Court Opinion

ID: 5690989
Source: CourtListenerOpinion
Date Created: 2022-01-12 15:26:17.031019+00
Date Added: 2024-06-11T08:40:08.353002
License: Public Domain

Goldstein, J., dissents
and votes to modify the judgment, on the law and the facts, by adding a provision thereto declaring that the disability insurance policy is cancelled and the parties have no further obligations to each other, and as so modified, to affirm the judgment insofar as appealed and cross-appealed from, with the following memorandum:
In 1991, the plaintiff purchased the subject disability insurance policy from the defendant, First UNUM Life Insurance Company. The policy provided that as part of the claim process, the insured was obligated to undergo “a medical examination or a personal interview as often as we reasonably request while the claim is pending.”
In or about October 1994, the plaintiff claimed disability benefits pursuant to the policy, inter alia, for carpal tunnel syndrome. The defendant paid benefits to the plaintiff from January 1, 1995, until mid-1997 when the plaintiff refused to undergo an electromyelograph (hereinafter EMG) test. In a letter dated July 9, 1997, the defendant’s claims examiner stated that “we have not received any indication that Ms. Hurley will be having an EMG. Therefore, this claim has been closed.” In addition, the claims examiner’s letter stated that there was “lack of significant clinical and objective findings to support the degree of impairment Ms. Hurley claims exists.”
The plaintiff commenced the instant action, inter alia, for a judgment declaring that she was disabled and that the defendant was obligated to continue to pay her disability insurance benefits. In its answer, the defendant asserted as a defense that the plaintiff was barred from recovering benefits owing to her refusal to cooperate with the defendant’s investigation of her alleged disability.
At a nonjury trial, evidence was adduced that the plaintiff submitted to an EMG test in December 1994, the results of which were within normal range. The results did not change her treating physician’s diagnosis of carpal tunnel syndrome. When the defendant asked that the plaintiff submit to another EMG test in 1997, she refused, claiming that the test, which involves the placement of a needle through the skin, was “an invasive procedure,” which was “uncomfortable” and not “conclusive.” However, she acknowledged that she was not concerned about any risk to her safety from the test.
The Supreme Court concluded that the plaintiff’s refusal to submit to the EMG test constituted a breach of her duty to cooperate under the policy. I agree.
*515The issue of the plaintiff’s refusal to submit to an EMG test was raised in the letter of the defendant’s claims examiner dated July 9, 1997, which stated that “we have not received any indication that Ms. Hurley will be having an EMG. Therefore, this claim has been closed” and further stated that there were insufficient “clinical and objective findings to support the degree of impairment Ms. Hurley claims exists.” The claim was denied on two grounds: (1) failure to submit to the EMG, and (2) insufficient evidence of continued disability. The failure to cooperate was explicitly raised as a defense in the defendant’s answer. Therefore, the failure to cooperate was a proper issue before the Supreme Court.
An insurance company is entitled to obtain information promptly to enable it to decide upon its obligations and protect against false claims (see Davis v Allstate Ins. Co., 204 AD2d 592 [1994]; Argento v Aetna Cas. & Sur. Co., 184 AD2d 487 [1992]). The plaintiff offered no reasonable excuse for her failure to submit to a second EMG test. She had previously submitted to the test in 1994 without complaint or adverse consequences. At worst, the EMG test, which involves insertion of a needle under the skin, is minimally invasive. Since the defendant asked for the second EMG test over two years after the plaintiff submitted to her first EMG test, her failure to comply violated the provision of the policy which required her to submit to a medical examination “as often as we reasonably request while the claim is pending.” Since this is an action for a declaratory judgment, the Supreme Court should have declared that the insurance policy was cancelled and that the parties had no further rights or obligations under the policy (see Lanza v Wagner, 11 NY2d 317 [1962], appeal dismissed 371 US 74 [1962], cert denied 371 US 901 [1962]; Coleman v New Amsterdam Cas. Co., 247 NY 271 [1928]; United States Fid. & Guar. Co. v von Bargen, 7 AD2d 872 [1959], affd 7 NY2d 932 [I960]).
If I were to reach the merits, I would find that the evidence in the record that the plaintiff is not disabled warrants remittitur to the Supreme Court for further findings of fact. Evidence was submitted that in carpal tunnel syndrome cases there should be a recovery. Therefore updated reports of the claimant’s condition are necessary. Further, the defendant submitted evidence that the plaintiff’s disability was not continuing. The defendant’s expert, Dr. Lawrence Miller, testified that he examined the plaintiff on December 17, 1998, and found “there was nothing wrong with her.” Dr. Miller noted that the plaintiff could flex and extend her wrist. He performed a “malingerer’s test” which is positive if the patient is feigning a disability. Dr. *516Miller pushed, on two bones without pressing on any nerves, and the plaintiff claimed the pain went into her shoulder which was impossible since “[i]f you are pressing on no nerves at all you are not going to have pain shooting up to the shoulder.”
Contrary to the conclusion of the majority, it cannot be said that the defendant’s proof was confined to the argument that without the EMG test there was no objective proof of the plaintiffs disability. Clearly, the evidence in the trial record presents issues of fact which warrant further findings of fact by the trial court.