Tuesday, June 30, 2009

May an insurance carrier's expert offer an opinion beyond the confines of his peer or IME report?

In affirming the denial of plaintiff's summary judgment motion, the Appellate Term, First Department in Krishna v Liberty Mut. Ins. Co. 2009 NY Slip Op 51312(U)(App. Term 1st Dept. 2009) reiterated its position (Response Medical Equipment v. General Assur. Co.13 Misc.3d 129[A][App. Term 1st Dept. 2006]; Mollins v. Allstate Ins. Co.20 Misc.3d 141[A][App. Term 1st Dept. 2008]) that an insurance carrier's expert may comment on medical evidence not contained in a peer report or IME report in support of its lack of medical necessity defense.

The pertinent portion of the Krishna opinion states the following: "The initial peer review report relied upon by defendant, as amplified upon defendant's receipt of additional documentation from plaintiff regarding his claim, set forth sufficient facts to raise a triable issue as to the medical necessity of the health services and diagnostic tests performed by plaintiff. "

Priority of payment disputes must be adjudicated through Ins. Law 5105 intercompany arbitration

The law is simple: Disputes involving whether an insurance carrier in a no-fault coverage dispute is primary, secondary, or tertiary must be resolved through intercompany arbitration. This fact pattern was presented four years ago in SZ Medical, P.C. v. Lancer Ins. Co.7 Misc.3d 86 (App. Term 2d Dept. 2005) and was again presented in M.N. Dental Diagnostics, P.C. v Government Employees Ins. Co. 2009 NY Slip Op 29266(App. Term 1st Dept. 2009).

Workers Compensation defense

I would be remiss if I did not thank Dave Barshay for the citation to this blog in his article. I also must thank David Gottlieb for posting Mr. Barshay's citation to this article on his blog. While I am not sure it is really critical that you read this blog, despite what Mr. Gottlieb says to the contrary, I thank him for the compliment nonetheless. Now that the peremptory "thank yous" are out of the way, now onto the cases.

A.B. Med. Servs., PLLC v American Tr. Ins. Co., 2009 NY Slip Op 29271 (App. Term 2d Dept. 2009)

A.B. Med. Servs., PLLC v American Tr. Ins. Co., 2009 NY Slip Op 51262(U)(App. Term 2d Dept. 2009)

A.B. Med. Servs., PLLC v American Tr. Ins. Co., 2009 NY Slip Op 51263(U)(App. Term 2d Dept. 2009)

Inwood Hill Med., P.C. v Metropolitan Prop. & Cas. Ins. Co. 2009 NY Slip Op 51264(U)(App. Term 2d Dept. 2009)

The day after the no-fault wrap up, the Appellate Term, Second Department issued a slue of opinions regarding the Workers Compensation defense, which was consistent with what Mr. Barshay's article stated. Again, I discussed this issue on a previous blog post.

However, when the issue is phrased in light of the "exceptional" circumstance of non-coverage, as recently opined upon by the Court of Appeals in Fair Price, the Workers Compensation defense is waivbale.

However, when this issue is evaluated through the prism of "standing", the Appellate Division's conclusion may not be correct. As the law stands right now, a service rendered by an independent contractor or an improperly formed medical corporation is not subject to the "preclusion" sanction, through the failure to timely or properly deny a claim. This is because an independent contractor and an improperly formed corporation lacks standing to prosecute a no-fault claim. It thus follows that based upon 65-3.19, the Workers Compensation defense, in relation to a claim for medical benefits, should not be subject to the 30-day pay or deny rule. This follows from the simple conclusion that an injured person and his or her assignee lack standing to prosecute such a first-party no-fault claim for medical benefits.

The above standing analysis in no way applies to wage benefits, since the regulations explicitly state that no-fault wage coverage is secondary to Workers Compensation wage coverage.

Thursday, June 18, 2009

Conclusory affidavits will not defeat an insurance carrier's summary judgment motion

Bronze Acupuncture, P.C. v Mercury Ins. Co.
2009 NY Slip Op 51219(U)(App. Term 2d Dept. 2009)

This case hints at what a medical provider must proffer in its answering papers to stave off an insurance carrier's summary judgment motion, based upon the lack of medical necessity of a rendered service.

In this case, a conclusory or boilerplate affidavit attesting to a service's lack of medical necessity is insufficient to raise an issue of fact.

Here is the holding:

"The papers submitted by defendant in support of its motion, including the affirmed IME [*2]report and an affidavit executed by the acupuncturist who performed the IME, established, prima facie, a lack of medical necessity for the services at issue. The opposing affidavit submitted by plaintiff's treating acupuncturist merely stated that she disagreed with the results of the IME report without setting forth any facts to support her conclusion. Consequently, the opposition papers failed to raise a triable issue of fact as to medical necessity."

This should be compared to the operative language inPark Slope Medical and Surgical Supply Inc. v. New York Central Mut. Fire Ins. 22 Misc.3d 141(A)(App. Term 2d Dept. 2009) , where the court held the following: "[p]laintiff submitted an affidavit from Dr. Shapiro in which he stated that he disagreed with the peer review report and affidavit furnished by defendant because he concluded that the supplies provided were medically necessary. Since the affidavit of Dr. Shapiro demonstrated the existence of an issue of fact as to medical necessity."

The next question will be what facts are sufficient to support the conclusion that a service is medically necessary. I guarantee it is not going to be the regurgitation of the documents a peer review doctor examined. I also guarantee it is not going to be the boilerplate one size fits all affidavit we saw in Park Slope, which we can probably now say is bad law.

I know there will be many more of these types of appeals, and this issue will be answered at some time in the future.

Nunc pro tunc under the former serve and file regime

J.R. Dugo, D.C., P.C. v New York Cent. Mut. Ins. Co.,
2009 NY Slip Op 29261 (App. Term 2d Dept. 2009)

I suspect that if this case was decided in 2005, it might have been more relevant to the practice of law. As it is, it explains one of the reasons why the serve and file system was abolished in the lower court system. I would only say that the Civil Court, City Court and District Court clerks routinely allowed Plaintiffs to purchase index numbers well after the 14 or 21 day period after service was complete.

The practice of law under the now-abolished serve and file system was nightmarish from the aspect that the defendant who wanted to move on a case within 60-days of joinder of issue had to either: (1) purchase an index number; or (2) wait until Plaintiff served Defendant with the index number. This gave the Plaintiff the clear advantage, since the Defendant was many times at the mercy of the Plaintfif to inform the said Defendant of the index number.

It also was a rare event when nunc pro tunc relief would not be afforded to the Plaintiff. In any event, this case explains why the public policy of the state is advanced through the lower courts, save the justice courts, following the Superior Courts' method of commencing a case.

Saturday, June 13, 2009

An angry Appellate Division strikes a complaint based upon discovery violations

Northfield Ins. Co. v Model Towing & Recovery
2009 NY Slip Op 04878 (2d Dept 2009).

While this case represents nothing unique, the path the Appellate Division took was. The facts, as relayed to the reader, are that the following discovery orders were in place and in some way were violated:

1. Preliminary conference (7/28/05)- discovery was ordered to be completed prior to the Compliance Conference (12/19/06) .

2. Compliance conference (12/19/06) - discovery was ordered to be completed by 2/14/07.

3. There were various status conferences in between the dates of 2/14/07 and 12/12/07.

4. At the 12/12/07 status conference, discovery was ordered to be completed on or before 1/16/08.

5. Discovery was not completed on 1/16/08 .

6. A motion was interposed based upon the failure to comply with the 1/16/08 order. The Court in this order set forth a discovery schedule, and stated that it was to be obeyed under penalty of a 3126 remedy, upon a subsequent motion. In English, it looked as if the violation of this order would result in a conditional order of preclusion or a conditional order of dismissal.

Excluding status conferences and the P.C. order, there were 2 orders. Moreover, only one resulting order was the result of a motion made on notice.

The Defendant appealed the 1/16/08 order on the basis that the Court should have stricken the complaint. What happened next is something that is very rarely seen in downstate New York practice: The Appellate Division reversed the order of Supreme Court and struck the complaint.

Now for those of us who have practiced in Supreme Kings (my favorite example) as defendants and have had the opportunity to make discovery based motions in CCP, you will observe that it is almost impossible to obtain an order containing conditional preclusion or dismissal language, let alone an order that will unconditionally strike the complaint. Almost 10 discovery orders can be violated and a conditional order of dismissal, conditional order of preclusion or an absolute order of preclusion or dismissal will never occur. That is life, and we accept it because when these orders get appealed, the Appellate Division will usually not find an abuse of discretion and affirm the order of the Supreme Court, with the Defendant paying one bill of costs and disbursements to the recalcitrant Plaintiff.

Here, there were 3 disobeyed orders (including the P.C. order) and some status conferences that appeared to be disregarded. The Appellate Division, on appeal, reversed Supreme Court and struck the complaint. Since the SOL probably expired, the dismissal order was with prejudice. My question is as follows: are we going to see this type of vigilance in other cases, or is this case just an anomaly?

Thursday, June 11, 2009

A no fault claim representative's affidavit may cure inaccuracies in the NF-10 form

We kind of saw it in a previous post involving a Mercury case where a claim representative's sworn affidavit could explain typographical errors in a resulting NF-10. Some wondered why the Appellate Term never expounded on this point. Now, they have.

Bath Med. Supply, Inc. v Country Wide Ins. Co.
2009 NY Slip Op 51145(U)(App. Term 2 Dept. 2009)

The highlights are as follows:

"Plaintiff contends that defendant's opposing papers did not establish that the claim determination period was tolled because, while the affidavit of defendant's no-fault litigation supervisor sets forth the dates on which the verification requests were mailed, the denial of claim forms set forth incorrect dates as to when final verification was requested. However, the unsworn denial of claim forms do not purport to state the dates on which defendant first requested verification, whereas, in the sworn affidavit, defendant's no-fault litigation supervisor states the dates on which verification was first requested, the dates on which the verification was received and the dates on which the denial of claim forms were mailed. To the extent the unsworn denial of claim forms suggest that defendant may have sent a further request for verification after receiving the verification it initially sought, they do not contradict the sworn statement by defendant's no-fault litigation supervisor or otherwise nullify defendant's position that the claim determination period was tolled."

My observation is that the days of challenging denials for typographical errors have ended. We saw this starting with AB v. Liberty and extending through Al Correa v. State Farm, as well as other cases decided subsequent to Al Correa.

I suppose the best questions to ask are as follows. First, how much of an NF-10 needs to be filled out in order to preserve the defense(s) on it? Second, how many mistakes are allowed to be present on the NF-10, so as to preserve the defenses on the denial? We shall await the answer to these questions.

It is prima facie day

I suppose to the extent the Appellate Term, Second Department has been on the 4518 band wagon, it is nice to see the rule that certain evidentiary objections need to preserved in order to raise them on appeal. According to my count, there were 11 prima facie challenges in the June 10, 2009, posted cases. The preserved challenges were successful in all but one case. I suppose the question is: what must an affidavit contain to satisfy a medical provider's prima facie case, and does it matter which branch of the Appellate Term, Second Department is adjudicating the issue?

Sunday, June 7, 2009

Motion to Reargue - the 30 day period is not absolute

From a procedural standpoint, a question that has arisen is whether a motion seeking leave to reargue or, in certain cases, leave to renew is timely made. Following the 1999 amendment to the statute, there has been debate as to whether the 30-day period to make the motion will be tolled when a timely notice of appeal is filed. This was answered in the negative a few times, but the recent trend has been to answer this inquiry in the affirmative. A recent case highlights this point.

Terio v. Spodek, 2009 N.Y. Slip Op. 04412 (2d Dept. 2009)

"Contrary to the plaintiff's contention, the Supreme Court providently exercised its discretion in granting that branch of the motion...which was for leave to reargue. Reich's appeal from the Supreme Court's order dated December 17, 2007, was pending and unperfected as of the time that the motion for reargument was made. Under these circumstances, the Supreme Court providently entertained that branch of Reich's motion which was for leave to reargue notwithstanding that it was made beyond the 30-day limit set forth in CPLR 2221(d)(3)"

It follows that as long as a Notice of Appeal has been filed and the appellate brief is unperfected, the 30-day time period to move to reargue or to take advantage of the "change in law" provision in the leave to renew statute remains tolled.

Wednesday, June 3, 2009

EBT's in no fault practice - "laches does not apply"

Queens Chiropractic Mgt., P.C. v Country Wide Ins. Co. 2009 NY Slip Op 51073(U)(App. Term 2d Dept. 2009).

In yet another defeat to the Plaintiff's bar in no-fault actions in the Second Department, the Appellate Term has now held that the passage of time will not in and of itself act to waive the right of an insurance carrier seeking to take an EBT of the Plaintiff.

While the facts do not state it, an EBT in no-fault is conditioned on the EBT not being palpably improper, which outside the corporate structure world, would mean that the insurance carrier has presumably presented proof of a timely and valid denial. The case law has already discussed this point.

This decision, as many know, is in contrast to Accurate Medical, P.C. v. Travelers Ins. Co. 13 Misc.3d 133(A)(App. Term 1st Dept. 2006), which held that:

"the record reveals that defendant served plaintiff with a notice of deposition and written discovery demands in August 2004. Defendant did not object to plaintiff's written interrogatories nor did it avail itself of the opportunity to conduct plaintiff's deposition prior to plaintiff filing a notice of trial in April 2006. Under these circumstances, and in view of defendant's failure to show the need to conduct a deposition, the motion to vacate the notice of trial was properly denied."

Accurate Medical did not cite to any authority for its rule of law, whereas the Queens Chiropractor Court cited to Kornblatt v Jaguar Cars, 172 AD2d 590 (2d Dept. 1991). The pertinent section of Kornblatt states the following:

"Finally, the plaintiff's invocation of laches to prevent the production of the records lacks merit. In a deposition on March 9, 1988, JCI had requested the tax returns, but the plaintiff refused. Possessing the knowledge that JCI wanted the returns, then, any prejudice suffered by the plaintiff a year later when the court compelled their production was of his own making, and he cannot now complain."

Yet, a reading of Kornblatt shows that a party resisting an EBT demand can assert laches, provided he or she demonstrates prejudice. But, it is hard to imagine how a showing of "prejudice" would be proved in a majority of litigated no-fault cases.