[DOWNLOAD] "Berkowitz v. Neuman" by Supreme Court of New York # Book PDF Kindle ePub Free

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eBook details

• Title: Berkowitz v. Neuman
• Author : Supreme Court of New York
• Release Date : January 03, 2001
• Genre: Law,Books,Professional & Technical,
• Pages : * pages
• Size : 57 KB

Description

Order, Supreme Court, Bronx County (Alan Saks, J.), entered September 24, 1999, which, inter alia, denied defendants/third-party plaintiffs' motion for summary judgment seeking a declaration that the third-party defendants' termination and denial of insurance coverage was invalid and granted summary judgment dismissing the third-party complaint, unanimously modified, on the law, to deny summary judgment in favor of third-party defendants Mount Vernon City School District, Mount Vernon District Employee Health Benefit Plan, Mount Vernon Public Schools' Group Health Insurance and Mount Vernon Board of Education, and, except as thus modified, affirmed, without costs or disbursements. This is an action by plaintiff nursing home to recover amounts allegedly due for nursing home services rendered to defendant/third-party plaintiff Mildred Neuman, who, as a retired employee of the City School District of the City of Mount Vernon, was a beneficiary under the City of Mount Vernon District Employee Health Benefit Plan, which was administered by American Group Administrators (AGA) until about August 31, 1997. Thereafter, United HealthCare (United) became the insurance carrier for the Mount Vernon School District. Under the plans administered by both AGA and United, Mildred Neuman was covered for treatment determined to be ""medically necessary""; coverage for ""custodial care"" was excluded. After AGA, the Mount Vernon third-party defendants (hereinafter Mount Vernon) and United denied coverage for services rendered subsequent to August 31, 1996, the Neumans brought a third-party action against them for, inter alia, a declaratory judgment that their termination and denial of insurance coverage was invalid and moved for partial summary judgment seeking such a declaration. Third-party defendants AGA and United separately cross-moved for summary judgment against the Neumans. The Supreme Court denied the Neumans' motion and granted summary judgment in favor of all the third-party defendants. The court found the Neumans' medical proof deficient, since the physician who examined Mildred Neuman and found that she suffered from ""severe medical conditions which require continued care and treatment by skilled medical care professionals"" was admittedly unfamiliar with the specific criteria used under the applicable policies in determining when benefits are to be afforded. Rather, the court relied on the affidavit of United's physician, who had reviewed Mildred Neuman's medical records and was, the court noted, ""familiar with the criteria established under the appropriate policies with regard to the awarding of benefits based upon continued medical necessity."" The court also held that AGA was entitled to summary judgment dismissing the third-party complaint on the additional ground that it was not an insurer but rather a plan administrator. We modify to deny summary judgment in favor of Mount Vernon. 1

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