, the Appellate Division relied on 11 NYCRR 65-3.8 (l), which states that “[f]or the purposes of counting the 30 calendar days . . . , with the exception of section 65-3.6 [follow-up requirements], any deviation from the rules set out in this section shall reduce the 30 calendar days allowed.” In Prestige, the insurer requested an EUO of the provider four days after the expiration of the 15-day time period from which the assignor’s EUO was conducted, resulting in the provider having to subtract those four days from the 30 days it had to pay or deny the claim after the provider failed to show up for the scheduled EUO follow-up on April 23, 2012.

Similarly here, defendant insurer sent a letter requesting an EUO of the provider on January 9, 2014, some 21 calendar days, or 15 business days, after the EUO was conducted of the assignor on December 19, 2013. It therefore did not have to subtract any days from the 30 days it had in which to issue a denial after the provider failed to appear for its EUO on February 18, 2014. Since defendant issued its denial on February 20, 2014, only two days after the EUO no-show, its denial was timely. Defendant also properly established that it properly generated and mailed the two EUO notification letters, and that the insurer failed to appear for the EUO. (IDS Prop. Cas.{**56 Misc 3d at 294} Ins. Co. v Stracar Med. Servs., P.C., 116 AD3d 1005 [2d Dept 2014]; Synergy First Med., P.L.L.C. v Allstate Ins. Co., 53 Misc 3d 130[A], 2016 NY Slip Op 51365[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]; Professional Health Imaging, P.C. v State Farm Mut. Auto. Ins. Co., 52 Misc 3d 134[A], 2016 NY Slip Op 51026[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]).

Accordingly, the defendant’s motion for summary judgment is granted and the plaintiff’s cross motion for summary judgment is denied.