All-County Medical & Diagnostic P.C. v. Progressive Casualty Insurance

8 Misc. 3d 616
CourtNassau County District Court
DecidedMay 13, 2005
StatusPublished

This text of 8 Misc. 3d 616 (All-County Medical & Diagnostic P.C. v. Progressive Casualty Insurance) is published on Counsel Stack Legal Research, covering Nassau County District Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
All-County Medical & Diagnostic P.C. v. Progressive Casualty Insurance, 8 Misc. 3d 616 (N.Y. Super. Ct. 2005).

Opinion

OPINION OF THE COURT

Scott Fairgrieve, J.

[617]*617The defendant moves for an order pursuant to CPLR 3042 (c) compelling the plaintiff to respond to the defendant’s demand for a bill of particulars and for an order pursuant to CPLR 3124 compelling the plaintiff to produce a witness for examination before trial, or, in the alternative, to strike the plaintiff s pleadings for noncompliance. The plaintiff opposes the defendant’s motion.

The defendant’s motion to strike the plaintiffs complaint for plaintiffs failure to respond to the defendant’s demand for a bill of particulars is denied as moot, as the plaintiff has since answered the defendant’s bill of particulars. Moreover, contrary to the defendant’s assertion in its reply affirmation, the court finds said responses to be sufficient.

The defendant also seeks to dismiss the plaintiffs complaint upon the failure of the plaintiffs treating physician to appear for an examination before trial (EBT).

The court has broad discretion in limiting or regulating the use of disclosure devices (see, Brignola v Pei-Fei Lee, M.D. P.C., 192 AD2d 1008 [3d Dept 1993]).

UDCA 1101 (a) requires that the Nassau County District Court adopt all of the procedures set forth in the CPLR with regard to disclosure.

CPLR 3101 states, in pertinent part, that:

“(a) Generally. There shall be full disclosure of all matter material and necessary in the prosecution or defense of an action, regardless of the burden of proof, by:
“(1) a party, or the officer, director, member, agent or employee of a party;
“(2) a person who possessed a cause of action or defense asserted in the action . . . .”

Accordingly, pursuant to CPLR 3101 (a), in the Nassau County District Court there shall be “full disclosure of all matter material and necessary in the prosecution or defense of an action, regardless of the burden of proof.” (Emphasis added.) The words “material and necessary” should be interpreted liberally to “require disclosure, upon request, of any facts bearing on the controversy which will assist preparation for trial by sharpening the issues and reducing delay and prolixity. The test [to determine if the information sought is material and necessary] is one of usefulness and reason” (see, Allen v Crowell-Collier Publ. Co., 21 NY2d 403, 406 [1968]; see also U.S. Ice Cream Corp. v Carvel Corp., 190 AD2d 788 [2d Dept 1993]). The term [618]*618“necessary” has been construed to mean “needful” rather than “indispensable” (see, Allen v Crowell-Collier Publ. Co., 21 NY2d 403, 407 [1968], supra). “If there is any possibility that the information [was] sought in good faith for possible use as evidence-in-chief or in rebuttal or for cross-examination, it should be considered ‘evidence material ... in the prosecution or defense’ ” (Matter of Comstock, 21 AD2d 843, 844 [4th Dept 1964]). However, the Allen case makes clear that disclosure extends to all relevant information calculated to lead to relevant evidence not just information that can be used as evidence-in-chief (see, CPLR 3101; Siegel, Practice Commentaries, McKinney’s Cons Laws of NY, Book 7B, CPLR C3101:7, at 18, citing West v Aetna Cas. & Sur. Co., 49 Misc 2d 28 [1965], mod 28 AD2d 745 [3d Dept 1967]; see also Wiseman v American Motors Sales Corp., 103 AD2d 230 [2d Dept 1984]). “If the data elicited is within the broad scope of CPLR 3101 (a) as construed in the Allen case, the excursion should be called a ‘relevant inquiry’. That would leave [the term] ‘fishing expedition’ to describe the inquiry that goes beyond that extended compass” (Siegel, Practice Commentaries, McKinney’s Cons Laws of NY, Book 7B, CPLR C3101:8, at 19). Furthermore, matters relating to disclosure lie within the broad discretion of the trial court, as it is in the best position to determine what is material and necessary (see, Allen v Crowell-Collier Publ. Co., 21 NY2d 403 [1968], supra; see also, Andersen v Cornell Univ., 225 AD2d 946 [3d Dept 1996]).

Applying the principles established in the Allen case to the issue of an insurance carrier’s right to an EBT of a medical provider in a no-fault case, the court finds that, provided certain conditions are met by an insurance carrier, the carrier is entitled to an EBT of a medical provider. The Court of Appeals has clearly held that, pursuant to the no-fault regulations, in a case in which no additional verification is timely sought, an insurance carrier must pay or deny a claim of no-fault benefits within 30 days from the receipt of a claim or be precluded from interposing a defense to the denial of the claim, with limited exceptions (see, Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 [1997]). In the case of a defense of “medical necessity,” the courts have held an insurance carrier is precluded from raising a defense of “medical necessity” where the denial was not timely and that summary judgment in favor of the medical provider is appropriate in such situations, provided the plaintiff submits proper proof of the claim and the [619]*619amount of the loss (see, Presbyterian Hosp. v Maryland Cas. Co., 90 NY2d 274 [1997], supra; Howard M. Rombom, Ph.D., P.C. v Interboro Mut. Indent. Ins. Co., 186 Misc 2d 847 [App Term 2000]). Thus, when the insurance carrier has failed to issue a timely denial, no further discovery, which includes an EBT of the medical provider, is permissible on any defense, except if the insurance carrier’s defense falls within limited exceptions. The limited exceptions set forth in the Presbyterian case are where untimely denials are of no consequence because the insurer is not required to pay the claim and where the claim is ultimately deemed invalid (see, Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 [1997], supra). Such situations include, inter alia, fraud and a lack of coverage defense based upon a belief that the alleged injury does not arise out of the insured accident (see, Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]; Mount Sinai Hosp. v Triboro Coach, 263 AD2d 11 [2d Dept 1999]).

If an insurance carrier has made a timely denial, based upon “medical necessity,” then its objective in seeking an EBT of the medical provider is not a means of harassing the medical provider, but rather the insurance carrier is trying to obtain relevant information on its defense of “medical necessity.” Certainly in cases where an insurance carrier timely denied the no-fault claim, based upon the ground of “medical necessity,” the carrier is entitled to explore why the medical provider or treating physician determined the treatment to be necessary. However, if an insurance carrier seeks an EBT of a medical provider, to inquire about the “medical necessity” of the treatment provided to the plaintiffs assignor, when the insurance carrier has failed to timely deny the medical provider’s claim, such failure will preclude an EBT of plaintiff and any other defenses not raised. The defendant must satisfy the following standard expressed in Socrates Psychological Servs., P.C. v Progressive Cas. Ins. Co. (7 Misc 3d 642, 654 [Civ Ct, Queens County 2005]) which, in relying on Metropolitan Radiological Imaging, P.C. v State Farm Mut. Auto. Ins. Co. (7 Misc 3d 675 [2005]), stated:

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Presbyterian Hospital v. Maryland Casualty Co.
683 N.E.2d 1 (New York Court of Appeals, 1997)
Central General Hospital v. Chubb Group of Insurance Companies
681 N.E.2d 413 (New York Court of Appeals, 1997)
Allen v. Crowell-Collier Publishing Co.
235 N.E.2d 430 (New York Court of Appeals, 1968)
General Accident Insurance Group v. Cirucci
387 N.E.2d 223 (New York Court of Appeals, 1979)
In re the Accounting of Genesee Valley Union Trust Co.
21 A.D.2d 843 (Appellate Division of the Supreme Court of New York, 1964)
West v. Aetna Casualty & Surety Co.
28 A.D.2d 745 (Appellate Division of the Supreme Court of New York, 1967)
Wiseman v. American Motors Sales Corp.
103 A.D.2d 230 (Appellate Division of the Supreme Court of New York, 1984)
U.S. Ice Cream Corp. v. Carvel Corp.
190 A.D.2d 788 (Appellate Division of the Supreme Court of New York, 1993)
Brignola v. Pei-Fei Lee
192 A.D.2d 1008 (Appellate Division of the Supreme Court of New York, 1993)
Andersen v. Cornell University
225 A.D.2d 946 (Appellate Division of the Supreme Court of New York, 1996)
Mount Sinai Hospital v. Triboro Coach, Inc.
263 A.D.2d 11 (Appellate Division of the Supreme Court of New York, 1999)
Melbourne Medical, P.C. v. Utica Mutual Insurance
4 Misc. 3d 92 (Appellate Terms of the Supreme Court of New York, 2004)
Socrates Psychological Services, P.C. v. Progressive Casualty Insurance
7 Misc. 3d 642 (Civil Court of the City of New York, 2005)
Metropolitan Radiological Imaging, P.C. v. State Farm Mutual Automobile Insurance
7 Misc. 3d 675 (Civil Court of the City of New York, 2005)
West v. Ætna Casualty & Surety Co.
49 Misc. 2d 28 (New York Supreme Court, 1965)
Howard M. Rombom, Ph D, P. C. v. Interboro Mutual Indemnity Insurance
186 Misc. 2d 847 (Appellate Terms of the Supreme Court of New York, 2000)

Cite This Page — Counsel Stack

Bluebook (online)
8 Misc. 3d 616, Counsel Stack Legal Research, https://law.counselstack.com/opinion/all-county-medical-diagnostic-pc-v-progressive-casualty-insurance-nydistctnassau-2005.