Nassau Supreme Court Hears Case Regarding “Necessary Emergency Health Services”

The Nassau Supreme Court case involved an individual injured in an accident in which their blood-alcohol content was .15%. The toxicology report taken by the hospital also showed the individual had THC in her system at the time of admission to the hospital room. The Hospital submitted a bill for hospital services to the insurer in the amount of $43,212.59. After learning of the toxicology report, the insurer requested verification in the form of a breakdown of which hospital services constituted emergency health services.

When an insured person gets injured as a result of operating a motor vehicle in an intoxicated condition, the insurer may question whether they can deny personal injury protection to the negligent driver. Prior to 2011, New York no-fault insurers had the ability to deny paying out the coverage benefits. However, in January 2011, New York State amended Insurance Law § 5103(b)(2) which required the insurers to cover payments for “necessary emergency health services rendered in a general hospital.” While the amendment has been the topic of several arbitration settlements, the case of St. Barnabas Hospital v. Government Employees Insurance Company was the first that has made its way to a New York court.

The Nassau Supreme Court case involved an individual injured in an accident in which their blood-alcohol content was .15%. The toxicology report taken by the hospital also showed the individual had THC in her system at the time of admission to the hospital room. The Hospital submitted a bill for hospital services to the insurer in the amount of $43,212.59. After learning of the toxicology report, the insurer requested verification in the form of a breakdown of which hospital services constituted emergency health services. In doing so, the insurer requested a “breakdown of charges up to where the patient was found to be stabilized.”

The Hospital refused to provide the documentation for the insurer because they claimed the breakdown was not required under insurance or no fault law. They responded by stating that the entirety of the services provided were “necessary emergency health services.” After the insurer failed to pay the bill, the Hospital commenced the action. The insurer moved for summary judgement under Insurance Law § 5103(b)(2), claiming that they were not going to pay the bill until they could determine the proper amount of “necessary emergency health services.”

The insurer provided evidence of a letter issued by the New York State Insurance Department which sought clarification of the amendment to Insurance Law § 5103(b)(2). In the letter, the Insurance Department defined “necessary emergency health services” as “sudden pain or injury that is treated until the patient is stabilized, generally in the emergency room.”

In reviewing the medical bill, the court recognized that the patient was admitted to the hospital for approximately three days. Because the insurer provided sufficient proof that the patient was intoxicated by alcohol and marijuana, the court ruled that the insurer was entitled to request information regarding the breakdown of services. The court further ruled that the hospital was to provide the insurer with a breakdown of all services, and the insurer was to assess when the no-fault coverage ceases, if at all. Following the assessment, the insurer must pay the appropriate amount of the claim.

Insurers who are seeking to argue under this particular Insurance Law have the burden of proving: (1) that the insured was intoxicated or impaired by drugs; AND (2) that the intoxication or impairment was a proximate cause of the accident. A failure to prove both elements may undermine a “necessary emergency health services” verification request. While the court has not yet seen many of these cases, some arbitration matters have dismissed cases for a failure to prove both elements.

Since 1950, the law firm of Montfort, Healy, McGuire, & Salley LLP has represented clients in insurance coverage disputes in Nassau, Suffolk, Queens (Long Island), Kings (Brooklyn), New York (Manhattan), Richmond (Staten Island), Bronx and Westchester counties. Our lawyers have experience representing insurance companies and individuals in insurance coverage disputes related to construction accidents, product liability, motor vehicle accidents, premises liability, personal injury defense, medical malpractice, and hospital liability. If you are seeking assistance regarding an insurance coverage dispute, contact us at (800)-240-4082, or fill out our contact form here.

To read the full case decision click here.

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