Opinion
Index No. CV-009422-20/NY
08-05-2022
American Transit Insurance Company, Petitioner, v. Mark S. McMahon MD, P.C. A/A/O RUBIN GOMEZ, Respondent.
Peter C. Merani, P.C. (Adam Waknine, of counsel), New York City, for petitioner. Samandarov & Associates, P.C. (David M. Gottlieb, of counsel), New York City, for respondent.
Unpublished Opinion
Peter C. Merani, P.C. (Adam Waknine, of counsel), New York City, for petitioner.
Samandarov & Associates, P.C. (David M. Gottlieb, of counsel), New York City, for respondent.
RICHARD TSAI, J.
In this special proceeding arising out of a no-fault arbitration, petitioner American Transit Insurance Company (ATIC) seeks to vacate the determination of a master arbitrator affirming the award of a no-fault arbitrator, which awarded respondent first-party no-fault benefits (Motion Seq. No. 001). Respondent Mark S. McMahon MD, P.C. a/a/o Rubin Gomez opposes the petition and seeks attorney's fees incurred in opposing the petition.
BACKGROUND
Respondent Mark S. McMahon MD, P.C is the assignee of claims for no-fault benefits for arthroscopic surgery performed on the right knee of Rubin Gomez on October 31, 2017, for injuries allegedly arising out of an automobile accident on June 3, 2017 (see petitioner's exhibit B, NF-10 form and Explanation of Benefits). ATIC denied the claims on the ground that the surgery and surgically related services to the right knew were not causally related to the accident, based on a peer review, and "no medical necessity and no causal relationship between the accident and the shoulder surgery of 10/31/17" (see id.). Respondent then submitted the claims to no-fault arbitration (see petitioner's exhibit D, no-fault arbitration request).
A no-fault arbitration hearing of respondent's claims was held before the American Arbitration Association on January 8, 2020 (see petitioner's exhibit A, no-fault arbitrator award).
Arbitrator Marcie Glasser ruled in favor of respondent, finding that "Claimant had a causally-related ongoing knee injury for which surgery was medically necessary under the circumstances" (see id. at 5). The no-fault arbitration award dated January 14, 2020 states, in relevant part:
"With regard to medical necessity defense, I find that [ATIC]'s Peer Review Report is sufficient to meet its burden of proof and to rebut [respondent]'s evidence. Thereafter, the burden shifts back to [respondent] to present competent medical proof as to the medical necessity for the knee arthroscopy, by a preponderance of the credible evidence.... Ultimately, the burden of proof rests with the [respondent].
* * *
I find that this burden as to medical necessity has been met by [respondent]'s medical records, the Rebuttal Report, Letter of Medical Necessity of Dr. McMahon, and the evidence collectively. I am convinced that the Claimant attempted an ample course of non-operative conservative treatment measures including physical therapy under the circumstances, and the decision to perform arthroscopic knee surgery was reasonable to repair the meniscus tear. Moreover, this finding is supported by the fact that the credibility of the Peer Review Report is diminished as it is found to be conclusory in nature, and because Dr. Skolnick primarily relied upon the independent radiology report of Dr. Fitzpatrick which bears minimal weight in this determination. The treating radiologist and the treating orthopedist both reviewed the MRI which showed a tear of the posterior horn of the medial meniscus. The Rebuttal Report appropriately addressed the issues of the Peer Review Report. The orthopedic surgeon, Dr. McMahon, based on his professional experience, examination and treatment of the Claimant determined that the surgery for the meniscus tear was in accordance with the standard of care. I find that the Claimant had a causally-related ongoing knee injury for which surgery was medically necessary under the circumstances"(petitioner's exhibit A, no-fault arbitrator award at 4-5). On the issue of lack of causation, the award states, in relevant part:
"I find that Respondent has not adequately demonstrated lack of causation, and therefore, the defense cannot be sustained. The Peer Review Report of Dr. Skolnick is found to be conclusory with regard to the issue of causation. Moreover, Dr. Skolnick relied on the Independent Radiology Evaluation of Dr. Fitzpatrick, which states that the MRI findings, specifically the cartilage thinning, are degenerative in nature, but the Independent Radiology Evaluation, was not specific as to the tear in relation to the thinning cartilage. In the Addendum, Dr. Skolnick stated that he agrees with the treating radiologist's report that the MRI showed a tear of the meniscus; however, according to the independent radiology review of Dr. Fitzpatrick, there was no evidence of traumatic injury. I find that Dr. Skolnick's determination that the MRI showed no traumatic injury is without appropriate reliance on the independent radiology review of Dr. Fitzpatrick. The Peer Reviewer himself interpreted the MRI as showing a meniscus tear, which is in accordance with the interpretation of the MRI by the treating orthopedist and the treating radiologist. The independent radiologist did not state with specificity that the meniscus tear is degenerative in nature and there is a lack of support for the opinion that the injury is not causally related to the accident. I find that the reliance on the Independent Radiology Review is misplaced, and Dr. Skolnick's finding of lack of causation is conclusory"(id. at 5).
The arbitrator also awarded interest from the date of 1/21/2019, and attorney's fees in the amount "in accordance with newly promulgate 11 NYCRR 65-4.6(d) on the amount awarded of $4,702.03 at a rate of 2% per month, simple and ending with the date of payment of the Award" (id. at 7). The arbitrator also directed ATIC to pay respondent $40 for reimbursement of the fee paid to the Designated Organization, unless the fee was previously returned pursuant to an earlier award (id.).
On appeal, Master Arbitrator Robert Trestman affirmed the original arbitrator's award in its entirety. The master arbitration award, dated March 24, 2020 states, in relevant part:
"I have carefully reviewed the parties' briefs, the record on appeal, as presented by respondent and the pertinent case law, including the two cases hereinabove cited by respondent. The arbitrator's detailed findings and conclusions as to the medical necessity and causal relationship issues were within the arbitrator's sound discretion and rational interpretation of the evidence and which I do not find to be reversible error within my purview as a Master Arbitrator.... Within my powers as a Master Arbitrator, I cannot conduct a de novo review of the case and I cannot substitute my interpretation or my view as to the weight or credibility of the evidence over that of the lower arbitrator, especially as the arbitrator's decision appears to be rational and based on the evidentiary record"(petitioner's exhibit A, master arbitration award, at 2-3).
The master arbitrator also awarded $195 to the applicant for attorney's fees for having prevailed in the master arbitrator's review of the award (see id. at 5).
On July 29, 2020, ATIC commenced this proceeding pursuant to CPLR 7511 to vacate the master arbitrator's award.
DISCUSSION
"Judicial review of a master arbitrator's award is restricted, by the terms of the statute, to the grounds for review set forth in article seventy-five of the CPLR" (Matter of Petrofsky [Allstate Ins. Co.], 54 N.Y.2d 207, 211 [1981] [internal quotation marks omitted]; Insurance Law § 5106 [c]). Pursuant to CPLR 7511 (b), an arbitration award may be vacated if the court finds that the rights of a party were prejudiced by (1) corruption, fraud, or misconduct in procuring the award; (2) partiality of an arbitrator; (3) the arbitrator exceeding his, her, or their power or imperfectly executed it that a final or definite award was not made; or (4) the failure to follow the procedures of CPLR article 75. Additionally,
"[w]here, as here, there is compulsory arbitration involving no-fault insurance, the standard of review is whether the award is supported by evidence or other basis in reason. This standard has been interpreted to mean that the relevant test is whether the evidence is sufficient, as a matter of law, to support the determination of the arbitrator, [and whether the determination] is rational and is not arbitrary and capricious"(Matter of Miller v Elrac, LLC, 170 A.D.3d 436, 436-37 [1st Dept 2019], lv denied 33 N.Y.3d 907 [2019], citing Matter of Petrofsky, 54 N.Y.2d at 211).
According to ATIC, the arbitrators ignored explicit evidence that ATIC had submitted, failed to apply the proper evidentiary burdens, and rendered an award that was not final and definite that was prejudicial to petitioner (affirmation of petitioner's counsel ¶ 62). Citing the standards applicable to an insurer's motion for summary judgment on the ground of medical necessity, ATIC contends that, once it offered it peer review report of Dr. Skolnick, the burden should have shifted to respondent to rebut with evidence establishing that the services were medically necessary (see id. ¶¶ 21-23). ATIC contends that respondent failed to meet its burden because "Respondent offered no significant rebuttal to actually rebut the findings of Dr. Skolnick" (id. ¶ 34).
ATIC argues, "Dr. Skolnick submitted an addendum dated 3/7/19. In it, Dr. Skolnick directly addressed Dr. McMahon's general statements concerning an alleged tear in the knee necessitating the surgery. Dr. Skolnick stated there was no right knee fracture or dislocation" (id. ¶ 31). According to ATIC, "[t]he no-fault arbitrator exceeded his bestowed powers as there was no basis simply to cast aside the entirety of petitioner's evidence" (id. ¶ 38).
Respondent maintains that "ATIC's evidence was not cast aside. It was carefully reviewed and found to be insufficient, in light of the facts and Respondent's rebuttal (affirmation in opposition of respondent's counsel ¶ 11). Respondent contends that petitioner's disagreement with the arbitrator's findings of fact is not a basis to vacate the award (id.). Respondent further argues, "Applicant was not required to prove that the motor vehicle [sic] exacerbated a pre-existing condition. That was ATIC's burden if ATIC wanted to prove that the injury was not caused by the accident....it is well-settled that exacerbation of a preexisting condition is compensable under no-fault."
In reply, ATIC argues that the issue of causality was never considered (reply affirmation of petitioner's counsel ¶ 7). ATIC submits that "the arbitrator failed to apply the rules in connection to a lack of causation defense" (id.. ¶ 10). According to ATIC, "lack of causation does not require a citation to medical rationales as to whether or not certain types of treatment should be administered. The causation issue is not whether or not a doctor should administer treatment" (id. ¶ 11). ATIC maintains, "the peer review doctor is not required to cite any medical authorization as to support his conclusion for lack of causation as the issue is not one regarding lack of medical necessity. The arbitrator confused the proof required with that of prima facie proof for a lack of medical necessity defense" (id. ¶ 17).
The court agrees with respondent.
"The master arbitrator's determination of the law need not be correct: mere errors of law are insufficient to set aside the award of a master arbitrator" (Matter of Liberty Mut. Ins. Co. v Spine Americare Med., 294 A.D.2d 574, 577 [2d Dept 2002]). Where error of law is at issue, the test is "whether any reasonable hypothesis can be found to support the questioned interpretation. Generally, a court will not set aside an arbitrator's award for errors of law or fact unless the award is so irrational as to require vacatur" (Matter of Carty v Nationwide Ins. Co., 212 A.D.2d 462, 462 [1st Dept 1995]); accord Matter of Hanover Ins. Co. v State Farm Mut. Auto. Ins. Co., 226 A.D.2d 533 [2d Dept 1996]).
Here, ATIC fails to establish that the no-fault arbitrator's award was so irrational as to require vacatur. First, the burden of proof applicable at trial involving medical necessity and an insurer's burden on a motion for summary judgment are not described in the same terms.
"In a no-fault trial dealing with a defense of lack of medical necessity, an insurer has an initial burden to rebut the presumption of medical necessity which attaches to a claim form; however, it is the plaintiff [provider] who has the ultimate burden of proving, by a preponderance of the evidence, that the services at issue were medically necessary"(Radiology Today, P.C. v Geico Ins. Co., 58 Misc.3d 132 [A], 2017 NY Slip Op 51768[U] n 1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017]; Dayan v Allstate Ins. Co., 49 Misc.3d 151 [A], 2015 NY Slip Op 51751[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]).
Here, it is abundantly apparent that the no-fault arbitrator ruled that respondent had met its ultimate burden of demonstrating that the services at issue were medically necessary by a preponderance of the evidence (see petitioner's exhibit A, no-fault arbitrator award, at 5).
The no-fault arbitrator also found that "[ATIC] has not adequately demonstrated lack of causation" (no-fault arbitrator award, at 5). The no-fault arbitrator thoroughly considered the evidence. A reasonable hypothesis can be found to support this interpretation. Insofar as there was no dispute that respondent had established its prima facie case, ATIC "had the burden to proffer evidence in admissible form demonstrating that the assignor's alleged injuries were not causally related to the accident" (A & A Dental, P.C. v State Farm Ins. Co., 19 Misc.3d 135 [A], 2008 NY Slip Op 50709[U] [App Term, 2d Dept, 2d & 11th Jud Dists 2008]).
The no-fault arbitrator rejected as conclusory the Peer Review Report of Dr. Skolnick with regard to the issue of causation. It would appear that the no-fault arbitrator concluded that the tear was caused by trauma, given that "the independent radiologist did not state with specificity that the meniscus tear is degenerative in nature" (see petitioner's exhibit A, no-fault arbitrator award, at 5). ATIC essentially argues that the no-fault arbitrator should not have found that the tear was caused by trauma because Dr. Skolnick stated in his Addendum that there was no evidence of a fracture or dislocation. However, the no-fault arbitrator's finding that ATIC did not meet its burden that the surgery was not causally related to the accident is consistent with the no-fault arbitrator's credibility determinations about Dr. Skolnick and Dr. Fitzpatrick.
Contrary to ATIC's argument, there is no basis to conclude that the arbitrator made a mistake of law by ignoring ATIC's evidence that services rendered Rubin Gomez were not medically necessary; the arbitrator simply made a factual determination that they were medically necessary (Miller, 170 A.D.3d at 437). ATIC argues, in essence, that the arbitrator's determination was an error of law because the arbitrator did not resolve issues of credibility in ATIC's favor. "However, where, as here, the evidence is conflicting and room for choice exists, this Court may not weigh the evidence or reject the choice made by the arbitrator" (Matter of Powell v Bd. of Educ. of Westbury Union Free School Dist., 91 A.D.3d 955, 955-56 [2d Dept 2012]). "Obviously, if a court cannot 'weigh' the evidence, it cannot weigh credibility, which in the end is simply a component of that evidence" (Matter of McMahan & Co. [Dunn Newfund I], 230 A.D.2d 1, 5 [1st Dept 1997]).
The fact that the no-fault arbitrator accepted respondent's affirmed rebuttal letter over Dr. Skolnick's peer review report and Addendum presented an issue of Dr. Skolnick's credibility for the factfinder to resolve. These are not errors of law, notwithstanding that the ATIC's peer review report and other evidence in the record might support a contrary result. The no-fault arbitrator credited the written testimony of respondent's physician over that of ATIC's peer reviewer.
To the extent that ATIC argues that the award "went against the entire weight of the unrebutted evidence" (see petition ¶ 38),
"[a] master arbitrator's powers of review do not encompass such a review of the facts, nor do they authorize him to determine the weight of the evidence. This is not to say that in making his determinations as to whether the arbitrator's determination is correct, that the master arbitrator will conduct no review of the facts; rather, it means his review in this respect is limited to whether or not the evidence is sufficient, as a matter of law, to support the determination of the arbitrator"(Matter of Petrofsky, 54 N.Y.2d at 212). "[T]he master arbitrator is without power to vacate an award based upon a de novo review of the evidence" (Matter of Smith v Firemen's Ins. Co., 55 N.Y.2d 224, 232 [1982]).
Here, the master arbitrator correctly determined that the evidence was sufficient, as a matter of law, to support the original arbitration's determination (see State Farm Mut. Auto. Ins. Co. v Stack, 55 A.D.3d 594, 595 [2d Dept 2008] [testimony of expert witness, who based his opinion upon his examination of defendant and his review of defendant's relevant medical records, including, inter alia, CT scans and MRIs, was sufficient to establish that defendant's condition was causally related to the accident]; cf. Advanced Orthopedics, PLLC v GEICO, 63 Misc.3d 136 [A], 2019 NY Slip Op 50500[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2019] [record supported the dismissal of complaint because Civil Court found defendant's expert witness credibly testified that the surgery was not causally related to accident in question]). Thus, the master arbitrator did not exceed his/their powers.
ATIC's argument that the award was not final or definite is without merit. "An award is deficient in this regard and subject to vacatur only if it leaves the parties unable to determine their rights and obligations, if it does not resolve the controversy submitted or if it creates a new controversy" (Matter of Meisels v Uhr, 79 N.Y.2d 526, 536 [1992]). Here, the no-fault arbitration award determined ATIC's and [respondent]'s rights and obligations, resolved the claims submitted to arbitration, and did not create any new controversies.
Although not raised by petitioner, the court notes that the fact that the no-fault arbitration award did not specify an exact amount of interest or attorney's fees awarded does not render the award indefinite, because the amounts may be ascertained through computation of simple arithmetic (see Matter of Hunter [Proser], 274 AD 311, 312 [1st Dept 1948] , affd 298 NY 828 [1949]).
Therefore, ATIC's petition to vacate the master arbitrator's award is denied.
CPLR 7511(e) mandates confirmation of the award upon denial of an application to vacate or modify the award (Blumenkopf v Proskauer Rose LLP, 95 A.D.3d 647, 648 [1st Dept 2012]). Therefore, the award is confirmed.
The no-fault arbitrator awarded respondent the amount of $4,702.03, with interest from 1/21/2019, plus attorney's fees (petitioner's exhibit A, no-fault arbitrator award at 6-7). Interest on overdue payments is fixed by regulation at the rate of 2 per cent per month (11 NYCRR 65-3.9 [a]). The total amount of interest due on $4,702.03 from 1/21/2019 until 1/14/2020 (the date of the award) is $1,106.86(2% x $4,702.03 x 11 months 24 days). The amount of attorney's fees awarded by the no-fault arbitrator is therefore $1,161.78(20% x [$4,702.03 + $1,106.86) (11 NYCRR 65-4.6 [d]).
In addition, the master arbitrator awarded $195 in legal fees for the master arbitration (see petitioner's exhibit A, master arbitrator award).
Respondent is also entitled to recover costs of the proceeding in the amount of $50.00, for the amount of the judgment is more than $6,000, and no notice of trial has been filed (CPLR 8101; NY City Civ Ct Act § 1901 [a], [b] [1]).
Citing 11 NYCRR 65-4.10 (j) (4), respondent also requests that the court award attorney's fees in the amount of $1,000, for 2.5 hours (calculated at a rate of $400 per hour) spent to oppose the petition (see affirmation in opposition of respondent's counsel ¶ 19).
ATIC opposes the request, claiming that $400.00 is a "marquee rate for private litigation" (reply affirmation of petitioner's counsel ¶ 24). ATIC argues that the hourly rate for attorney's fees should not exceed the hourly rates of attorney's fees for a master arbitration, which are capped at $65.00 an hour, and $650.00 in total (id. ¶¶ 24-27).
Respondent correctly indicates that it is entitled to recovery attorney's fees incurred in the Article 75 proceeding. If a valid claim for first-party no-fault benefits is overdue, the claimant is entitled to recover reasonable attorney's fees for services necessarily performed in connection with securing payment of the overdue claim, subject to limitations promulgated by the superintendent in regulations (Insurance Law § 5106 [a]). No-fault regulations provide that "[t]he attorney's fee for services rendered... in a court appeal from a master arbitration award and any further appeals, shall be fixed by the court adjudicating the matter" (11 NYCRR § 65-4.10[j][4]). "The term 'court appeal' applies to a proceeding taken pursuant to CPLR article 75 to vacate or confirm a master arbitration award (Matter of Country-Wide Ins. Co. v TC Acupuncture P.C., 179 A.D.3d 414, 414 [1st Dept 2020]).
ATIC's argument raises a threshold issue of whether there any regulatory limits on amount of attorney's fees incurred in connection with Article 75 proceeding to vacate or confirm a master arbitration award.
As ATIC points out, the no-fault regulations limit the amount of attorney's fees recoverable for services rendered in connection with the master arbitration itself. For example, for preparatory services, the attorney is entitled to "a fee of up to $65 per hour, subject to a maximum fee of $650," and "a fee of up to $80 per hour for oral argument before the master arbitrator" (see 11 NYCRR 65-4.10 [j] [2] [i], [ii]). For disputes subject to arbitration or court proceedings involving a "policy issue," the no-fault regulations also limit the attorney's fee for the arbitration or litigation of all issues to "a fee of up to $70 per hour, subject to a maximum fee of $1,400" (11 NYCRR 65-4.6 [c]; see Kamara Supplies v GEICO Gen. Ins. Co., 67 Misc.3d 129[A], 2020 NY Slip Op 50414[U] [App Term, 1st Dept 2020]).
"'[P]olicy issues' enumerated on the denial of claim form at bar are clearly limited to include only: (1) the policy was not in force on the date of the accident (box 3); (2) the injured person is excluded under policy conditions or exclusion (box 4); (3) the policy conditions were violated, which is limited to two categories involving late submission of a notice of claim (box 5); (4) the injured person is not an eligible injured person (box 6); (5) and the injuries did not arise out of use or operation of a motor vehicle (box 7)" (Kamara Supplies, 67 Misc.3d 129[A], 2020 NY Slip Op 50414[U], *1). ATIC does not contend that the arbitration involved a "policy issue." No "policy issues" were checked off as reasons for denial on the denial of claim form (see petitioner's exhibit B).
However, there do not appear to be any no-fault regulations limiting the amount of attorney's fees recoverable for services rendered in a proceeding taken pursuant to Article 75 of the CPLR to vacate or confirm a master arbitration award (see e.g. Matter of Hempstead Gen. Hosp. v Natl. Grange Mut. Ins. Co., 179 A.D.2d 645, 646 [2d Dept 1992]).
In Matter of Hempstead General Hospital, the Appellate Division, Second Department implicitly endorsed the calculation of the attorney's fees upon a reasonable hourly rate without any limitations, for services rendered in a proceeding to vacate or confirm a master arbitration award. There, the Supreme Court had determined that petitioner was entitled to counsel fees in vacating a master arbitration award, and that the petitioner's counsel's work was worth $175 per hour, for a total of $7,000 (179 A.D.2d at 646). However, the Supreme Court reduced the award to $756, on the ground that it would only award a fee on that portion of the work performed directly on behalf of the client (id.). On appeal, the Appellate Division, Second Department, modified the Supreme Court's order to increase the award of counsel fees to the full amount of $7,000 (id.).
The court finds that the time that respondent's counsel spent on this Article 75 proceeding and the hourly rate were reasonable. Accordingly, respondent is awarded $1,000.00 in attorney's fees for services rendered in opposing the petition.
CONCLUSION
Upon the foregoing cited papers, it is hereby ORDERED and ADJUDGED and the petition to vacate the arbitration award (Motion Seq. No. 001) is DENIED, and it is further
ADJUDGED that the award of the master arbitrator Robert Trestman, dated March 24, 2020 rendered in favor of respondent Mark S. McMahon MD P.C. a/a/o Rubin Gomez against petitioner American Transit Insurance Company, affirming the award of the no-fault arbitrator Marice Glasser issued on January 14, 2020 is confirmed; and it is further
ADJUDGED that respondent Mark S. McMahon MD P.C. a/a/o Rubin Gomez, having an address at 876 Park Avenue, New York, NY 10075, do recover from petitioner American Transit Insurance Company, having an address at 5 Broadway, Freeport, New York 11520, the amount of $4,702.03, plus interest at the rate of 2% per month from the date of 1/21/2019 until 1/14/2020, in the amount of $1,106.86, plus attorney's fees in the amount $1,161.78, plus $40.00 as reimbursement for a fee previously paid by respondent, plus attorney's fees incurred in the master arbitration in the amount of $195.00, plus attorney's fees incurred in this proceeding in the amount of $1,000.00, together with costs of this proceeding in the amount of $50.00, for the total amount of $8,255.67, and that the respondent have execution therefor.
This constitutes the decision, order, and judgment of the court.