Scott A. Ginsberg

We successfully defended and submitted post-hearing arguments and secured dismissal of a New York no-fault arbitration matter. The applicant, a major medical provider, filed an arbitration matter in the amount of $361,601.62, claiming our client owed it for the claimant’s unpaid medical bills following a major motor vehicle accident. The claimant had been involved in the motor vehicle accident and sought payment for medical treatment for a series of treatments rendered while hospitalized, post-accident. Counsel for the medical provider argued that the medical billing was never properly nor timely denied, therefore, payment of the claims was overdue. However, we successfully argued at the arbitration hearing that the applicant’s client failed to provide the requisite statutorily required medical assignment-of-benefits form, assigning the hospital the right to sue on behalf of the injured party. After arguments were heard, the arbitrator ordered post-hearing submissions to be filed by both sides. After researching, drafting and filing a post-hearing submission, the arbitrator ruled in our client’s favor, thereby dismissing the matter based on the applicant’s total failure to submit the requisite form, saving our client hundreds of thousands of dollars.

The arbitrations were commenced by medical providers against the respondent-carrier for non-payment of medical bills insofar as the policyholder and the claimant engaged in material misrepresentation in the procurement of the policy, and in the presentation of the claim. We submitted a defense brief that included numerous exhibits, including examination under oath transcripts, an affidavit from the respondent-carrier’s underwriting department and screenshots of insurance premium payments from the claimant to the policyholder. At the hearings, the defense argued that the respondent-carrier owed no duty of coverage insofar as the policyholder and the claimant engaged in material misrepresentation in the procurement of the policy and in the presentation of the claim. Specifically, the policyholder fraudulently obtained an insurance policy with the respondent-carrier on behalf of the claimant. The misrepresentation was deemed “material” insofar as the respondent-carrier would have charged a higher premium based on the actual garaging location of the insured vehicle and, moreover, would not have otherwise insured the claimant. The arbitrator held that the respondent-carrier established, by a preponderance of credible evidence, that the instant loss involved fraud and misrepresentation in the procurement of the insurance policy; the policyholders’ misrepresentation with regard to the ownership, operation and garaging of the insured vehicle was material; the respondent-carrier would not have issued the policy if the facts had been disclosed by the policyholders, and that the respondent-carrier was justified in denying the claim.

We successfully secured dismissal of a New York no-fault/PIP arbitration commenced by a medical provider against a major insurance carrier for non-payment of medical bills. At the hearing, the carrier argued that the provider was ineligible for reimbursement of the disputed charges because it was not licensed in New York State with the Department of Education and the Department of State when the services at issue were rendered. Under the New York no-fault/PIP regulations, a provider of health care services is not eligible for reimbursement under the insurance law if it fails to meet any applicable state or local licensing requirements. In support of the threshold defense, we submitted copies of printouts from these Departments as conclusive evidence that the provider was not properly licensed in New York State when the services were rendered and was therefore ineligible for New York no-fault reimbursement.

Obtained a dismissal at trial in Civil Court of the City of New York, Queens County. ​The plaintiff, an acupuncture facility, alleged wrongful denial of personal injury protection/no-fault benefits relating to acupuncture services rendered to its assignee, a claimant who sought benefits under the defendant-carrier’s policy. The trial judge granted dismissal of the complaint on the basis of the carrier’s defense, that payments were issued in accordance with the applicable fee schedule and, therefore, nothing further was owed to the plaintiff.

We obtained summary judgment in Civil Court of the City of New York, New York County. ​The plaintiff commenced an action seeking reimbursement of PIP benefits under the defendant-carrier's policy for anesthesia rendered to the claimant during a surgical procedure. After establishing that the claimant failed to appear at multiple, duly-scheduled independent medical examinations—a condition precedent to coverage—the complaint was dismissed.