Besides competitive pricing, attentive service and the ability to precisely tailor the plans and coverages to my very needs, Morgan is able to cater to the motorsports enthusiast, because he is a driver himself. Unfortunately, I also had a chance to go through a claim, which was promptly and efficiently handled as promised. Duffy has been able to efficiently meet my clients collector car insurance needs, and has earned their and my confidence.
District Court, Lowell Division Present: Insurance, Motor vehicle personal injury protection benefits, Coordination-of-benefits clause, Unfair act or practice. Contract, Insurance, Coordination of benefits clause.
Consumer Protection Act, Insurance. In a civil action brought by a health care provider claiming entitlement to unpaid personal injury protection benefits under a compulsory automobile insurance policy pursuant to G. The case was heard by J. Gaimari for the plaintiff.
Amica initially denied all payments to Duffy in September and October,on the basis of an independent medical examination IME [Note 5] conducted by an orthopedic surgeon, which indicated that Cormier would not need further professional medical care beyond a date roughly one month before she began treatment with Duffy.
However, Amica had previously advised Cormier and her counsel of this development on July 22,one month before Cormier began treatment with Duffy.
See note 1, supra; Dominguez v. Duffy was on actual notice of the coordination of benefits requirement no later than July, -- a point in time still well within the two years allowed for the presentation of PIP claims under the statute [Note 9] -- and yet he still failed to coordinate benefits.
He then waited nearly an additional four years to bring this action. Duffy cannot maintain that he could rely on bills he previously submitted to Amica for payment in full as, without any documentation on the partial payments he received subsequently, Amica could have made substantial overpayments to him if it had conceded coverage.
However, where it is undisputed that Amica provided Duffy with "written notice of its intent not to make [medical] payments" and "specif[ied] reasons for said nonpayment," G.
However, a denial based on the initial PIP threshold is only a conditional denial.
Therefore, Duffy was well advised that before any of his bills could be considered for payment, he would need to refute the opinion in the IME report. This he did not do. There is no evidence in the record that Duffy ever challenged the substance of the IME cutoff to put Amica on notice that it needed to do anything further to evaluate his claims for payment.
Duffy contends that the IME report did not state a definitive conclusion that Cormier had reached a medical endpoint but only a prediction that she would reach such an endpoint in four weeks.
He argues that where the statute allows insurers to have independent physical examinations performed "as often as may be reasonably required," G. He disputes that under the circumstances here Amica had no duty of investigation to determine the medical necessity of any post-IME medical treatment that Cormier received.
First, the IME report stated explicitly that Cormier would have a decreasing partial disability for the next four weeks. The simple fact that Amica received medical bills from Duffy, then a new provider on the case, would not put it on notice that the IME required updating, especially where the actual opinion in the IME report was not that the symptoms would have disappeared but only that any remaining symptoms could be managed with a home exercise program after four more weeks.
The denial letters it did send at least "impliedly invited" a response from Duffy, but none was ever received. See Dominguez, Mass.
Decision and order of the Appellate Division affirmed. FOOTNOTES [Note 1] Under that scheme, designed in large part to "provide an inexpensive and uncomplicated procedure for obtaining compensation for injuries sustained in automobile accidents," Dominguez v.
See note 6, infra. In any case where benefits due and payable remain unpaid for more than thirty days, any unpaid party shall be deemed a party to a contract with the insurer responsible for payment and shall therefore have a right to commence an action in contract for payment of amounts therein determined to be due in accordance with the provisions of this chapter.The Sacramento Bee offers advertising and marketing solutions to reach the people of Sacramento and Northern California.
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