Mtr. Of State Ins Co. v. Domotor

In Mtr. Of State Ins Co. v. Domotor, 266 A.D.2d 219, 697 N.Y.S.2d 348 (2d Dept. 1999), the insurance company initially provided medical benefits to the appellant assignor but then issued an IME cut-off denial based upon its expert's opinion that the assignor no longer needed medical treatment. The assignor nevertheless continued to obtain medical care although she submitted no further claims to the insurance company. She subsequently demanded arbitration to resolve the issue of the insurance company's liability. The court ruled that once an insurance company had unequivocally repudiated liability on the claim by sending a letter disclaiming coverage, it could not "insist upon adherence to the terms of its policy." 266 AD2d at 220. The insurance company's letter of disclaimer thus negated the insured's otherwise absolute obligation to comply with the conditions precedent under the policy to provide a timely written proof of loss. Id at 220-21. The assignor was therefore entitled to arbitrate her claim that she was entitled to such medical benefits following the issuance of the denial, even though the bills for those services were never submitted to the insurer prior to her demand for arbitration. Id.