Foster Diagnostic Imaging v. General Assurance Co.

10 Misc. 3d 428
CourtCivil Court of the City of New York
DecidedOctober 17, 2005
StatusPublished

This text of 10 Misc. 3d 428 (Foster Diagnostic Imaging v. General Assurance Co.) is published on Counsel Stack Legal Research, covering Civil Court of the City of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Foster Diagnostic Imaging v. General Assurance Co., 10 Misc. 3d 428 (N.Y. Super. Ct. 2005).

Opinion

[429]*429OPINION OF THE COURT

Jack M. Battaglia, J.

These two actions for first-party no-fault benefits raise similar issues arising from the insurer’s denial of the claims because of the respective assignors’ failure to appear for preclaim medical examinations. In action No. 1, Foster Diagnostic Imaging, EC. seeks payment of a bill for $902.28 for an MRI of the cervical spine of its assignor, Correna Cosine. In action No. 2, Ocean Transportation, Inc. seeks payment of a bill for $550 for transportation rendered to its assignor, Bryan Woodriffe. Defendant General Assurance Company refused to pay either bill. The actions were consolidated for joint trial held on August 8, 2005.

At trial, General Assurance stipulated that plaintiffs submitted proper proof of claim sufficient to establish prima facie that the bills should have been paid. (See A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86, 87 [App Term, 2d & 11th Jud Dists 2004].) Elaintiffs in turn stipulated that General Assurance had timely denied the claims on the ground that the respective assignors had not appeared for preclaim medical examination. (See Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 18, 20-21 [App Term, 2d & 11th Jud Dists 2004].)

With these stipulations of proper proof of claim and timely denial, General Assurance “had to proffer evidence in admissible form establishing the failure of plaintiffs assignor to appear for the IMEs,” including evidence that the “requests for such IMEs were mailed to plaintiffs assignor.” (See Amaze Med. Supply Inc. v State Farm Mut. Auto. Ins. Co., 8 Misc 3d 139[A], 2005 NY Slip Op 51315[U], *1-2 [App Term, 2d & 11th Jud Dists 2005].) If General Assurance satisfied that burden, plaintiffs were required to “explain the [assignor’s] failure to attend the IME by offering a valid excuse for such nonappearance, or proof that, under the circumstances, the IME request was unreasonable and, thus, not authorized” by the regulations. (See Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 7 Misc 3d at 22.) Alternatively, plaintiffs were required to “independently establish [the] medical necessity [of the billed-for services] by admissible evidence.” (See id. at 23.)

These evidentiary burdens are gleaned from the growing body of appellate case law on motions for summary judgment, in the absence of virtually any case law that addresses these issues after trial. In this court’s view, when the insurer timely denies for [430]*430the assignor’s failure to attend a preclaim medical examination, the insurer bears the burden of persuasion on the assignor’s “failure to comply with a reasonable and proper preclaim IME request” (see id. at 22), and the assignee/provider bears the burden of persuasion on the medical necessity of the services (see Bedford Park Med. Practice P.C. v American Tr. Ins. Co., 8 Misc 3d 1025[A], 2005 NY Slip Op 51282[U], *3 [Civ Ct, Kings County 2005]).

General Assurance offered the testimony of two witnesses: Rhonda Steinback, one of its employees, and Jackie Winters, an employee of Metro Medical Services, a third-party contractor that arranges for medical examinations at General Assurance’s request. Through Ms. Winters, copies of six medical examination scheduling letters were admitted into evidence.

With respect to Foster Diagnostic, its assignor, Correna Gosine, was advised by letter dated March 25, 2002 that she had been scheduled for examination with a chiropractor, psychologist, physiatrist, and acupuncturist, and was advised by letters dated April 4 and April 5, 2002 that she had been rescheduled for examination by the same four professionals. With respect to Ocean Transportation, its assignor, Bryan Woodriffe, was advised by letter dated February 13, 2002 that he had been scheduled for examination by a chiropractor, physiatrist, and acupuncturist, and was advised by letter dated February 26, 2002 that he had been rescheduled for examination by the same three professionals.

None of these scheduling letters were signed by Ms. Winters, and she did not personally mail any of them. In her testimony, however, Ms. Winters “describ[ed] the standard office practice or procedures [Metro Medical] uses to ensure that such letters are properly addressed and mailed,” and, thus, “create[d] a presumption of mailing.” (See Amaze Med. Supply Inc. v State Farm Mut. Auto. Ins. Co., 8 Misc 3d 139[A], 2005 NY Slip Op 51315 [U], *2.)

In addition, through Ms. Winters, General Assurance introduced into evidence printouts from Metro Medical’s computer database, designated “patient notes,” for both assignors. The patient notes show for each entry a date and the identifying initials of the Metro Medical employee who made the entry. The patient notes for assignor Correna Gosine show that a Metro Medical employee left messages on Ms. Gosine’s voice mail advising of both the original and rescheduled appointments, and the patient notes for Mr. Woodriffe show that a Metro Medical [431]*431employee spoke to Mr. Woodriffe about the original appointments, and left a message with another person about the rescheduled appointments.

The evidence that neither Ms. Gosine nor Mr. Woodriffe appeared for any of the examinations is somewhat more tenuous. Ms. Winters testified that Metro Medical is advised by the professional by telephone or fax if the assignor does not appear for the scheduled appointment. There is no writing in this case advising that either assignor failed to appear for an appointment. Rather, the patient notes contain entries that the assignors failed to appear for any of the appointments, without showing in any case by what manner or from whom the information was obtained.

Courts have been willing to admit into evidence as a part of the “business records” of an enterprise writings or recorded oral information received from persons not employed by the enterprise, when those writings or information is received from someone who owes a “business duty” to the recipient to provide them accurately and when the recipient relies on the writing or information to properly conduct its business. (See People v Cratsley, 86 NY2d 81, 90-91 [1995]; People v DiSalvo, 284 AD2d 547, 548-549 [2d Dept 2001]; William Conover, Inc. v Waldorf, 251 AD2d 727, 728 [3d Dept 1998]; Pencom Sys. v Shapiro, 237 AD2d 144, 144 [1st Dept 1997]; Plymouth Rock Fuel Corp. v Leucadia, Inc., 117 AD2d 727, 728 [2d Dept 1986].)

Courts have refused “business records” treatment, however, when the identity of the person providing the information is unknown. (See People v Roberts, 304 AD2d 364 [1st Dept 2003]; Van Dina v City of New York, 292 AD2d 267, 267-268 [1st Dept 2002]; Dickson v Queens Long Is. Med. Group, 289 AD2d 193, 193 [2d Dept 2001]; Hamilton v City of New York, 262 AD2d 283, 283 [2d Dept 1999].)

Neither of General Assurance’s witnesses testified to the formal relationship between the insurer and Metro Medical, nor is it likely that either would have the personal knowledge to do so.

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Related

People v. Cratsley
653 N.E.2d 1162 (New York Court of Appeals, 1995)
Plymouth Rock Fuel Corp. v. Leucadia, Inc.
117 A.D.2d 727 (Appellate Division of the Supreme Court of New York, 1986)
Wilson v. Bodian
130 A.D.2d 221 (Appellate Division of the Supreme Court of New York, 1987)
Pencom Systems, Inc. v. Shapiro
237 A.D.2d 144 (Appellate Division of the Supreme Court of New York, 1997)
Cohn v. Haddad
244 A.D.2d 519 (Appellate Division of the Supreme Court of New York, 1997)
William Conover, Inc. v. Waldorf
251 A.D.2d 727 (Appellate Division of the Supreme Court of New York, 1998)
Hamilton v. City of New York
262 A.D.2d 283 (Appellate Division of the Supreme Court of New York, 1999)
People v. DiSalvo
284 A.D.2d 547 (Appellate Division of the Supreme Court of New York, 2001)
Dickson v. Queens Long Island Medical Group, P. C.
289 A.D.2d 193 (Appellate Division of the Supreme Court of New York, 2001)
Van Dina v. City of New York
292 A.D.2d 267 (Appellate Division of the Supreme Court of New York, 2002)
Bruce-Bishop v. Jafar
302 A.D.2d 345 (Appellate Division of the Supreme Court of New York, 2003)
People v. Roberts
304 A.D.2d 364 (Appellate Division of the Supreme Court of New York, 2003)
A.B. Medical Services PLLC v. Lumbermens Mutual Casualty Co.
4 Misc. 3d 86 (Appellate Terms of the Supreme Court of New York, 2004)
Stephen Fogel Psychological, P.C. v. Progressive Casualty Insurance
7 Misc. 3d 18 (Appellate Terms of the Supreme Court of New York, 2004)

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Bluebook (online)
10 Misc. 3d 428, Counsel Stack Legal Research, https://law.counselstack.com/opinion/foster-diagnostic-imaging-v-general-assurance-co-nycivct-2005.