Schulman v. Group Health Inc – Case Brief Summary (New York)

In Schulman v. Group Health Inc. (11 Misc 3d 90, 816 NYS2d 806 [App Term, 1st Dept 2006]), the court upheld a small claims decision that the insurer must pay the insured $5,000 despite an external appeal agent's decision denying coverage.

The court regarded the term "binding" in Insurance Law § 4914 (b) (4) (A) (iv) as meaning that the external appeal agent's determination "marks the end of any administrative appeal" (Schulman v. Group Health Inc. at 91).

This decision was, in turn, affirmed by the First Department (Schulman v. Group Health Inc., 39 AD3d 223, 833 NYS2d 62 [2007]).

The Court looked to the legislative history of Insurance Law § 4914 (b) (4) (A) (iv) and (v), finding that the legislators intended to provide a new, low-cost, expedited layer of review for consumers but not to supplant the review already available in the courts.