Source: http://masscases.com/cases/distapp/2015/2015massappdiv61.html
Timestamp: 2019-04-20 10:39:39+00:00

Document:
Present: Swan, P.J., Coven & Nestor, JJ.
Singh, J. [Note 1] in the Concord Division.
Elizabeth H. Manos and Francis A. Gaimari for the plaintiff.
Heath R. Walker and	Peter J. Riordan for the defendant.
SWAN, P.J. John Duffy, D.C. (Duffy) treated Yvonne Cormier (Cormier) for injuries she received in a vehicular accident on July 13, 2008. The vehicle was insured by Metropolitan Property and Casualty Insurance Company (Metropolitan), and Cormier also had a health insurance policy with CIGNA HealthCare (CIGNA). Treatment ended on December 5, 2008, and Duffys bills totaled $5,835.00. Metropolitan paid $2,000.00 under its personal injury protection (PIP) coverage, and CIGNA paid additional sums, leaving an unpaid balance of $937.40. An independent medical examination commissioned by Metropolitan concluded that Cormier had reached an end result on November 3, 2008, and Metropolitan refused payment for any expenses incurred thereafter.
On May 1, 2013, Duffy sued Metropolitan for the $937.40 balance pursuant to G.L. c. 90, § 34M. Metropolitan averred as an affirmative defense that Duffy failed in his statutory duty to coordinate benefits with CIGNA and did not provide to Metropolitan an explanation of benefits (EOB) from CIGNA. Metropolitan moved for summary judgment on these grounds. In support of its motion, Metropolitan submitted affidavits of its claims representative, stating that the company never received an EOB from Duffy, and records of CIGNA certified by its keeper of records, indicating that CIGNA had in fact made partial payments on the claim and on several occasions sent its EOB to Duffy, up to December 31, 2008. [Note 2] Duffy responded with sworn copies of his bills and reports relating to Cormiers treatment. The Concord District Court allowed the motion for summary judgment, and Duffy has appealed from that judgment.
110 (2008); Citibank (S.D.) NA v. Surabian, supra.
With respect to the form of the affidavit from Metropolitan, it was written and (ultimately) signed by the insurers claims representative assigned to this case. Even though the affidavit does not use the words upon personal knowledge as in Duffy v. Commerce Ins. Co., 2009 Mass. App. Div. 196 , 198, the affiant was qualified to speak to the review of the very file that she handled. The certification from CIGNA was executed (again, ultimately) by CIGNAs record keeper and asserted that the documents (consisting of EOB notices) were made in good faith, in the regular course of business, prior to the instant litigation, and that it was the regular course of CIGNAs business to make such records at the time of their creation, all in compliance with Beal Bank, SSB v. Eurich, 444 Mass. 813 , 815 (2005), G.L. c. 233, § 78, and Mass. G. Evid. § 803(6)(A) (2014). The affidavit and record certification were properly received and considered by the motion judge.
As to the allowance of the motion itself, [s]ummary judgment is appropriate where there are no genuine issues of material fact and the moving party is entitled to judgment as a matter of law. Boazova v. Safety Ins. Co., 462 Mass. 346 , 350 (2012).
keeping with the applicable law. Id. The procedure for Duffy to follow is well established by Sabino Chiropractic Office, Inc. v. Arbella Mut. Ins. Co., 2008 Mass. App. Div. 260 . After receipt of $2,000.00 in PIP benefits, Duffy was to file his bills with CIGNA for coverage over that amount. Once CIGNA declined to pay some of the bills, Duffy was then obliged to forward bills for the unpaid portions to Metropolitan for determining any further PIP coverage. The only way for Duffy to accomplish this was to provide Metropolitan with CIGNAs EOB. As Duffy failed to submit [his] claims in this fashion, it was not improper for the defendant to refuse to pay them. Id. at 262, quoting Mejia v. American Cas. Co., 55 Mass. App. Ct. 461 , 466 (2002).
[Note 1] The Honorable Sabita Singh recused herself from this appeal, and did not participate in its review or decision.
[Note 2] The certified records are the EOB notices, which consist of a series of notices sent to Duffy over a period of time, each setting forth the amounts of Duffys separately billed services and the amount that CIGNA has agreed to pay to Duffy for each service pursuant to its contract with Cormier.
[Note 3] The last EOB statement was addressed to Duffys business name, Waltham Chiro (shown as Waltham Chiropractic elsewhere in the record), at Duffys address, 425 River Street, Waltham.
[Note 4] The fact that Metropolitan initially wrote to Duffy giving another reason for refusing payment -- namely, treatment after the cutoff date set forth in its independent medical examination -- does not, as we noted in Northshore Chiropractic v. Commerce Ins. Co., 2010 Mass. App. Div. 168 , 171, affect Metropolitans reliance on its defense of failure to provide the EOB, since Duffy, as a PIP plaintiff, bore the burden of proving compliance with the conditions precedent to recovery. Id. at 169, citing Royal-Globe Ins. Co. v. Craven, 411 Mass. 629 , 634 (1992).

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