Bajaj v Progressive Ins. Co.
Annotate this CaseDecided on November 20, 2006
Civil Court of the City of New York, Queens County
Dr. Deepika Bajaj a/a/o Krzysztof Wielgosz, Plaintiff,
against
Progressive Insurance Company, Defendant.
000013/2005
Thomas D. Raffaele, J.
After a bench trial, which was held before this Court on November 20, 2006, the Court finds as follows:
In this action, plaintiff provider-assignee seeks recovery of first-party no-fault benefits for medical services provided to assignor Krzysztof Wielgosz. The parties stipulated to the fact that the plaintiff had established its prima facie case, and that the insurer had timely denied the bills in question, with the only issue remaining for trial being the insurer's defense of lack of medical necessity. The insurer, rather than presenting the live testimony of its peer-review expert, neurologist Daniel J. Feuer, M.D., submitted for the Court's consideration the transcript of his deposition for admission pursuant to CPLR §3117(a)(4). Said deposition was noticed approximately three months following the filing of a notice of trial in this matter. Defense counsel conceded that he did not move to strike the notice of trial prior to noticing the deposition. Plaintiff's providing physician, Dr. Deepika Bajaj, provided live rebuttal testimony at the trial.
IDefendant was not authorized to take the deposition of its expert after the notice of trialwas filed.
Initially, the Court finds that defendant Progressive, absent a court order issued following a motion demonstrating "unusual or unanticipated conditions," was not entitled to notice or to conduct a pretrial examination of their expert peer-review witness. The Uniform Civil Rules for the New York City Civil Court (22 NYCRR §208.17) provide that: [*2] (c) Within 20 days after service of such notice of trial, any party may move to strike the action from the calendar or to keep it from being placed thereon. The affidavit in support of the application must specify the reason the action is not entitled to be on the calendar.(d) After any action has been placed on the trial calendar pursuant to this rule, no pretrial examination or other preliminary proceedings may be had, except that if some unusual or unanticipated conditions subsequently develop which make it necessary that further pretrial examination or further preliminary proceedings be had, and if without them the moving party would be unduly prejudiced, the court may make an order granting permission to conduct such examination or proceedings and prescribing the time therefor. Such an order may be made only upon motion on notice showing in detail, by affidavit, the facts claimed to entitle the moving party to relief under this subdivision.
Defendant conceded on the record that no such application was ever made. Where a moving party demonstrates that "unusual or unanticipated conditions" have developed after the filing of a notice of trial which make it necessary that further pretrial examinations or proceedings be conducted in order to prevent undue prejudice to the movant, the trial court may, in its discretion, grant permission to conduct such additional discovery (see 22 NYCRR 208.17 [d]; see generally 22 NYCRR 202.21). Appellate courts have held that "unusual or unanticipated conditions" contemplates a condition which is "not in the control of the party seeking further discovery and . . . [causes] actual rather than potential prejudice" to third-party defendant (Audiovox Corp. v Benyamini, 265 AD2d 135, 140 [2d Dept. 2000]), such as where a plaintiff suddenly is required to undergo surgery after the notice of trial is filed, (see e.g. David v Guardian Life Ins. Co. of Am., 2005 NY Slip Op 25332, 2 [App. Term, Second Dept. 2005]) . In the case at bar, defendant has known that the deposed witness was expected to be called at trial since September of 2005, when the physician conducted his peer review on defendant's behalf. Defendant failed to conduct a deposition of the doctor during the pretrial disclosure process. A notice of trial was filed on March 6, 2006. No motion to strike the notice of trial was ever made. The defendant noticed and conducted the peer review doctor's examination before trial on June 5, 2006, three months after the notice of trial was filed. Plaintiff's counsel by timely letter advised defense counsel that he objected to the post-notice of trial deposition. Clearly, the defendant failed to comply with the procedures set forth under 22 NYCRR 208.17[d]), nor did defendant show that any "unusual or unanticipated conditions" developed so as to justify further pretrial disclosure after the filing of the notice of trial (see Parker Chapin Flattau & Klimpl, LLP v Bamira, 2005 NY Slip Op 51208U, 2 [App. Term 1st Dept. 2005]).
II.Defendant's expert's opinion was based on documents not in evidence and thereforeinadmissible.
Defendant nonetheless claims that the late deposition testimony may be used pursuant to CPLR §3117(a)(4).
CPLR §3117(a)(4) provides that: the deposition of a person authorized to practice medicine may be used by any [*3]party without the necessity of showing unavailability or special circumstances, subject to the right of any party to move pursuant to section 3103 to prevent abuse.
However, even if the transcript itself is admissible pursuant to the above CPLR section, the contents thereof are subject to further scrutiny on the ground of the competence of the expert's testimony, or lack thereof. In the case at bar, even assuming, arguendo, that there were conditions justifying the taking of the deposition of defendant's expert subsequent to the filing of the notice of trial, the Court finds that the opinions expressed in the deposition were based upon documents which were not introduced into evidence at the deposition. Moreover, there was no evidence in the record of their reliability based upon the familiarity of the deposed witness with the procedures for the keeping of such records. Therefore, to admit the opinions at trial would be violative of the Second Department's rule in Wagman v Bradshaw, 292 AD2d 84 [2d Dept. 2002]).
In Wagman, the Second Department held that:
It is well settled that, to be admissible, opinion evidence must be based on one of the following: first, personal knowledge of the facts upon which the opinion rests; second, where the expert does not have personal knowledge of the facts upon which the opinion rests, the opinion may be based upon facts and material in evidence, real or testimonial; third, material not in evidence provided that the out-of-court material is derived from a witness subject to full cross-examination; and fourth, material not in evidence provided the out-of-court material is accompanied by evidence establishing its reliability.
(Wagman v Bradshaw, supra at 86-87 [2d Dept. 2002]).
In Astrel v Yarborough, 2006 NY Slip Op 5302, 1 [2d Dept. NY App. Div. 2006], the Second Department recently reaffirmed this rule, holding that "[g]iven the absence of evidence as to the reliability of those out-of-court medical records, the Supreme Court providently exercised its discretion in granting the defendant's motion" [to preclude the physician's testimony] (see DeLuca v Ding Ju Liu, 297 AD2d 307 [2d Dept. 2002]).
The Second Department, in Jemmott v Lazofsky, (5 AD3d 558, 560 [2d Dept. 2004]), held that a trial court erred in (a) admitting two MRI reports of the plaintiff's knee and permitting a doctor to offer redirect testimony regarding their contents, since the reports were prepared by other health care professionals who did not testify at the trial and the MRI film was not admitted into evidence and (b) permitting the plaintiff's attorney to cross-examine the defendant's medical expert witness regarding an MRI film of the plaintiff's back and the accompanying MRI report, as neither the MRI film nor the report were admitted into evidence, and directed a new trial on the issue of damages (see also D'Esposito v Kepler, 14 AD3d 509, 510 [2d Dept. 2005]); Wierzbicki v Mathew, 8 AD3d 476, 477 [2d Dept. 2004]; see also Sunnyside Plus v Allstate Ins. Co., 2005 NY Slip Op 25110 [Civil Ct. Queens Co., 2005, Dunbar, J.]).
In the matter before this Court, the deposition transcript of the peer-review physician indicates that neurologist Daniel J. Feuer, M.D. relied upon the following records: [A] report of EMG testing of the upper extremeties by Dr. Bajaj dated 8/11/05, an EMG of the lower extremeties by Dr. Bajaj dated 8/11/05, a chronic pain assessment report dated 8/3/05, a report of MRI of the left knee dated 8/1/05, psychological evaluation dated 7/27/05 and a report of consultation of Dr. Cohen [*4]dated 8/8/05. (See transcript, p. 10, lines 3-9).
Dr. Feuer's opinion was based upon a lack of documentation of "any consistent radicular or neuropathic complaints referable to the upper extremities which would support the necessity for this testing," (see transcript p. 13, lines 12-15), along with "inconsistent findings reported in this case" (see transcript, p. 14, lines 9-10). The records referenced were not certified or authenticated (see CPLR §§4518, 3122-a). The EMG and MRI studies were not authenticated at the deposition or at trial using the expedited method provided by CPLR §4532-a, nor were all of the records utilized by the peer-review physician authenticated by Dr. Bajaj at trial. There was no testimony from the peer-review doctor or anyone else as to the reliability of such out-of-court records. As a result, Dr. Feuer's opinion was based partly if not totally upon records which were not in evidence, and their reliability was not established. Thus, under Wagman and its progeny, it would be error for this Court to consider expert opinion based upon these records.
III.Strong policy reasons militate against permitting a trial by pretrial examination alone.
While not dispositive on this trial, the Court is constrained to discuss the following policy considerations:
The purpose of a trial is a search for the truth rather than an exercise in gamesmanship or a contest of strategies (see Finn v Morgan, 46 AD2d 229, 234 [2d Dept. 1974]; Ward v Kovacs, 55 AD2d 391 [2d Dept. 1977]). The court has a judicial responsibility to formulate rules of procedure to protect the integrity of the truth-finding process. A practice which hinders the search for truth is not one which ought to function under the broad imprimatur of the courts.
A deposition contains no more than testimonial evidence of the party-deponent and is merely the vehicle by which this evidence comes before the trier of fact. CPLR. §3117 confers upon the deposition no special qualities rendering its use immune to ordinary rules of trial practice. Thus, the discretionary power to control the use of live witnesses applies with equal force to control the use of a deposition. (See Feldsberg v Nitschke, 49 NY2d 636 [1980] leave denied 50 NY2d 1059 [1980]).
A trial court sitting as a trier of fact has discretion to require live testimony, rather than a transcript which is handed up for the Court's later perusal, particularly where, as here: (a) the defendant's entire case relies upon the testimony of a peer-review expert who will opine as to the medical necessity of the service at issue, and (b) where the expert's opinion is entirely based upon his review of some records provided to him by an insurance carrier or its intermediary vendor.It is of great value to the court sitting as the trier of fact to observe the demeanor of the witnesses during their testimony in order to assess their credibility. Depriving the court of the opportunity to view the witness' demeanor during testimony is a serious departure from accepted court standards, and should not be entertained lightly. Likewise, it is the cornerstone of the court's search for truth that all testimony be subjected to the rigors of cross-examination. Neither the physician's testimony at the deposition, which plaintiff's counsel objected and did not appear for, nor the testimony at trial, where the defendant decided not to have the doctor appear for, was subjected to cross-examination. These venerable devices, intended to promote the ends of justice for litigants appearing before the Court, cannot function as intended when parties rely principally, if not exclusively, upon an out-of-court perusal of a transcript of a deposition.
Further adding to the repugnancy of the process is the fact that these depositions are taken after a notice of trial was filed. Plaintiff's counsel must then choose whether to attend an [*5]unsanctioned deposition and delay the disposition of the case, or risk a waiver of his right to challenge the use of such deposition at trial. Given the legion of no-fault cases in Queens County, the Court cannot countenance additional delays through the use of a procedure which contravenes the Uniform Rules for the New York City Civil Court, strains judicial resources, and delays the administration of justice.
To permit this practice to proliferate would be tantamount to encouraging the defendants to submit a second summary judgment motion where the first has already been considered, and to capriciously label it a "trial." Indeed, such a "trial" fails to put the defendants to their burden of proof by presenting live testimony in support of its defense.
IV.The deposition of Dr. Feuer does not satisfy the defendant's burden of demonstrating a lack of medical necessity.
Even were this Court to consider Dr. Feuer's deposition in support of the defendant's medical-necessity defense, it would not, in any event, sustain the defendant's burden of proof in this regard.
As a general proposition, the court sitting as trier of fact is free to assess and reject even uncontradicted expert opinion, (see West Tremont Med. Diagnostic, P.C. v GEICO Ins. Co., 2006 NY Slip Op 51871U, 2 [App. Term 2d Dept. 2006]; 58A NY Jur. 2d, Evidence and Witnesses §676). The insurer bears both the burden of production and the burden of persuasion with respect to medical necessity of the treatment or testing for which payment is sought. (See Kings Medical Supply, Inc. v Country-Wide Ins. Co., 5 Misc 3d 767 [Civ. Ct. Kings County 2004]; Nir v Allstate Ins. Co., 2005 NY Slip Op 25090, 2 [Civ. Ct. Kings Co. 2005]). In the trial context, few decisions clarify defendant's burden of proof, or what evidence may be sufficient to establish that the services were medically unnecessary. Trial courts have held that, at a minimum, defendant must establish a factual basis and medical rationale for the lack of medical necessity of plaintiff's services (see A.B. Med. Servs. P.L.L.C. v NY Cent. Mut. Fire Ins. Co., 2005 NY Slip Op 50662U, 2 [Civil Ct. Kings Co. 2005]; A.R. Med. Art, P.C. v State Farm Mut. Auto. Ins. Co., 2006 NY Slip Op 50260U, 2 [Civil Ct. Kings Co. 2006] ; Long Is. Radiology v Allstate Ins. Co., 2006 NY Slip Op 51090U, 3 [Sup. Ct. Nassau Co., 2006]; Citywide Social Work & Psy. Serv. P.L.L.C. v Travelers Indemnity Co., 3 Misc 3d 608 [Civil Ct. Kings Co. 2004]; Inwood Hill Medical P.C. v Allstate Ins. Co., 3 Misc 3d 1110[A] [Civil Ct. Kings Co. 2004]). If defendant at trial provides an insufficient factual basis or medical rationale for its peer review report at trial, the court may afford the peer review report minimal weight, and defendant may fail to sustain its burden of proof. A peer review report's medical rationale is insufficient if it is unsupported by or controverted by evidence of medical standards. A peer review report's factual basis may be insufficient if it fails to provide specifics of the claim, is conclusory, or otherwise lacks a basis in the facts of the claim (see e.g Amaze Medical Supply v Allstate Ins. Co., 3 Misc 3d 43, 2004 NY Slip Op 24119 [App. Term 2d Dept. 2004]). For example, a defendant may not establish lack of medical necessity if the only reason for the denial was that the peer review doctor did not have enough information in the claim file upon which a determination could be made (see Park Neurological Servs. v Geico Ins., 4 Misc 3d 95, 2004 NY Slip Op 24210 [App Term, 2d Dept. 2004]). Hence, a peer review may be insufficient if it is based upon merely a lack of evidence which was available, but inexplicably not supplied to the peer-review doctor by the insurance company. One court has held that a peer review report may [*6]be insufficient if the peer review doctor merely reviewed records, rather than examined the insured patient, in preparing the peer review report (see Alliance Medical Office, P.C. v Allstate Ins. Co., supra; see also Fifth Avenue Pain Control Center v Allstate Ins. Co., supra.). For example, the medical rationale may be insufficient if not supported by evidence of the "generally accepted medical/professional practice" (Citywide Social Work & Psy. Serv. P.L.L.C. v Travelers Indemnity Co., supra at 608 ). "Generally accepted practice is that range of practice that the profession will follow in the diagnosis and treatment of patients in light of the standards and values that define its calling" (Citywide Social Work & Psy. Serv. P.L.L.C. v Travelers Indemnity Co., supra at 616). Alternatively, if the plaintiff offers evidence that its medical services were consistent with generally accepted medical practice, the defendant's peer review report may be afforded less weight and defendant may fail to sustain its burden of proof at trial (see Elm Medical P.C. v American Home Assurance Co., 2003 NY Misc. LEXIS 1337, 2003 NY Slip Op. 51357U [Civil Ct. Kings Co. 2003] [Defendant peer review doctor's conclusion that the electrodiagnostic testing was not "properly documented" did not contradict plaintiff's testimony of medical necessity and defendant failed to carry its burden]).
Instructive in this context is Nir v Allstate Ins. Co., (2005 NY Slip Op 25090, 3 [Civil Ct. Kings Co. 2005]), in which defendant's doctor recommended denial of plaintiff's claim because, in his opinion, the diagnostic testing performed by plaintiff Dr. Nir was done prematurely. During testimony, the peer review doctor cited only a review of Dr. Nir's medical reports as the basis for his peer review report. He did not physically examine the patient before writing the peer review report. He cited no medical authority, standard, or generally accepted medical practice as a medical rationale for his findings. Finally, defendant was not able to explain how the tests could be medically unnecessary when the tests did in fact yield positive findings of nerve damage. Such scant factual basis and medical rationale was held not to sustain defendant's burden of proof.
This court finds that, even if admissible, the opinion by the defendant's peer-review physician contained in the deposition transcript on the issue of lack of medical necessity is lacking in a factual basis, unsupported by cogent medical rationale as to generally accepted medical/professional practice, wholly conclusory, and based almost entirely upon his review of records which were not in evidence. By failing to appear in court, the Court is foreclosed from determining whether there were records available which were not provided to the peer-review doctor which would have been relevant to his review. When compounded by the court's inability to observe the doctor's demeanor and the lack of cross-examination, an opinion of this qualitative nature is essentially of little value to the court in rendering a just decision. Despite the fact that Dr. Feuer claims to have reviewed Dr. Bajaj' records of examinations on both 7/21/05 and 8/11/05, he selectively fails to mention that, contrary to his testimony, Dr. Bajaj did in fact find consistent radicular or neuropathic complaints in the upper extremities. On rebuttal during trial, Dr. Bajaj, who did appear before the Court, testified as to her findings of weakness and spasms on the left upper extremity indicating a denervation and nerve damage related to the C6-C7 region, thereby efficaciously rebutting and contravening Dr. Feuer's deposition testimony.Based upon all of the foregoing, the Court renders judgment after trial in the full amount prayed for by the plaintiff, along with statutory interest, costs and attorneys' fees. The Clerk of the Court is directed herein to enter judgment accordingly.
This constitutes the opinion, decision, and order of the Court. [*7]
___________________________
Hon. Thomas D. Raffaele
Judge, Civil Court
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