Coming Soon–New and Exciting Changes to nofaultparadise

Langan affirmed by Court of Appeals (compare with Unitrin, if you want to get aggravated)

State Farm Mut. Auto. Ins. Co. v Langan
2011 NY Slip Op 02437
Decided on March 29, 2011
Court of Appeals
Lippman, Ch. J.
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
This opinion is uncorrected and subject to revision before publication in the Official Reports.

LIPPMAN, Chief Judge: [*2]

At issue in this appeal is whether the insured decedent, the victim of an intentional crime, was injured as the result of an accident within the meaning of the uninsured motorist endorsement and certain other provisions of the insured’s policy. Since the occurrence must be viewed from the insured’s perspective, we conclude that it was indeed an accident and that the insured is entitled to benefits under the policy provisions at issue.

Decedent, Neil Conrad Spicehandler, was struck by a vehicle at 7th Avenue and 32nd Street in Manhattan on February 12, 2002. He sustained a compound fracture of his left lower leg, requiring surgery, and died from complications shortly after the operation. Decedent was one of many who were injured when the driver, Ronald Popadich, intentionally drove his vehicle into pedestrians. Popadich later pleaded guilty to second degree murder and admitted that he intended to cause Spicehandler’s death.

Decedent was an insured under an automobile liability policy purchased by defendant Langan through plaintiff State Farm. As the administrator of decedent’s estate, Langan made a claim seeking to recover benefits under the policy’s uninsured/underinsured motorist (UM) endorsement, mandatory personal injury protection endorsement (PIP endorsement) and death, dismemberment and loss of sight endorsement (Coverage S)[FN1]. The policy’s UM endorsement provides that it “will pay all sums that the insured or the insured’s legal representative shall be legally entitled to recover as damages from the owner or operator of an uninsured motor vehicle because of bodily injury sustained by the insured, caused by an accident arising out of such uninsured motor vehicle’s ownership, maintenance or use” subject to relevant policy exclusions. The PIP endorsement and Coverage S likewise state that they will pay benefits for injuries sustained as the result of “an accident.” These endorsements exclude coverage on several bases, but none specifically excludes coverage for an injury that results from intentional conduct. State Farm denied and disclaimed liability because it determined, as relevant here, that decedent’s death was caused not by an accident, but by the intentional conduct of the operator of the vehicle.

State Farm commenced this declaratory judgment action seeking a declaration that it was not obligated to provide benefits in connection with decedent’s death. Defendant answered and counterclaimed, requesting a declaration that State Farm was required to provide coverage under the policy. Plaintiff’s motion and defendant’s cross motion for summary judgment were denied because the parties had not, at that point, provided the court with information regarding [*3]the outcome of the criminal action against Popadich, which the court deemed “essential” to determining whether decedent’s injuries were caused by an intentional act. The Appellate Division upheld the portion of the Supreme Court order that denied summary judgment on the issue of whether the incident was covered by the policy, finding that there was insufficient proof to determine whether decedent had been the victim of an intentional crime, but that, if he had, the incident would not be covered (18 AD3d 860, 862 [2d Dept 2005]).

After Popadich was convicted of second degree murder, State Farm renewed its motion for summary judgment, again seeking a declaration that it was not required to provide benefits under the policy. Langan opposed the motion and cross-moved for summary judgment, urging that whether the incident was an accident within the meaning of the policy must be determined from the perspective of the insured. Supreme Court granted State Farm’s motion and denied Langan’s cross motion on the basis of Popadich’s conviction.

On appeal, a majority of the Appellate Division modified to declare that State Farm was required to provide benefits under the Mandatory PIP and Coverage S endorsements and, as so modified, affirmed (55 AD3d 281 [2d Dept 2008]). The Court determined that State Farm was not required to provide UM benefits because the purpose of statutorily required uninsured motorist coverage is to provide an individual with the same level of coverage he or she would be entitled to if injured in an accident with an insured motorist covered by an applicable policy. Since a standard liability policy would not have covered Popadich for his intentional criminal conduct, the Court found that Langan’s UM coverage was not applicable under the circumstances presented here. However, the Court determined that in other contexts it was appropriate to determine whether a particular event was an accident from the insured’s point of view, that the incident was clearly unexpected from decedent’s perspective and that, as a result, State Farm was required to provide coverage under the PIP and S Coverage endorsements.

Two Justices dissented in part and would have affirmed Supreme Court’s order declaring that State Farm was not required to provide coverage. The dissent agreed that Langan was not entitled to UM benefits under current law based on Popadich’s intentional conduct, but observed that there had been a recent national trend to allow for coverage in similar circumstances and that strong public policy considerations weighed in favor of coverage. The dissent would have denied PIP and S Coverage benefits based on the law of the case and, in any event, disagreed that the same term should be interpreted differently within the same policy. Both parties appeal pursuant to leave granted by the Appellate Division, which certified for our review the question of whether its order was properly made. We modify and answer the certified question in the negative.

This appeal turns on whether decedent’s injuries were caused by an accident [*4]within the meaning of the policy. Although the endorsements at issue do not define the term “accident,” we have previously held that it is not to be “given a narrow, technical definition,” but should be interpreted according to how it would be understood by the average person (Miller v Continental Ins. Co., 40 NY2d 675, 676 [1976]). We have determined that, for purposes of automobile insurance policies, the term “accident” means an event typically involving violence or the application of external force (see Michaels v City of Buffalo, 85 NY2d 754, 758 [1995]). In order to determine whether a particular event was “accidental, ‘it is customary to look at the casualty from the point of view of the insured, to see whether or not . . . it was unexpected, unusual and unforeseen’” (Miller, 40 NY2d at 677 [citation omitted]). Although we have noted that the perspective of the injured victim should not be used to determine whether an accident has occurred, “‘[b]ecause an injury is always fortuitous to a non-consenting victim’”
(Michaels, 85 NY2d at 759 [citation omitted]), here we have the situation where the victim is also the insured.

It is clear that, viewed from the insured’s perspective, the occurrence was an unexpected or unintended event — and therefore an “accident” — even though Popadich admittedly intended to strike decedent with the vehicle. The language of the policy also suggests that this type of situation would be covered as it was an accident caused by the use of a motor vehicle that did not have an applicable insurance policy. Significantly, Insurance Department regulations require that an automobile owner’s liability insurance policy contain a provision specifying “that assault and battery shall be deemed an accident unless committed by or at the direction of the insured” (11 NYCRR § 60-1.1 [f]). Although the provisions at issue here do not involve liability coverage, the regulation is relevant to the understanding of the extent of coverage provided by the endorsements.

The argument against requiring coverage, advanced by State Farm and relied upon by the Appellate Division, is based on the general principle that mandatory uninsured motorist benefits are meant to provide coverage that is coextensive with, and not greater than, that afforded by a standard liability policy. They rely on our statement that the purpose of mandatory UM benefits is “‘to provide the insured with the same level of protection he or she would provide to others were the insured a tortfeasor in a bodily injury accident’” (Raffellini v State Farm Mut. Auto. Ins. Co., 9 NY3d 196, 204 [2007], quoting Matter of Prudential Prop. & Cas. Co. v Szeli, 83 NY2d 681, 687 [1994]).

In support of its position, State Farm relies on McCarthy v Motor Veh. Acc. Indem. Corp. (16 AD2d 35 [4th Dept 1962], affd 12 NY2d 922 [1963]), a case where the plaintiff-victim was injured when the insured motorist committed an intentional assault against her using his vehicle. After the insurer denied coverage because the occurrence was not an [*5]accident within the meaning of the policy, plaintiff sought to recover under the policy’s MVAIC endorsement — a statutorily required endorsement intended to afford coverage to a person injured by an uninsured or unidentified motorist, equal to that available to one injured by a motorist covered by an applicable liability policy (see McCarthy, 16 AD2d at 38). MVAIC is funded by assessments levied against all of the insurance companies licensed to conduct business in the state (see McCarthy, 16 AD2d at 39). McCarthy held that since an intentional assault committed by an insured motorist was not an accident subject to coverage under the standard liability policy, such an occurrence would likewise be excluded from coverage under the MVAIC endorsement (see McCarthy, 16 AD2d at 43). The Court also determined that allowing recovery under MVAIC would be inconsistent with the purpose for which the special fund had been established (see McCarthy, 16 AD2d at 44).

This case differs from McCarthy in two important respects. First, UM coverage, although required by statute, is part of the insured’s own policy — a policy that the insured selected and for which he pays premiums. Benefits received through coverage under the UM endorsement do not come out of a State fund. Second, the insured is the victim in this case, not the tortfeasor, and the public policy against providing coverage for an insured’s criminal acts is not implicated.

We hold that, consistent with the reasonable expectation of the insured under the policy and the stated purpose of the UM endorsement (to provide coverage against damage caused by uninsured motorists), the intentional assault of an innocent insured is an accident within the meaning of his or her own policy. The occurrence at issue was clearly an accident from the insured’s point of view and Langan is entitled to benefits under the UM endorsement.

This result is also in keeping with the national trend toward allowing innocent insureds to recover uninsured motorist benefits under their own policies when they have been injured through the intentional conduct of another (see e.g. American Family Mut. Ins. Co. v Petersen, 679 NW2d 571 [Iowa 2004]; Shaw v City of Jersey City, 174 NJ 567, 811 A2d 404 [2002]; Wendell v State Farm Mut. Auto. Ins. Co., 293 Mont 140, 974 P2d 623 [1999]). Although the above decisions are not binding on this Court, we are persuaded that the view that has been adopted by these jurisdictions is the better one.

For many of the same reasons, Langan is entitled to coverage under the PIP endorsement and Coverage S. The average insured’s understanding of the term “accident” is unlikely to vary from endorsement to endorsement within the same policy. The occurrence, from the insured’s perspective, was certainly unexpected and unforeseen and should be considered an accident subject to coverage. Contrary to State Farm’s argument, we perceive no danger that this result will frustrate efforts to fight fraud in the no-fault insurance system. Significantly, there is [*6]no allegation whatsoever of fraud in this case and it is patent that benefits should continue to be denied to those who intentionally cause their own injuries.

The argument that Langan is entitled to attorneys’ fees was not addressed by the courts below and should be remitted to Supreme Court for its determination in the first instance.

Accordingly, the order of the Appellate Division should be modified, without costs, by granting defendant judgment declaring in accordance with this opinion and remitting to Supreme Court for further proceedings in accordance with this opinion, and, as so modified, affirmed. The certified question should be answered in the negative.

SMITH, J. (dissenting):

I would affirm the order of the Appellate Division.

As a general matter, it is true that whether a particular event is an “accident” should be viewed from the point of view of the insured. The insured here was Spicehandler, the event was an accident from his point of view, and his estate was therefore properly allowed to recover under the so-called PIP and Coverage S endorsements.

But uninsured/underinsured motorists (UM) coverage is different. Its purpose is to protect an insured who is injured by a tortfeasor without liability insurance — a purpose accomplished by putting the insured in the position that he would have been in if the tortfeasor had been insured. This requires a determination of whether the tortfeasor could have made a claim under a hypothetical policy of liability insurance — and the tortfeasor should thus be treated as the “insured” for purposes of analysis. Since Popadich drove his car into Spicehandler on purpose, the event was not an accident from Popadich’s point of view; Popadich could not have obtained indemnification from a liability insurer; and Spicehandler’s estate should not be permitted to recover under the UM endorsement.

This is essentially what we held when we affirmed the Appellate Division’s decision in McCarthy v Motor Veh. Acc. Indem. Corp. (16 AD2d 35 [4th Dept 1962], aff’d 12 NY2d 922 [1963]). The majority tries to distinguish McCarthy on what it calls two grounds, which seem really to be one — that UM coverage is “part of the insured’s own policy” and that “the insured is the victim in this case, not the tortfeasor” (majority op at 8). The distinction will not withstand analysis. The purpose of UM coverage is the same as the purpose of the MVAIC endorsement at issue in McCarthy: “to afford coverage,” as the majority puts it, “to a person injured by an uninsured or unidentified motorist, equal to that available to one injured by a motorist covered by an applicable liability policy” (majority op at 7-8). The essential rationale for McCarthy is that the victim of an uninsured motorist should not be in a better position than the victim of an insured one. That rationale was sound in McCarthy, and is sound here. [*7]

I see no justification for departing from McCarthy. A more serious argument might be made — though it is not made here — for a more significant change in the law: modifying, in cases involving automobile liability policies required by statute, the general rule that liability insurance cannot cover intentional torts. As McCarthy mentions, a standard automobile liability policy provides coverage only for accidents, and thus would not cover “an assault and battery committed by the insured” (16 AD2d at 41; see also, e.g., Matter of Travelers Indem. Co. v Richards-Campbell, 73 AD3d 1076 [2d Dept 2010]; Matter of Aetna Cas. & Sur. Co. v Perry, 220 AD2d 497 [2d Dept 1995]). This limitation seems to be derived from the long-established rule, based on public policy, that insurance may not indemnify a tortfeasor for intentional wrongdoing (Messersmith v American Fid. Co., 232 NY 161, 165 [1921]; Town of Massena v Healthcare Underwriters Mut. Ins. Co., 98 NY2d 435, 445 [2002]). Courts in some jurisdictions have made compulsory liability insurance an exception to this rule, reasoning that the purpose of liability insurance, to the extent that it is required by law, is to protect injured victims, not tortfeasors, and that victims should be protected no less against intentional than against negligent torts (e.g., Speros v Fricke, 98 P3d 28, 36-38 [Utah 2004]; Dotts v Taressa, 182 W Va 586, 390 SE 2d 568 [1990]; Wheeler v O’Connell, 297 Mass 549, 9 NE 2d 544 [1937]). Whether such an exception is justified, and if so whether it should be created by judges or by legislators, are questions that we should not address until we have a case that presents them.
* * * * * * * * * * * * * * * * *
Order modified, without costs, by granting defendant judgment declaring in accordance with the opinion and remitting to Supreme Court, Nassau County, for further proceedings in accordance with the opinion herein, and, as so modified, affirmed. Certified question answered in the negative. Opinion by Chief Judge Lippman. Judges Ciparick, Graffeo, Pigott and Jones concur. Judge Smith dissents and votes to affirm in an opinion in which Judge Read concurs.
Decided March 29, 2011

Footnotes

Footnote 1: This action solely concerns claims made under Langan’s own policy — not the policy of either the driver or the vehicle.

Third-Party Biller

New York Hosp. Med. Ctr. of Queens v Country Wide Ins. Co.
2011 NY Slip Op 01628
Decided on March 1, 2011
Appellate Division, Second Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
This opinion is uncorrected and subject to revision before publication in the Official Reports.

Joseph Henig, P.C., Bellmore, N.Y., for appellants.
Jaffe & Koumourdas, LLP, New York, N.Y. (Jean H. Kang of
counsel), for respondent.

DECISION & ORDER

In an action to recover assigned first-party no-fault benefits for medical services rendered, the plaintiffs appeal, as limited by their brief, from so much of an order of the Supreme Court, Nassau County (Murphy, J.), entered July 14, 2010, as denied that branch of their motion which was for summary judgment on the first cause of action.

ORDERED that the order is reversed insofar as appealed from, on the law, with one bill of costs payable to the plaintiff New York Hospital Medical Center of Queens, and that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action is granted.

The plaintiffs established their prima facie entitlement to judgment as a matter of law on the first cause of action by submitting, inter alia, the requisite billing forms, the affidavits from its third-party biller, the certified mail receipts, and the signed return-receipt card referencing the patient and the forms, which demonstrated that the plaintiff New York Hospital Medical Center of Queens (hereinafter the plaintiff) mailed the necessary billing documents to the defendant, that the defendant received them, and that the payment of no-fault benefits was overdue (see Insurance Law § 5106[a]; 11 NYCRR 65-3.8[a][1]; Westchester Med. Ctr. v GMAC Ins. Co. Online, Inc., 80 AD3d 603; Westchester Med. Ctr. v Countrywide Ins. Co., 45 AD3d 676; New York & Presbyt. Hosp. v Countrywide Ins. Co., 44 AD3d 729, 730; Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 34 AD3d 532, affd 9 NY3d 312).

In opposition, the defendant failed to raise a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324). The defendant’s verification requests, dated April 22, 2008, and May 22, 2008, respectively, requested “Rev. 01/04 NF5 & Assignment of Benefit Forms signed (No Stamps).” The plaintiff responded by providing exactly what was requested of it. The defendant cannot now complain that the NF5 or the Assignment of Benefits Forms provided by the plaintiff were “outdated,” as its verification requests only sought the January 2004 version of the NF5 Form and its accompanying assignment. Contrary to the Supreme Court’s conclusion, the affidavit of the defendant’s representative was insufficient to raise a triable issue of fact, as the plaintiff’s documented responses demonstrate that it [*2]complied with the defendant’s verification requests.

The defendant’s remaining contentions are without merit.

Accordingly, the Supreme Court should have granted that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action.
DILLON, J.P., COVELLO, FLORIO and HALL, JJ., concur.

New, New Regs

ISSUED 3/3/2011 FOR IMMEDIATE RELEASE

ADDITIONAL PUBLIC COMMENT SOUGHT ON PROPOSED CHANGES TO NO-FAULT AUTOMOBILE REGULATION

The New York State Insurance Department is seeking additional public comment on how the state’s no-fault automobile insurance regulation should be changed to help reduce fraud and abuse and make the no-fault system more user-friendly.

The Department today announced that it has posted a revised working draft of proposed changes to Regulation 68 at this location on the Department’s website, http://www.ins.state.ny.us/r68_link.htm.

Regulation 68 implements the state’s no-fault law which allows accident victims to collect directly from their insurance companies for medical and hospital expenses and lost wages, regardless of who was at fault in an accident.

Since issuing the working draft late in 2009, the Department has solicited feedback by conducting numerous meetings with stakeholders. In addition, the Department received written comments on its proposals from 127 interested parties.

“The Department has worked hard to evaluate all of the input we received. The revised working draft reflects that feedback and it is being made available now to give stakeholders another opportunity to review our proposals and submit additional comments,” Superintendent James Wrynn said.

“We want to make sure that the new rules that are put in place effectively address the no-fault issues that need to be corrected. At the same time, we need to make sure these new rules are fair and equitable to all,” Wrynn said.

Stakeholders will have 30 days to submit additional comments before the Department finalizes its proposed changes to the regulation. Comments on the working draft can be submitted to the Department directly via the website.

Proposed revisions to Regulation 68 would address such issues as streamlining the claims process, providing insurers with additional tools to combat fraud, overbilling and fee overcharging and reforming the health service exam and exam under oath procedures.

The changes being considered to the no-fault regulation represent the first significant revisions to the regulation since 2002. New York’s no-fault law went into effect in 1974.

According to a report recently released by the Department, there were 12,807 reports of suspected fraud involving no-fault insurance in 2010.

Rare Appellate Division First Department No-Fault Case– Interesting Issue

M.N. Dental Diagnostics, P.C. v Government Employees Ins. Co.
2011 NY Slip Op 01333
Decided on February 22, 2011
Appellate Division, First Department
 
 

Order of the Appellate Term of the Supreme Court of the State of New York, First Department, entered June 24, 2009, which affirmed an order of the Civil Court, Bronx County (Julia I. Rodriguez, J.), entered on or about February 15, 2007, finding the issue of which insurer is the primary insurer must be submitted to arbitration, unanimously affirmed, with costs.

Insurance Law § 5105(b) requires that mandatory arbitration be used to resolve all disputes between insurers as to their responsibility for the payment of first-party benefits. 11 NYCRR 65-3.12(b) provides that “[i]f a dispute regarding priority of payment arises among insurers who otherwise are liable for the payment of first-party benefits, then the first insurer to whom notice of claim is given . . . shall be responsible for payment to such person. Any such dispute shall be resolved in accordance with the arbitration procedures established pursuant to section 5105 of the Insurance Law and section 65-4.11 of this Part.”

Defendant argues that its denial of benefits raised an issue of coverage, rather than of payment, because it was not “otherwise [] liable” for the payment of first-party benefits. However, 11 NYCRR 65-4.11(a)(6) provides that “any controversy between insurers involving the responsibility or the obligation to pay first-party benefits (i.e., priority [of] payment or sources of payment as provided in section 65-3.12 of this Part) is not considered a coverage question and must be submitted to mandatory arbitration under this section.” Thus, as “the first insurer to whom notice of claim [was] given” (11 NYCRR 65-3.12[b]), defendant was responsible or obligated to pay the no-fault benefits for the health services provided by plaintiff, irrespective of any issues of priority or source of payment. By denying plaintiff’s claim on the stated ground that no-fault benefits were payable by another insurer (Fidelity and Guaranty Insurance Co.), defendant raised an issue as to which insurer was obligated to pay first-party [*2]benefits, which “[c]learly . . . is an inter-company dispute subject to mandatory arbitration” (see Paramount Ins. Co. v Miccio, 169 AD2d 761, 763 [1991], lv denied
78 NY2d 851 [1991]; Matter of Pacific Ins. Co. v State Farm Mut. Auto. Ins. Co., 150 AD2d 455, 456 [1989]).

New York’s Auto Insurers Are Not Profitable!!! (So stop saying they are)

Each year up in Albany the insurance industry lobbies the Legislature for changes to New York’s auto insurance laws.  Mandatory arbitration.  Preclusion lift.  Strip the claimant of the right to cross-examine the peer doctor.  Take away the right to assign.  Straight-faced, they tell legislators that they are unprofitable, and if these changes aren’t made they will have to leave the market.   They cite the same report every year, issued by the same Industry-funded organization, telling the doom and gloom of what its like for NY auto insurers.  Some Legislators fall for it, some don’t.  At the same time, these same auto insurers blitz TV, radio, print and every other imaginable media with an inane amount of advertisements, competing with each other to corner the market of the allegedly unprofitable New York auto insurance business.   Weird, right?  Gluttons for punishment? 
Each year I wait for the National Association of Insurance Commissioners (“NAIC”") report on insurer profitability.  NAIC, created in 1871, is the organization of insurance regulators from the 50 states, the District of Columbia and the five U.S. territories. It is neither an industry-backed, nor a provider-backed, organization.  In a word, it is impartial.  Anyway, the 2010 version of the report was recently released.  The 384 page report examines the profitability in property/casualty insurance by state and by line of insurance. In other words, in addition to every other piece of information you could possibly want to know, the report tells exactly how much New York’s auto insurers collected in premiums, how much they paid out, and how those numbers compare to the rest of the nation.  Here are some of the numbers, and I only hope the Legislators take the time to review the report, rather than rely on industry-funded propaganda. 
Auto insurers alone collected $9.9 BILLION in premiums from New Yorkers in 2009 (the last year for which data was available).  They paid $6.5 BILLION (66.2%) in incurred losses (net paid losses during the current year plus the change in loss reserves since the prior year end) for ALL auto insurance.  That’s a $3.4 BILLION “surplus.”  Over the last 10 years, New York’s auto insurers have averaged 62% in incurred losses, better than the nationwide average of 63.2%.  The past 3 years, New York’s auto insurers have averaged 63.6% in incurred losses, while the nationwide average was 63%.   By comparison, in 2009, Michigan’s auto insurers had incurred losses of 114%.  Florida- 70.2%.  New Jersey- 73.7%.  Kentucky 70.9%.  Oklahoma- 67.3%.  Arkansas- 65%.  Colorado- 65.9%.  Delaware- 66.9%.  Maryland- 65.8%.  Massachusetts- 64.4%.

Go figure.

Acupuncture Fee Schedule Tossed

RAZ Acupuncture PC a/a/o Cornejo Norma, Plaintiff v. GEICO General Ins. Co., Defendant, 013670/09

After the attorneys for the plaintiff made their motion based upon the New York State Constitution to determine whether the actions of the Workers’ Compensation Commission were invalid, the attorneys for the defendant failed to address a single issue put forth in the moving papers. Instead, while they addressed issues not raised by plaintiff’s counsel, they never addressing the state constitutional issues. The issues raised in the defense counsel’s papers were similarly not addressed by the plaintiff’s counsel in its reply. And so this court was left to its own resources in determining the issues involved.

 The Workers’ Compensation Commission must have recognized the fact that they had failed to file the requisite fee schedules and what the effects might be. Thus, shortly after the plaintiff’s motion was made, the Workers’ Compensation Commission did, in fact, file the acupuncturists fee schedules with the Secretary of State, thereby apparently acknowledging its obligation to file, inasmuch in the schedules there was no discretion given to anyone as to whether to apply the fee schedule, and thus required mandatory action accordingly.

 This court makes the determination herein, that the application of a Workers’ Compensation fee schedule to determine payment for acupuncture services under an automobile No-Fault scenario, as adopted by the Superintendent of Insurance in his Advisory Opinion dated October 6, 2004, is invalid, because the application thereof fails to substantially comply with the procedures required by Article IV, Section 8 of the New York Constitution and the State Administrative Procedure Act, since it was not first properly filed and published with the Department of State. Nonetheless, this determination will have little impact on prior no-fault determinations as to acupuncturist fees since almost all prior determinations resulted in judgments no longer appealable. However, from the time of the filing of the schedules with the Secretary of State, the schedules will thenceforth be valid.

 The purpose of Article IV, Section 8 of the New York Constitution1 was to assure public knowledge of regulations having the force and effect of the law (People v. Cull, 26 Misc2d 668 [1961]; affd 10 NY2d 123 [1961]). Whether filing and publication is required depends upon the nature of the policy; if it is merely an interpretation or explanation of a preexisting rule or general policy, filing is not required; if it implements or applies law, filing and publication is required. (Cubas v. Martinez, 8 NY3d 611 [2007]; State Administrative Procedure Act §102[2][a][i]; [b][iv]). Anything which the agency does not file, and which the courts hold to be a rule or regulation, will be denied by the courts the legal effect that would be accorded to it if it were filed.

 The State Administrative Procedure Act defines what constitutes a rule2, as well as what is not included in that definition (State Administrative Procedure Act §102[2][a]; [2][b]). “[R]ates subject to prior approval by the superintendent of insurance” are not considered to be rules (State Administrative Procedure Act §102[2][b][ix]). Under New York Insurance Law, rates payable to medical providers under no-fault insurance is not a rate subject to prior approval.3 The Court of Appeals has acknowledged that their “cases show that there is no clear bright line between a ‘rule’ or ‘regulation’ and interpretive policy” (Cubas v. Martinez, 8 NY3d at 621), but has said that “[o]nly a fixed, general principle to be applied by an administrative agency, without regard to other facts and circumstances relevant to the regulatory scheme of the statute it administers, constitutes a rule or regulation required by NY Constitution, article IV, §8…to be filed in the office of the Department of State and published in the State Register” (New York City Transit Authority v. New York State Department of Labor 88 NY2d 225, 229 [1996]; citing Matter of Roman Catholic Dioceses v. New York State Dept. of Health, 66 NY2d 948, 951 [1985]; Matter of Schwartfigure v. Hartnett, 83 NY2d 296, 301 [1994]; Matter of Cordero v. Corbisiero, 80 NY2d 771, 772-773 [1992]). In New York City Transit Authority v. New York State Department of Labor, 88 NY2d 225, the Court of Appeals held that where the Department of Labor (DOL) imposed penalties on the Transit Authority during health and safety inspections based on guidelines in a DOL manual that was not filed and published, the DOL’s penalty guidelines did not constitute a rule or regulation required by the New York Constitution to be filed with the Secretary of State because the penalty guidelines allowed for discretion (in what penalties were to be imposed and in what amount), and did not establish a “rigid, numerical policy invariably applied across-the-board to all claimants without regard to individualized circumstances or mitigating factors” (Id. at 230; see also Matter of Schwartfigure v. Hartnett, 83 NY2d at 301).

 In Rubin v. Campbell (48 NY2d 805, 807 [1979]), the Court of Appeals held that “the failure to file [a regulation with the Secretary of State] did not divest [the Department of Health] of their inherent power to police the quality and value of services rendered by physicians participating in the Medicaid program and to take remedial measures against those whose services are found to be inadequate”. Although the determinations made by the Department of Health were upheld despite the regulations not being properly filed with the state, the regional health director for the Department of Health, like the DOL inspectors in Transit Authority, supra, had discretion to determine what violations had been committed and what penalty should be invoked. “Since these standards vest the decision makers with significant discretion with which to independently exercise their professional judgment, the standards constitute not ‘rules’ but guidelines.” Medical Socy of State v. Serio, 100 NY2d 854, 868 [2003]; citing Schwartfigure v. Hartnett, 83 NY2d at 301.

 ”The Superintendent of Insurance has power to prescribe regulations to effectuate the powers given to him by law and to interpret, clarify and implement legislative policy provided that his regulations are not inconsistent with some specific statutory provision”, (In re Midwest Mutual Insurance Company, 96 AD2d 530 [2nd Dept 1983]; see also Medical Socy of State v. Serio, 100 NY2d at 863-864; Ostrer v. Schenck, 41 NY2d 782, 785 [1977]). In Midwest Mutual, the superintendent’s “Circular Letter No. 2″, which attempted to impose a requirement to notify an insured of a 15-day grace period following notice of cancellation by letter, did not constitute an official regulation because it was not filed in the Department of State, in violation of Article IV, Section 8. Midwest Mutual at 530, 531. Similarly, where new regulations were not promulgated by the Superintendent of Insurance in substantial compliance with the requirements of State Administrative Procedure Act, the new regulations were “invalid, null and void, and, as a matter of law, their promulgation by [the Superintendent of Insurance] was arbitrary, capricious and an abuse of discretion” (Matter of Medical Socy of State of NY v. Levin, 185 Misc2d 536 [Sup Ct, NY County 2000], affd 280 AD2d 309 [1st Dept 2001]; cited by Medical Socy of State v. Serio, 100 NY2d at 862).

 In the case-at-hand, the crucial question becomes: was the fee schedule adopted by the Superintendent of Insurance one in which there was discretion in application, or did the fee schedule establish a “rigid, numerical policy invariably applied across the board”? 88 NY2d at 229.

 In his October 6, 2004 advisory opinion, the Superintendent stated that the No Fault Insurance fee schedule would include the fee schedule adopted by the Workers’ Compensation Board on October 1, 2003 for acupuncture services provided by doctors and chiropractors licensed to perform acupuncture. Since the fee schedules were not published, whether the use of the schedules as a reference violates the procedures required by Article IV, Section 8, depends on whether the fee schedules were to be used as guidelines in making a determination, or whether they were determinative payment amounts for services. As there was no discretion in adjusting the amount of the fee based on “individualized circumstances or mitigating factors” (Transit Authority at 230), the application of the fee schedule in this case is invalid. Therefore, it is

ORDERED, that the application of the fee schedule is hereby determined to be invalid, and it is further

 ORDERED, that the plaintiff is entitled to recover the fair and reasonable value of the acupuncture bills rendered, which will require a trial or hearing on the merits of each case unless the parties can agree to stipulate to another basis for determination.

1. Article IV, Section 8 states: “No rule or regulation made by any state department, board, bureau, officer, authority or commission, except such as relates to the organization or internal management of a state department, board, bureau, authority or commission shall be effective until it is filed in the office of the department of state. The legislature shall provide for the speedy publication of such rules and regulations, by appropriate laws.”

2. According to the State Administrative Procedure Act §102[2][a], “‘Rule’ means (i) the whole or part of each agency statement, regulation or code of general applicability that implements or applies law, or prescribes a fee charged by or paid to any agency or the procedure or practice requirements of any agency, including the amendment, suspension or repeal thereof and (ii) the amendment, suspension, repeal, approval, or prescription for the future of rates, wages, security authorizations, corporate or financial structures or reorganization thereof, prices, facilities, appliances, services or allowances therefore or of valuations, costs or accounting, or practices bearing on any of the foregoing whether of general or particular applicability.”

3. Rates or rating plans that require prior approval by the superintendent include rate filings for: “(1) workers’ compensation insurance; (2) motor vehicle insurance, or surety bonds, required by section 370 of the VTL; (3) joint underwriting; (4) motor vehicle assigned risk insurance; (5) insurance issued by the New York Property Insurance Underwriting Association; (6) risk sharing plans authorized by 2318 of this article; (7) title insurance; (8) medical malpractice liability insurance; (9) insurance issued by the Medical Malpractice Insurance Association; (10) mortgage guaranty insurance; (11) credit property insurance, as defined in section 2340 of this article; and (12) gap insurance; (13) private passenger automobile insurance.” NY ISC Law §2305[b].

 

Wow

According to the New York Post, the New York State Insurance Department, which has been around for 150 years, will be disbanded and consolidated into a single agency with the Banking Department and the Counsumer Protection Board.  According to the report, Governor Cuomo became convinced that the agencies were ”outdated in an era when insurance companies often function as banks and engage in securities and other investment-type businesses.”  Wow.

Updated: Tue., Jan. 4, 2011, 1:46 AM home

Gov forming super watchdog

By FREDRIC U. DICKER and BRENDAN SCOTT, Post Correspondents

ALBANY — Gov. Cuomo will reveal plans tomorrow to replace the powerful Banking and Insurance departments, as well as the lesser-known Consumer Protection Board, with a less costly single agency, as he delivers a grim first State of the State Address, The Post has learned.

The Banking Department, which traces its history to 1782, has enormous regulatory power over all state-chartered banks and lending institutions. The Insurance Department, formed in 1860, plays a key role in regulating virtually all insurance companies that operate in New York.

Both employ thousands of state workers, and the unprecedented consolidation is expected to lead to a significant labor reduction. But sources said the consolidation would produce a more efficient agency with even stronger industry oversight.

Cuomo was said by a source familiar with the decision to have become convinced during his four years as attorney general that the two massive regulatory agencies were “outdated in an era when insurance companies often function as banks and engage in securities and other investment-type businesses.”

Cuomo also plans to fold the far smaller consumer agency into the new department because many of its functions already are carried out by the Attorney General’s Office and other state agencies.

Creating the powerful regulatory agency will need approval from the Legislature.

Cuomo will lay the foundation for the most sweeping set of budget cuts since the Great Depression in what some are calling a “pain and suffering” State of the State Address to New York’s 212 lawmakers and more than a thousand private citizens.

In an effort to help generate a climate willing to accept severe budget cuts, Cuomo announced he was cutting his own pay, that of Lt. Gov. Robert Duffy and dozens of top staffers by 5 percent.

Cuomo’s speech isn’t expected to contain the worst of what’s coming — potentially more than 10,000 state layoffs, the dramatic downsizing of many agencies and the abolition of others, sources said.

App Term 1st on Mailing and some other good stuff

Lenox Hill Radiology, PC v Tri-State Consumer Ins. Co.
2010 NY Slip Op 20530
Decided on December 30, 2010
Appellate Term, First Department
 
 

“Mallela” Trial

Back in 2008, along with Craig Sanders and Andrew Cooper of Hession, Bekoff, Cooper and LoPiccolo,  I conducted a consolidated “Mallela” trial involving 30 cases of Dr. Herbert Rabiner, who those that practice this area of law in New York are familiar.  Dr. Rabiner’s cases have been some of the seminal ones on Mallela-esque issues.  This case, however, was the first time the issue of whether his various MRI P.C.s were  ”Mallela corporations” was tried.  The trial took place over the course of several months before Justice Bernice Daun Siegal.  Dr. Rabiner, his accountant, and various employees testified after being called as witnesses by defendant.  Defendant also proffered a handwriting expert in support of its case.  At the close of defendant’s case, plaintiff moved for and was granted a directed verdict, and defendant appealed.  On appeal, defendant contended:

1.  The Court erred in finding that the defendant failed to establish plaintiff was owned and operated by its management company;

2. The Court erred in finding that defendant had to establish its “fraud” defense by clear and convincing evidence rather than by a preponderance of the evidence;

3.  The Court erred in awarding interest from when the claims became overdue rather than when denials were issued (These cases were from 1990s, so this issue was huge);

4.  The Court erred in awarding compounded interest (same); and

5.  The Court erred in not dismissing the actions as violative of the statute of limitations.

On December 20, the Appellate Term 2nd rendered decisions on the various cases, all affirming Justice Siegal’s rulings.  You can view one of the decisions here.  The others all rely on this one.  For No-Fault dorks, the trial transcript and appellate briefs are well worth the read.  There were a ton of interesting and novel evidentiary issues, and appellate counsel, especially Short and Billy, did a helluva job repping their respective clients.

Check out JT’s blog and Mura’s blog for their takes on this decision.   (And Roy is correct.  The court never reached issue #2, finding that under either standard, defendant failed to establish these were “Mallela” corps.)