ARBITRATION AWARD. Roseann Madonna, Esq., from Field Law Group, P.C. participated in person for the Applicant

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1 American Arbitration Association New York No-Fault Arbitration Tribunal In the Matter of the Arbitration between: CitiMedical I PLLC (Applicant) - and - USAA Casualty Insurance Company (Respondent) AAA Case No Applicant's File No. FL Insurer's Claim File No NAIC No ARBITRATION AWARD I, Preeti Priya, the undersigned arbitrator, designated by the American Arbitration Association pursuant to the Rules for New York State No-Fault Arbitration, adopted pursuant to regulations promulgated by the Superintendent of Insurance, having been duly sworn, and having heard the proofs and allegations of the parties make the following AWARD: Injured Person(s) hereinafter referred to as: Assignor [CL] Hearing(s) held on 08/30/2017 Declared closed by the arbitrator on 08/30/2017 Roseann Madonna, Esq., from Field Law Group, P.C. participated in person for the Applicant Mathew Gray, Esq., from Marshall Dennehey Warner Coleman & Goggin, P.C. participated by telephone for the Respondent 2. The amount claimed in the Arbitration Request, $ , was AMENDED and permitted by the arbitrator at the oral hearing. Applicant's counsel amended the amount in dispute to $ Stipulations WERE NOT made by the parties regarding the issues to be determined. 3. Summary of Issues in Dispute Whether Applicant established entitlement to No-Fault compensation for MRI studies performed upon Assignor; Whether Applicant is entitled to an amount greater than what Respondent paid; Page 1/6

2 4. Findings, Conclusions, and Basis Therefor Applicant was represented by Roseann Madonna, Esq., who appeared in person and presented oral arguments and relied upon documentary submissions. Respondent was represented by Mathew Gray, Esq., who appeared in person and presented oral arguments and relied upon documentary submissions. I have reviewed the submission contained in the American Arbitration Association's Electronic Case Folder. The dispute arises from the underlying automobile accident of April 26, 2015, in which the Assignor, a 34-year-old male, was a driver. Thereafter, Assignor sought private medical attention and underwent X-ray studies of the cervical lumbar and thoracic spine as well as pelvis on May 26, Applicant submitted the bills to Respondent and Respondent issued a partial payment and denied the remainder. Preliminarily, I find that Applicant has established its prima facie case. See Mary Immaculate Hospital v. Allstate Insurance Company, 5 A.D.3d 742, 774 N.Y.S.2d 564 (2nd Dept. 2004). Respondent preserved its defense as the denial were timely issued. The rates charged by Applicant must be in accordance with Insurance Law 5108, as the charges for services rendered "shall not exceed the charges permissible under the schedules prepared and established by the chairman of the Workers Compensation Board for Industrial Accidents, except where the insurer or arbitrator determines that unusual procedures or unique circumstances justify the excess charge." In addition, 5108 (c) states that, "no provider of health services may demand or request any payment in addition to the charges authorized pursuant to this section." I note, effective April 1, NYCRR 65-3(g)(1) had been amended and the no-fault regulations now read, "proof of fact and amount of loss sustained pursuant to insurance law 5106 (A) shall not be deemed supplied by an applicant to an insurer and no payment shall be due for such claimed medical services under any circumstances: (i) when the claim medical services were not provided to an injured party; or (ii) for those claim medical service fees that exceed the charges permissible pursuant to insurance law 5108 (A) and (B) in the regulations promulgated there under the services rendered by medical providers. (2) This subdivision shall apply to medical services rendered on or after April 1, These date of the tests fall within the amended regulations. Respondent's denials state one of the following "Reimbursed according to New York fee schedule with an additional adjustment for multiple modality reduction, as specified by the New York State Consolidated Laws Chapter 28 Article 51 Section 8." Or Reimbursed at billed amount with an additional adjustment for multiple modality reduction." Page 2/6

3 Respondent's counsel, at the hearing, maintained that Applicant did not properly bill according to the Workers' Compensation Radiology Fee Schedule. He did, however, concede that Applicant is entitled to $1.45. In reviewing Ground Rule 3c of the Radiology section of the Workers' Compensation Fee Schedule, states that "For three or more parts, whether contiguous or remote, the charge shall be the greater fee plus 75% of the lesser fee." Applicant is entitled to the greater fee plus 75% of the lesser fees as the X-rays were for four parts. Under Ground Rule 3 (c), Applicant would be entitled to $ (lumbar) plus 75% of $ (pelvis), $ (cervical) and $ (thoracic). Applicant would be entitled to $ under the Workers' Compensation Fee Schedule; however, Respondent only paid $ Thus, Applicant is awarded $36.36, which is the difference between what Applicant is entitled under the Fee Schedule and what Respondent paid. Respondent appropriately paid the other X-rays. Applicant is awarded $36.36 plus $1.45 for a total of $ Optional imposition of administrative costs on Applicant. Applicable for arbitration requests filed on and after March 1, I do NOT impose the administrative costs of arbitration to the applicant, in the amount established for the current calendar year by the Designated Organization. 6. I find as follows with regard to the policy issues before me: The policy was not in force on the date of the accident The applicant was excluded under policy conditions or exclusions The applicant violated policy conditions, resulting in exclusion from coverage The applicant was not an "eligible injured person" The conditions for MVAIC eligibility were not met The injured person was not a "qualified person" (under the MVAIC) The applicant's injuries didn't arise out of the "use or operation" of a motor vehicle The respondent is not subject to the jurisdiction of the New York No-Fault arbitration forum Accordingly, the applicant is AWARDED the following: A. Medical From/To Claim Amount Amount Amended Status CitiMedic al I PLLC 05/14/15-05/26/15 Awarded: $ $ $37.81 Page 3/6

4 Total $ Awarded: $37.81 B. The insurer shall also compute and pay the applicant interest as set forth below. (The filing date for this case was 07/21/2016, which is a relevant date only to the extent set forth below.) Applicant's award shall bear interest at a rate of two percent per month, calculated on a pro rata basis using a 30-day month from the date payment became overdue to the date of the payment of the award pursuant to 11 NYCRR (a). The end date for the calculation of the period of interest shall be the date of payment of the claim. General Construction Law 20 ("The day from which any specified period of time is reckoned shall be excluded in making the reckoning.") C. Attorney's Fees The insurer shall also pay the applicant for attorney's fees as set forth below Respondent shall pay Applicant a separate attorney's fee, in accordance with 11 NYCRR (d). Since the within arbitration request was filed on or after February 4, 2015, this case is subject to the provisions promulgated by the Department of Financial Services in the Sixth Amendment to 11 NYCRR 65-4 (Insurance Regulation 68-D). Accordingly, the insurer shall pay the applicant an attorney's fee, in accordance with 11 NYCRR (d). D. The respondent shall also pay the applicant forty dollars ($40) to reimburse the applicant for the fee paid to the Designated Organization, unless the fee was previously returned pursuant to an earlier award. This award is in full settlement of all no-fault benefit claims submitted to this arbitrator. State of New York SS : County of New York I, Preeti Priya, do hereby affirm upon my oath as arbitrator that I am the individual described in and who executed this instrument, which is my award. 09/05/2017 (Dated) Preeti Priya Page 4/6

5 IMPORTANT NOTICE This award is payable within 30 calendar days of the date of transmittal of award to parties. This award is final and binding unless modified or vacated by a master arbitrator. Insurance Department Regulation No. 68 (11 NYCRR ) contains time limits and grounds upon which this award may be appealed to a master arbitrator. An appeal to a master arbitrator must be made within 21 days after the mailing of this award. All insurers have copies of the regulation. Applicants may obtain a copy from the Insurance Department. Page 5/6

6 ELECTRONIC SIGNATURE Document Name: Final Award Form Unique Modria Document ID: 16db a745bcd7806d2abb3f2d2 Electronically Signed Your name: Preeti Priya Signed on: 09/05/2017 Page 6/6