Category Archives: Appellate Division

Re-Peers, Depositions of Peers, and Some Questions

A couple of months ago I tried to do some research on 3117(a)(4).  I was more or less trying to understand the impetus behind the provision.  As it turns out, I’m terrible at researching this.  I had a research librarian trying to help me out and I really couldn’t get anything on it.  That said, I’m pretty sure it is a patient treating mechanism, not a money saving mechanism.  The only reason to have a rule that allows for doctors’ depositions to be used at trial is to keep them out of court and in their offices, treating patients.  Lately, a few insurance companies have been using it as a money saving mechanism.  They have one doctor in their (ins co lawyer’s) office all day doing depositions for various cases–the doctors get paid a fixed (lower) rate, and the insurance companies don’t have to pay the doctors to appear at trial.  At trial, the insurance company lawyer reads the deposition into the record.  There is no doubt that CPLR R. 3117(a)(4) is being used as a money saving mechanism.  From experience, I can tell you that the doctors are available to testify.  There are days where they are in court to testify on over five cases for various insurers.  Do I blame them?  No, everyone needs to make a living. The point is, they aren’t treating patients.  The depositions aren’t allowing them to treat more patients.  They still come to court and testify on cases where depositions weren’t held.
Like I said, and I could be wrong (but I doubt it) CPLR R. 3117(a)(4) was not intended to be a money saving mechanism.

Is this something a party really wants to do?  Depositions are a completely different animal than trials.  It’s part of discovery.  Accordingly, there is a lot of leeway.  All those questions that you could never get away with at trial; you can ask them.  The questions need only be relevant.  If the insurance company refuses to allow their doctor to answer and bust the deposition, well, that will be their problem.  There is a lot of interplay between IME doctors, Peer Review doctors, the vendors that work in-between the doctors and the insurance companies.  The insurance companies play a role as well. Do you really want these questions asked?  Do you want the answers memorialized?  I’d guess no.  But, I could be wrong.  In the end, it could wind up costing far more than it would save.

Using this rule is a ballsy move.  One that most parties wouldn’t make but for desperation.  We can all agree that a jury wouldn’t like it.  Would a Judge?  Would anyone feel comfortable telling the trier of fact, especially one that went to law school, and one who is smarter than your average Joe that, “Yes your honor, I didn’t think it important that you see the witness.  No, you don’t have to worry about the witness’ demeanor.  It’s fine, trust me”

Feel free to comment.  If anyone has some insight into the legistlative history of 3117(a)(4), speak up.

If you wind up at one of these depositions, you’ll want to ask questions.  To help you along, here is a list of questions.  Some are stupid, others aren’t.  Feel free to add more in the comments.

  • How many times did you take the boards?
  • Med School grades
  • Has an insurance company ever asked you to change one of your reports?
  • Where did you get the journal cites for your reports?
  • Do you subscribe to any journals?  Which ones?
  • How much do you make from peers/IMEs/testifying
  • Tax records
  • Bank records
  • Has an insurance company or its representative ever withheld records?
  • Has Has an insurance company or its representative ever altered records?
  • How are the peer reviews/IMEs scheduled?
  • Who schedules them?  Insurance Company or Vendor?
  • Do you receive instructions before the peer/IME?  What are they
  • Is there a cover letter?  If so what does it say?
  • Are there any vendors or insurance companies you won’t work for?  If so, why?
  • Has an insurance company ever instructed you on how to testify?

I’ll add more as I think of them.  Add more in the comments if you want.

App. Div. Grants Leave in Alur

Hat tip to Mr. Toell for this one.

Alur Medical Supply, Inc. v Progressive Insurance Company, 2009 NY Slip Op 87894(U), (App. Div., 2nd, 2009) granted leave to appeal Alur Med. Supply, Inc. v Progressive Ins. Co., 2009 NY Slip Op 50657(U) (App. Term, 2nd, 2009)

Putting collateral estoppel to use, but without success

State Farm Ins. Co. v Frias, 2009 NY Slip Op 07825 (App. Div., 2nd, 2009)

Of the 10 defendants named in this action, only 3, Luccme, Urena, and Pedro Fernandez, answered the complaint, and the Supreme Court granted State Farm’s motion for leave to enter a default judgment against the other defendants. State Farm was directed to submit a proposed judgment on notice. Luccme and Urena were served with the proposed judgment, and did not object to its terms or submit a proposed counter-judgment of their own. On October 25, 2006, the Supreme Court entered a judgment against the defaulting defendants. The judgment declared that State Farm was not required to provide insurance coverage to the defaulting defendants because the incident of January 24, 2002, resulted from an intentional act; that, by reason of no coverage and the failure of State Farm’s insured to cooperate, State Farm was not obligated to defend or indemnify Frias or Abreu in any current or future proceeding, including the underlying action; and that State Farm was not required to pay any damages, awards, or benefits to any of the other defaulting defendants in any current or future proceedings, including the underlying action.

State Farm subsequently moved for summary judgment against the three nondefaulting defendants, including Luccme and Urena, based on those parts of the default judgment which declared that the January 24, 2002, collision resulted from an intentional act, and that State Farm was not obligated to defend or indemnify its insureds or to provide any coverage. State Farm argued that, because the three nondefaulting defendants had not proposed a counter-judgment, had not opposed State Farm’s proposed judgment, had not moved for leave to renew or reargue, had not moved to vacate the judgment, and had not appealed from the judgment, they were estopped from challenging the declarations contained in it. Luccme and Urena opposed State Farm’s motion and, in an order entered April 10, 2008, the Supreme Court granted the motion based on the failure of the nondefaulting defendants to oppose the proposed judgment. Luccme and Urena appeal from the resulting judgment. We reverse.

Inasmuch as State Farm initially moved for leave to enter a default judgment against the defaulting defendants only, the resulting judgment binds only those defendants, and may not be given preclusive effect to deprive Luccme and Urena, who appeared in the action, of their right to litigate the issues pertaining to coverage (see American Motorists Ins. Co. v North Country Motors, 57 AD2d 158, 160). Accordingly, we reverse the order insofar as appealed from.

Defendant obtained a default on some of the parties, then tried to use that default as collateral estoppel against the appearing parties.   Sneaky Sneaky.

Yes, this is what I do with my Saturday nights.  I read cases and blog.  I actually made coffee for this, because I was tired but wanted to blog.

Initially I said that Malcom Gladwell’s new book, What The Dog Saw, wasn’t that good; that it was far worse than his other books.  I was wrong.  It isn’t far worse.  More like slightly less than mostly worse.  It isn’t even really a book; it’s a collection of articles he’s written.  One of my favorite articles was, The Art of Failure: Why Some People Choke and Others Panic.  I hope that isn’t telling.  I probably should have found an article on success stories.  Anyway, his distinction between choking and panicking was interesting.  After reading the article, I noticed things that I would have otherwise missed.

There are about 20 articles in the book.  I liked about 8 of them.  Wait for this to come out in paperback.  Next up on the reading list is Superfreakonomics.  If you haven’t read Freakonomics, you should.  I’m almost done with that book on religious freedom.  And I’m still reading everything I said I was reading before.

While you’re here…

Here are some things I’ve found around the interweb that you might find interesting.  Money and Cognitive Bias, from Crime & Federalism.  Monster Energy Drink’s Monstery Conduct, from New York Personal Injury Law Blog.  7 Must Read Productivity Steps to Finally Getting Things Done, from Dumb Little Man.  Big ideas…, from Seth Godin’s Blog.  The Best Decline Letter of All-Time, from The Blog of Author Tim Ferriss.

Finally, I’m still working on the look and feel of this blog.  WordPress is more difficult to figure out that blogger and I don’t have as much time to work on it as I’d like.  Eventually I may have to break down and hire someone to fix it up.  So yeah, I’m working on it.




A bad denial

St. Barnabas Hosp. v Allstate Ins. Co., 2009 NY Slip Op 07824 (App. Div., 2nd, 2009)

“A proper denial of [a] claim [for no-fault benefits] must include the information called for in the prescribed denial of claim form (see 11 NYCRR 65-3.4[c][11]) and must promptly apprise the claimant with a high degree of specificity of the ground or grounds on which the disclaimer is predicated’” (Nyack Hosp. v State Farm Mut. Auto Ins. Co., 11 AD3d 664, 664, quoting General Acc. Ins. Group v Cirucci, 46 NY2d 862, 864). However, a timely denial of a no-fault insurance medical claim alone does not avoid preclusion where said denial is factually insufficient, conclusory, vague, or otherwise involves a defense which has no merit as a matter of law (see Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d 564, 565).

The defendant insurer, Allstate Insurance Company (hereinafter Allstate), issued a timely denial of claim within 30 days of its receipt of the completed hospital facility form (NYS Form N-F 5) from the plaintiff St. Barnabas Hospital, as assignee of Patrick Bateman (hereinafter the plaintiff) (see 11 NYCRR 65-3.5[g], 65-3.8[c]). Contrary to Allstate’s contention, however, the Supreme Court properly determined that the denial of claim, which incorrectly stated the amount of the claim and gave an invalid reason for the denial (see 11 NYCRR 65-3.3[d], 65-3.5[g]; see also Westchester Med. Ctr. v Lincoln [*2]Gen. Ins. Co., 60 AD3d 1045, 1046; Nyack Hosp. v Encompass Ins. Co., 23 AD3d 535, 536), was fatally defective (see Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d at 565; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 11 AD3d at 665; Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 226 AD2d 613, 614). Thus, Allstate failed to demonstrate the existence of a meritorious defense (see CPLR 5015[a][1]).

A.M. Med. Servs., P.C. v Avis Rent A Car, 2009 NY Slip Op 52177(U) (App. Term, 2nd, 2009)

In order to vacate the order granting plaintiff’s unopposed motion for summary judgment and the judgment entered pursuant thereto, defendant was required to establish both a reasonable excuse for its default and a meritorious defense (see CPLR 5015 [a] [1]; Eugene Di Lorenzo, Inc. v Dutton Lbr. Co., 67 NY2d 138, 141 [1986]). The affidavits submitted by defendant in support of its motion suffice to establish that defendant had a reasonable excuse for its failure to oppose plaintiff’s motion for summary judgment.

Defendant also demonstrated that it has a meritorious defense and raised a triable issue of fact. The affidavit submitted by defendant sufficiently established that the denial of claim forms were timely mailed in accordance with defendant’s standard office practice and procedure (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Furthermore, defendant submitted two affirmed peer review reports, each explaining why the services billed for were not medically necessary (see A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

EUO No-Show–DJ Denied

Progressive Northeastern Ins. Co. v Arguelles Med. P.C., 2009 NY Slip Op 32353(U) (Sup Ct, NY County 2009)

App. Div. 4th

Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co., 2009 NY Slip Op 06984 (App. Div., 4th)

Plaintiff, as assignee of 14 patients to whom it provided radiological services, commenced this action seeking to recover no-fault benefits pursuant to the contract between each patient and defendant insurer. We conclude that Supreme Court properly denied plaintiff’s motion for summary judgment on the amended complaint. Although plaintiff made a prima facie showing of entitlement to judgment as a matter of law by submitting evidence that the prescribed statutory billing forms were received by defendant and that defendant’s payment of no-fault benefits to plaintiff was overdue (see A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779, 780; LMK Psychological Servs., P.C. v Liberty Mut. Ins. Co., 30 AD3d 727, 728), defendant raised a triable issue of fact by submitting its denial of claim forms setting forth that the services for which plaintiff sought to recover no-fault benefits were not medically necessary (see Countrywide Ins. Co. v 563 Grand Med., P.C., 50 AD3d 313, 314; A.B. Med. Servs., PLLC, 39 AD3d at 780-781). Contrary to plaintiff’s contention, defendant is not precluded from denying the claims after the services were rendered on the ground of lack of medical necessity. Plaintiff’s assignors were entitled only to reimbursement for medically “necessary” expenses (Insurance Law § 5102 [a] [1]; seesee Long Is. Radiology v Allstate Ins. Co., 36 AD3d 763, 765). 11 NYCRR 65-1.1 [d]), and plaintiff assignee is subject to that lack of medical necessity defense (see Long Is. Radiology v Allstate Ins. Co., 36 AD3d 763, 765).

Contrary to plaintiff’s further contention, the court did not abuse its discretion in granting defendant’s motion to sever the 14 causes of action. “The decision whether to grant severance rests soundly in the discretion of the trial court and, on appeal, will be affirmed absent a demonstration of abuse of discretion or prejudice to a substantial right’ ” (Rapini v New Plan Excel Realty Trust, Inc., 8 AD3d 1013, 1014; see Soule v Norton, 299 AD2d 827, 828). [*2]Although this action was commenced “by a single assignee against a single insurer and all [causes of action] allege the erroneous nonpayment of no-fault benefits . . ., they arise from [14] different automobile accidents on various dates in which the [14] unrelated assignors suffered diverse injuries and required different medical treatment” (Poole v Allstate Ins. Co., 20 AD3d 518, 519).

H/T No Fault Defender

Discovery Delayed

Newell v Hirsch, 2009 NY Slip Op 06519 (App. Div., 2nd, 2009)

The Supreme Court also properly denied the defendant’s motion to compel the plaintiff to comply with his discovery demands served nearly three years after the note of issue was filed. In order to obtain such belated relief, the defendant was required to demonstrate unusual or unanticipated circumstances and substantial prejudice (see 22 NYCRR 202.21[d]; Audiovox Corp. v Benyamini, 265 AD2d 135, 138). The defendant did not do so.

ORAL ARGUMENT FOR INFINITY SCHEDULED

Mr. Toell first told us that the Appellate Division, Second Department granted leave to appeal Infinity Health Prods., Ltd. v Eveready Ins. Co., 21 Misc.3d 1 (App. Term, 2d). Now, the mystery author of No Fault Law – A defendant’s perspective tells us that a date has been set for argument.