Giving Someone a Widgie

Below please find a new widget I have created for the blog. Feel free to click "copy me" (which can be found when you mouseover the widget's title bar) and embed on your own site or blog. (Don't worry, I'm not holding my breath.)

Thanks to Thomas Swartz, Esq. for the tip.

Schepp, Part X_X

The Appellate Term, Second Department released its long awaited decisions today in Boston Post Rd. Med. Imaging, P.C. a/a/o Adrian Black v. Progressive Ins. Co., 2007 NYSlipOp 51173(U) (App. Term, 2d Dep't, 2007) and Boston Post Rd. Med. Imaging, P.C. a/a/o Ira Bright v. Progressive Ins. Co., 2007 NYSlipOp 51174(U) (App. Term, 2d Dep't, 2007). Judge Gianelli of District Court, Nassau County, Hempstead Part had granted Progressive, represented by McDonnell & Adels, summary judgment as to their contention that the provider was not a properly licensed entity under the meaning of State Farm v. Mallela, 4 NY3d 313 (2005), and hence not entitled to no-fault benefits.

Justices Rudolph, McCabe, and Tanenbaum don't see it that way. In their estimation, the evidence proffered by Progressive was insufficient to satisfy Mallela. Of course, they give no guidance as to why the evidence was insufficient or what evidence would actually be sufficient.

Very interestingly, the App. Term does implicitly hold that, if proven, the fact that a provider sold its accounts receivable would constitute a defense to no-fault payment. Compare, Andrew Carothers, M.D., P.C. v GEICO Indem. Co., 13 Misc 3d 549 (Civ. Ct., Kings Cty., 2006; Battaglia, J.). Somehow, though, an executed contract selling said accounts receivable (along with an admission of such contract by provider's counsel, but with a differing interpretation) does not prove same. The App. Term's evidentiary rationale is too weak to suffice as a explanation for their decision; we still live under the rule that allegations made in a motion are deemed admitted unless rebutted. Kuehne & Nagel v. Baiden, 36 NY2d 539 (1975); Schneider Fuel Oil, Inc. v. DeGennaro, 238 A.D.2d 495 (2d Dep't, 1997). It has also been true since at least 1899 that "[i]n a civil action[,] the admissions by a party of any fact material to the issue are always competent evidence against him, wherever, whenever or to whomsoever made." Reed v. McCord, 160 N.Y. 330, 341 (1899). Perhaps the Appellate Term is waiting for an opportunity to physically observe the execution of said contract.

Either way, despite that one glimmer of hope, at this point the rulings do not bode well for the carriers in the ongoing litigation with Dr. Schepp in Supreme Court, Nassau County or the numerous suits involving Andrew Carothers, M.D., P.C. (which was the successor entity to Dr. Schepp's Boston Post Road Medical Imaging, P.C., Preferred Medical Imaging, P.C., and Deajess Medical Imaging, P.C.). Presumably the carriers are hoping that the judges overseeing those matters will not be as gun-shy as the App. Term was in the decisions released today.

A Lifelong Swan Song

For what its worth, the BG&S website has some articles I've authored, each of which should have been published by now in "The Suffolk Lawyer," which is put out by The Suffolk County Bar Association:

• No-Fault MRI Providers' Suits Stayed Pending Declaratory Judgment Action
• Should Courts Referee No-Fault Referrals? Part 1
• Should Courts Referee No-Fault Referrals? Part 2

All of the articles should be of interest to readers of this blog. Enjoy.

A Short Notice

Please be advised that I am no longer associated with the office of Bruno, Gerbino & Soriano, LLP. I can still be contacted at djtoell @ gmail.com. A resume is available upon request for any interested persons. For the immediate future, I will be in Civil Court, Kings County for per diem appearances.

Let's Get Ready To Humble

The App. Div., 2d Dep't has some very spiffy PDF files available for the three decisions discussed yesterday, in case you happen to like attaching such spiffy-looking documents to your motion papers (or if you're Skip Short, Esq. and deservedly want to frame them): A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 2007 NY Slip Op 03636 (App. Div., 2d Dep't, 2007); A.B. Med. Servs., PLLC v GEICO Cas. Ins. Co., 2007 NY Slip Op 03635 (App. Div., 2d Dep't, 2007); and New York Univ. Hosp. Rusk Inst. v Government Employees Ins. Co., 2007 NY Slip Op 03671 (App. Div., 2d Dep't, 2007).

I also can't wait to see who throws the next punch in the battle royale occurring in the comments section of my previous post. Can anyone top a slapdown from David M. Barshay, Esq.? I'm thinking it will take another named partner. Then again, the looming spectre of Skip Short, and the results he got in the aforementioned cases, may provide the ultimate trump card...

Hell: Experiencing Intermittent Flurries

Three highly important decisions were put out today by the Appellate Division, Second Department: A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 2007 NY Slip Op 03636 (App. Div., 2d Dep't, 2007); A.B. Med. Servs., PLLC v GEICO Cas. Ins. Co., 2007 NY Slip Op 03635 (App. Div., 2d Dep't, 2007); and New York Univ. Hosp. Rusk Inst. v Government Employees Ins. Co., 2007 NY Slip Op 03671 (App. Div., 2d Dep't, 2007). These decisions reverse (both specifically and in practical terms) a host of Appellate Term, Second Department cases whereby it was held that a no-fault denial of claim form (NF-10) would be legally insufficient if it merely stated that said denial was based upon the results of a peer review or IME. That is, if a denial were based upon the results of a peer review or IME, the Appellate Term repeatedly held that a carrier had to issue a denial that either attached the peer/IME report or otherwise included the medical rationale of said report.

The Appellate Division's decision from today in A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. sets out the thrust of their reversal of the Appellate Term:

"To the extent the Appellate Term's order may be understood to require an insurer denying a claim for first-party no-fault benefits on the ground of lack of medical justification to include a medical rationale in its denial of claim form, we agree with the defendant that the court erred. The applicable regulations provide that if a no-fault claim is denied in whole or in part based on a medical examination or peer review report requested by the insurer, then the insurer shall release a copy of that report to, among others, the applicant or its attorney, upon written request (see 11 NYCRR 65-3.8[b][4]). Had it been the intent of the Department of Insurance to require the carrier to set forth a medical rationale in the prescribed denial of claim form (see NYS Form N-F 10; 11 NYCRR 65-3.4[c][11]), it would have so provided."

This is a seismic change with a level of force far beyond the Richter Scale in the realm of no-fault medical necessity litigation and arbitrations. It also solidifies a trend by the Appellate Division to pull back the reins on some of the more "creative" Appellate Term decisions.

I expect to see a legion of defense attorneys waving these decisions around in court tomorrow...

Gimme Gimme Gimme (Amendments After Midnight)

Please note that on March 14, 2007, the Third Amendment to Regulation 68-C (11 NYCRR § 65-3) and the Fourth Amendment to Regulation 68-D (11 NYCRR § 65-4) went into effect. The amendments concern arbitration procedures when disputes arise as to which insurance carrier is required to cover a given claim. My, how the New Regs have grown up since April 2002!

Whole Wheat Rollin'

Please take notice of the recent addition to my NY blawg roll on the left side of your screen: New York Legal Update by Thomas Swartz, Esq., a former court attorney with the App. Div., 2d Dep't. After only a few weeks, Mr. Swartz has developed an entertaining and informative blawg, so let's hope it becomes a fixture for NY practitioners (i.e., so that Mr. Swartz can't take it with him when his lease runs out).

Having One's Priorities in Order

Just when you thought it was safe to do online research on New York No-Fault Law, I make my triumphant return. Many thanks to the likes of David Barshay, Esq., Vincent Pirro, Esq., and many others who have accosted me in public for my failure to keep the blog updated. I could give you some excuses, but a) they don't even sound believable to me, and b) you wouldn't care, anyway, would you?

Onto the important stuff.

The Court of Appeals issued its decision yesterday in Nyack Hosp. v General Motors Acceptance Corp., 2007 NY Slip Op 02439 (Ct. of App., 2007) (There is also a PDF version available).

Oral arguments were heard back on Feb. 8. Your humble blogger was lucky enough to discuss the matter with both Joseph Henig, Esq. (counsel for Appellant-Plaintiff) and Craig J. Freiberg, Esq. (counsel for Respondent-Defendant). Both expressed valid concerns over the outcome of the case, and it is interesting to see how the Court worked out such a seemingly bland technical matter; they also seem to me to have come to the correct conclusion.

In sum, the Court held that a claim is not considered received for purposes of attaining priority of payment until all requested verification has been provided. Priority of payment is crucial where, as in Nyack v. GMAC, the policy is or is about to be exhausted, and the carrier therefore either cannot pay the claim at all or can only pay a portion thereof. Nyack Hospital, through Mr. Henig, contended that they should have received an additional $15,009.21, representing the difference in basic economic loss coverage available as of the day their claim was received by GMAC as opposed to the day on which GMAC received their responses to the verification requests.

Still, all is not perfect for the carriers. The Court held that a claim acquires priority status even if the eligible injured person has not yet submitted their OBEL ("Optional Basic Economic Loss") coverage election (see, if you want to fall asleep, the prescribed OBEL coverage endorsement at 11 NYCRR § 65-1.2), at least with respect to those claims or portions of claims that can still be paid out under the core $50,000 of basic economic loss coverage. So, while GMAC was justified in waiting some amount of time to give Nyack's claims priority, it should not have waiting for the OBEL election.

In hard numbers on the facts of this case, this means that Nyack will be getting a judgment for $863.21, representing the amount of basic economic loss coverage that GMAC paid out on other claims from the time that Nyack provided verification for its claim and GMAC received the eligible injured person's OBEL election. Attorney's fees will be a whopping $172.64.

Even if the final outcome in this matter was more or less trivial in comparison to the dollar amount being sought, I have little doubt that the impact of today's decision will be wide-reaching. Hospitals often submit the no-fault claims with the largest monetary value as to any given EIP (Nyack's claim alone was in excess of the coverage limits), and determining priority of payment can easily be a difference of tens of thousands of dollars.

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Generally speaking, it is a rarity for the Court of Appeals to take up a no-fault case. However, yesterday they granted leave for appeal in Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. See the App. Div., 2d Dep't's original decision at Hosp. for Joint Diseases v. Travelers, 34 A.D.3d 532 (App. Div., 2d Dep't, 2006). The decision is too vague to really set down the nature of the dispute, so any commentary from those familiar with the case would be appreciated.

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Dr. Andrew Carothers, M.D. is scheduled to be deposed this coming Tuesday, March 27 with regard to Matter of Andrew Carothers, M.D., P.C. v Insurance Cos. Represented by Bruno, Gerbino & Soriano LLP and Freiberg & Peck, LLP, 13 Misc.3d 970 (Civ. Ct., Richmond Cty., 2006) and numerous other matters pending in Richmond Cty.

No-Fault Song Parody Contest. (Seriously.)

I'm inclined to question the fitness to practice law of my friend Matthew S. Lerner, Esq. of the New York Civil Law blawg.

Today, he announced a no-fault-based song parody contest. He also points out that Deney Terrio's last name rhymes with the last name of former NYS Insurance Department Superintendent Gregory V. Serio (as in Med. Soc'y v. Serio, 100 N.Y.2d 854 (2003)). I'm a bit frightened to even mention that he (allegedly) makes something else rhyme with the last name of Dr. Robert Chandran Mallela, M.D. (as in State Farm v. Mallela, 4 N.Y.3d 313 (2005)).

I may just close down this blog entirely if anyone starts rhyming Frances J. Roggio (as in Roggio v. Nationwide Mut. Ins. Co., 66 N.Y.2d 260 (1985)); Karen DeGuisto (as in Presbyterian Hosp. a/a/o DeGuisto v. Maryland Cas. Co., 90 N.Y.2d 274 (1997)); or Pamela Mandresh (as in Central Gen. Hosp. a/a/o Mandresh v. Chubb Group of Ins. Cos., 90 N.Y.2d 195 (1997)).

Which Judicial District's Grievance Committee should I be contacting for Matthew? ;)