State Farm Mutual Automobile Insurance v. Mallela

372 F.3d 500
CourtCourt of Appeals for the Second Circuit
DecidedJune 18, 2004
DocketNo. 02-9407
StatusPublished
Cited by25 cases

This text of 372 F.3d 500 (State Farm Mutual Automobile Insurance v. Mallela) is published on Counsel Stack Legal Research, covering Court of Appeals for the Second Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
State Farm Mutual Automobile Insurance v. Mallela, 372 F.3d 500 (2d Cir. 2004).

Opinion

CALABRESI, Circuit Judge.

This case raises a question of state law that is unsettled, and of central importance to the functioning of New York’s no-fault automobile insurance scheme. It asks whether an insurance company may refuse to compensate medical providers for healthcare services that are within the scope of the no-fault program in every way except that they are provided by health care professionals employed by medical practices that, under state education and business laws, are unlawfully incorporated. On the motion of plaintiff-appellant State Farm Mutual Automobile Insurance Co. (“State Farm”), we CERTIFY the question to the New York Court of Appeals. See 22 N.Y.C.R.R. § 500.17.

I. BACKGROUND

State Farm filed this diversity action in the United States District Court for the Eastern District of New York (Sifton, /.), seeking declaratory and injunctive relief, [502]*502and compensatory and punitive damages, against defendants, a number of individuals and corporations whom State Farm has accused of participating in insurance fraud.

The district court dismissed the first complaint without prejudice, granting the plaintiff leave to replead.1 See State Farm Mutual Automobile Ins. Co. v. Mallela, 175 F.Supp.2d 401, 423 (E.D.N.Y.2001) (“State Farm I”). State Farm amended its complaint, making much the same claims, but adding several defendants and highlighting intervening amendments to the relevant insurance regulations. Judge Sifton, acting on a motion made by some defendants, dismissed the second amended complaint, this time with prejudice. See State Farm Mutual Automobile Ins. Co. v. Mallela, 2002 WL 31946762, at *17, 2002 U.S. Dist. LEXIS 25187, at * 64 (E.D.N.Y. 2002) (“State Farm II”).

State Farm then brought this appeal. But because the district court dismissed the complaint only as to the “Moving Defendants,” id,., although other defendants had been served, the order below was neither final nor appealable. See Ruffolo v. Oppenheimer & Co., 949 F.2d 33, 36 (2d Cir.1991). We raised the issue nostra sponte, and State Farm, in order retroactively to create a final judgment and establish appellate jurisdiction, agreed to dismiss with prejudice any outstanding claims against those defendants who had not moved to dismiss. See McManus v. Gitano Group, Inc., 59 F.3d 382, 383-84 (2d Cir.1995).

A. Statutory Scheme

We begin by reviewing the New York statutory and regulatory framework that governs this diversity case. In 1973, the New York State Legislature passed the precursor to today’s Comprehensive Motor Vehicle Insurance Reparations Act, see N.Y. Ins. Law §§ 5101 et seq. (formerly N.Y. Ins. Law §§ 670 et seq.), supplanting the state’s common law tort remedies for most injuries associated with automobile accidents with a no-fault insurance scheme. See Medical Soc’y v. Serio, 100 N.Y.2d 854, 860, 768 N.Y.S.2d 423, 800 N.E.2d 728 (2003). The purpose of the Act was to create a simple, efficient system that would provide prompt compensation to accident victims without regard to fault, and in that way reduce costs for both courts and insureds. See Serio, 100 N.Y.2d at 860, 768 N.Y.S.2d 423, 800 N.E.2d 728. The Act permits injured parties to recover benefits from insurers for “basic economic loss,” including medical expenses, that arise out of the use or operation of a covered motor vehicle. See N.Y. Ins. Law § 5102. It also provides for a “Fee Schedule” which establishes permissible charges for specific services offered by particular kinds of providers. See N.Y. Ins. Law § 5108, 11 N.Y.C.R.R. § 68.

The Superintendent of Insurance promulgated regulations to implement this statute, and has amended them several times. One set of revised regulations was struck down as a violation of the New York State Administrative Procedure Act in Matter of the Medical Society of the State of New York, Inc. v. Levin, 280 A.D.2d 309, 723 N.Y.S.2d 133 (N.Y.App.Div.2001). While an appeal from that decision was pending, the Superintendent again revised the regulations. The new revised regulations were approved by the Court of Appeals in Serio, 100 N.Y.2d at 862, 768 N.Y.S.2d 423, 800 N.E.2d 728.

[503]*503The regulations permit covered parties to assign their benefits to health care providers, who in turn submit claims to insurers for treatment and services given to the injured individual. See 11 N.Y.C.R.R. § 65-3.11. To guarantee that insureds are promptly compensated, the regulations also established strict, and brief, time periods for claim processing. Under these, insurers must, by forwarding the claimant certain prescribed forms, request any necessary “verification” of claims within ten days of receiving a completed claim. See 11 N.Y.C.R.R. § 65.15(d). Upon getting verification, insurers have thirty days within which to pay or deny a benefits claim. See 11 N.Y.C.R.R. § 65.15(g).

B. The Allegedly Key Sentence

A sentence which was added to the regulations in the last revision, and came into effect in 2001, is central to plaintiffs argument in the case before us. It reads:

A provider of health care services is not eligible for reimbursement under section 5102(a)(1) of the Insurance Law if the provider fails to meet any applicable New York State or local licensing requirement necessary to perform such service in New York or meet any applicable licensing requirement necessary to perform such service in any other state in which such service is performed.

11 N.Y.C.R.R. § 65-3.16(a)(12). Plaintiff contends that the requirement that any healthcare provider be properly licensed must be read in conjunction with the many statutes and rules that govern the licensing of healthcare providers in New York State. Specifically, because of the state’s longstanding concern that the so-called “corporate practice of medicine” could create ethical conflicts and undermine the quality of care afforded to patients, New York forbids non-physicians from employing physicians or controlling their practices. Thus, under New York’s Business Corporation Law, all professional service corporations [“P.C.s”] that are licensed to practice medicine must be owned and controlled only by licensed physicians. N.Y. Bus. Corp. Law §§ 1507, 1508. Additionally, P.C.s must file copies of their certificate of incorporation with the Department of Education and, from that Department, obtain certificates of authority to practice medicine. See N.Y. Educ. Law § 6507(4)(c). According to N.Y. Business Corporation Law § 1503, these certificates of incorporation must,

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Cite This Page — Counsel Stack

Bluebook (online)
372 F.3d 500, Counsel Stack Legal Research, https://law.counselstack.com/opinion/state-farm-mutual-automobile-insurance-v-mallela-ca2-2004.