On March 26, 2018 a
Exhibit,Appendix
was filed
involving a dispute between
Liberty Mutual Insurance Company,
Lm General Insurance Company,
and
Advanced Recovery Equipment And Supplies Llc,
Anesthesia Solutilons P.C.,
Barry Dublin Md,
Mlj Chiropractic P.C.,
Moshe Zirkiev,
Orthocaretech Inc.,
Protechmed Inc.,
Quality Orthopedics And Complete Joint Care P.C.,
Quest Diagnostics Incorporated,
Right Hand Medical Assist L.L.C.,
Robert Malakov, Physician, P.C.,
Roxbury Anesthesia, Llc,
Southwest Nassau Radiology, P.C.,
Stillwell Chiropractic P.C.,
Surgicore Of New Jersey City, Llc,
Valuecare Pharmacy Inc.,
Virginia Ferrigno, Lmt.,
for Commercial - Insurance
in the District Court of New York County.
Preview
0208227171098
INDEX NO. 652678/2018
FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018
CIVIL COURT OF THE CITY OF NEW YORK
COUNTY OF QUEENS
Index #:
Grand Central Acupuncture, PC
705180
A/A/O XXXXXXXXXXXXXX,
Plaintiff, SUMMONS
-against-
Plaintiff designates QUEENS
County as the place of trial.
Liberty Mutual Fire Insurance Company,
Defendant. The basisof the venue ispursuant to
CPLR 503 and Insurance Law 1212
To the above named defendant(s)
YOU ARE HEREBY SUMMONED to appear in the CivilCourt of the City of New York, County of Queens
at the office of the Clerk of the said Court at 89-17 Sutphin Blvd. in the County of Queens, City and State
of New York, within the time provided by law as noted below and to your
file answer to the c06-plaint with
the clerk: Upon your failure to answer, judgment willbe taken against you for the sum of $2,533.60 with
interest, together with costs of this action.
Dated: Brooklyn, New York . ..
June 6, 2017
RTF4F ITFI IS_ESQ.
GITELIS LAW FIRM, P.C.
ttorneys for Plaintiff
' 2nd
g16 004 Coney Island Avenue, FlOOr
Brooklyn, NY 11223
1(718) 871-5070
Plaintiff'saddress:
1762 McDonald Avenue Brooklyn NY 11230
Fileno. 43038
Defendant's Address:
1225 RXR Plaza, Suite 515 Uniondale NY 11556
NOTE: The law provides that: (a) Ifthis summons isserved by itsdelivery to you perscñaily within the
State of New York, you must appear and answer within TWENTY days after such service; or
(b) Ifthis summons is served by any means other then personal dê|ivery to you within the State
of New York, you mustappear and answer within THIRTY days after proof of service thereof isfiled with
the clerk of this Court.
0208227171098
INDEX NO. 652678/2018
FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018
CIVIL COURT OF THE CITY OF NEW YORK
COUNTY OF QUEENS
Grand Central Acupuncture, PC Index #:
A/A/O XXXXXXXXXXXXXX
Plaintiff, COMPLAINT
-against-
Liberty Mutual Fire Insurance Company,
Defendant.
Plaintiff,
complaining of the Defendant, shows to the court and alleges:
AS AND FOR A FIRST CAUSE OF ACTION
1. Defendant isan insurance company authorized to do business in the State of New York.
DV 2. That the Plaintiffsassignor was injured in an automobile accident on 11/15/2015.
DM- 3. That at the time of the accident there a an insurance benefits under the
existing policy containing
New York State No-Fault law issued by the Defendant.
DV 4. That one of the No-Fault benefits was payment of health service expenses.
of 5. That Grand Central Acupuncture, PC isa health service provider authorized to practice in the
State of New York.
gvd.. 6. That Grand Central Acupuncture, PC isthe assignee of XXXXXXXXXXXX as indicated by a
copy of the assignment attached hereto.
DE6 7. That as a result of the aforesaid accident, the assignor was entitled to receive No-Fault benefits.
%Ai. 8. The plaintiff-assignee rendered health service to the Plaintiffsassignor inconnection with
personal injuries sustained in said accident.
011 9. The Plaintiff-assignee submitted to the defendant a billand claim for payment in theamount of
$2,630.36 as annexed hereto.
DLB 10. That said billtogether with proper verification was submitted to the defeñdani on or about
5/23/2016.
0Ak 11. That there has been a partial payment made in the amount of $ 96.76.
evd- 12. That the Defendant has assigned claim or filenumber AOS-228-057944-40 to thismatter.
plf? 13. That the sum of $2,533.60 remains unpaid and outstanding.
14. That Plaintiff
assignee isentitled to interestat the rate of 2% compounded per month untilthe
amount due is paid in computed
full, from thirtydays afterthe date the claim was submitted to Defendant,
pursuant to New York State Insurance Law 5106.
AS AND FOR A SECOND CAUSE OF ACTION
01) 15. Plaintiff-assignee duly stated an account to the Defendant in the above amount and the same
was retained without objection.
0208227171098
INDEX NO. 652678/2018
FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018
f
16. By reason thereof an account was taken and stated between the parties thereto.
17. That this transaction is one in which no credit was extended to the Defendant and istherefore not
010 transaction."
a "consumer credit
AS AND FOR A THIRD CAUSE OF ACTION
o16 18. elaintiffhasretained a law firm to collect No-Fault benefits and is entitledto legal fees to be paid
by Defendant.
D 19. That the law firm retained by the plaintiffhas necessarily rendered legal services to the Plaintiffin
this action and isentitled to statutory legal fees.
WHEREFORE, Plaintiffdemands judgment against the Defendant, as recited in the complaint,
together with interest, cost and disbursement of thisaction.
Dated: Brooklyn, New York
June 6, 2017
STEVE GITELIS, ESQ.
GITELIS LAW FlRM, P.C.
2nd
2004 Coney island Avenue,
Brooklyn, NY 11223
1(718) 871-5070
0208227171098
INDEX NO. 652678/2018
FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM
NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018
Liberty Mutual Insu rance Company
, P.O. Box 1052
Montgomeryville, PA 18936-1052
HEALTH INSURANCE CLAIM FORM , . e
PPROVEDBY,NATIONALUNIFORMCLA1MCOMMITTEE (NUCC)02/12 O
PICA PICA
1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA DIHER 1a. INSURED'SI.D.
NUMBER (FoaProgramin Item)) ++
HEALTHPLAN ^^ BLKLUNG ·
madicatenQueatcas
-] n oo,/ooon
[--] semsenon
Q pon oon
SEX
poi) 03294757802
2. PATIENT'SNAME(LastName.FirstName,MiddleInitial) 3. PATIENTSgI 4. INSUREDSNAME(LastName.FirstName.MiddleInitial)
XX F XXXXXXXXXXXXXXXX
xxxxxxxxxxxxxxxxxxxxx
5. PATIENTSADDRESS(No..Street) 6. PATIENTRELATIONSHIP
TOINSURED 7. INSUREOSADDRESS(No..Street)
2xxxxxxxxxxxxxxx Spouse CN1d Other 2xxxxxxxxxxxxxxxxxxx
SenÜ
CITY STATE 8. RESERVEDFORNUCCUSE CITY STATE
No BROOKLYN NY o
BROOKLYN
ZIPCODE TELEPHONE(includeAreaCode) ZIPCODE TELEPHONE(includeAreaCode)
11214 34)7 713 6564 11214 ×××××××××××××.
(
9. OTHERINSUREDSNAME(LastName.FirstName,MiddleInitial)
10. ISPATIENT'SCONDITION
RELATEDTO: 11. INSUREDSPOLICYGROUPOR F EA NUMBER
AOS228057944405
a. OTHERINSUREO·S
POLICYOR GROUPNUMBER a. EMPLOYMENT?(Currentor Previous) DATEOFBIRTH
a. INSURED·S SEx
YES XXXXXXXXXXXXXX M
b. RESERVEDFORNUCCUSE b. AUTOACCIDENT? PLAC b. OTHERCLAIM10(Designatedby NUCC)
te)
YES NO
c. RESERVEOFORNUCCUSE c. OWER ACCIDENT? c. INS P NAM R PROGRAM N ME
tua nsurance ompany
d INSURANCEPLANNAMEOR PROGRAM NAME 101 CLA(MCODES(Designated
by NUCC) d. IS THEREANOTHER
HEALTHBENEFlTPLAN
YES NO H yes,completeitems9, 9aand9d.
READBACKOFFORMBEFORECOMPLETING & SIGNINGTHISFORM. 13.INSUREDSORAUTHORIZED PERSONSSIGNATURE I authorite
12. PATIENT'SORAUTHORIZED
PERSONSSIGNATURE I authorizethereleaseof any medicalor otherinlormation
necessary paymentof medicalbenefitsto the undersignedphysicianor supplierfor
to processthis claim.I alsorequestpaymentof governrnent
benefitseitherto myseltor to thepartywhoacceptsassignment
servicesdescribedcetow.
below.
Signature On File 11 16 2015 Signature On File
SIGNED __ ____ DATE SIGNED
14. DATEOF CURRENTIU ESS.INJURY,or PREGNANCY
MM Di
OUAL.
,431
(LMP)
OUAL.
, d
15. OTHERD
up
&5
2015 .
16. DATESPATIENTUNABLETOWORKINCURRENTOCCUPATION
FROM
MM , oD YY
TO
MM I DD , YY
17. NAMEOF REFERRING
PROVIDER OR OTHERSOURCE .· 18. HOSPITALiZATION
DATESRELATEDTOCURRENTSERVICES
da MM YY
MM i DD : YY OD
.. 17b. NP1 FROM s TO
19. AbDITlÖNALCLAIMINFORMATION
(Designatedby NUCC) 20. OUTSIDELAB? SCHARGES
ÜYES NO
0
21. DIAGNOSISOR NATUREOF ILLNESSOR INJURY.RelateA·L10servicetinebelow(24E 22. RESUBMISSION
S13.9xxA S23.3xxA S33.5xx iCDind.|S43.402A CODe ORIGINALREF.NO.
AI . . R / C. f 0.
NUMBER
23. PRIORAUTHORIZATION
E. { F. I G. I H. L
i. L-..DATE(S)OFSERVICEJ. I
24. A. B.
-
C.
K. |
0. PROCEDURES.
- L I
SERVICES.ORSUPPLIES E. F. G. H. I. J. 2
From To EOF (ExclainUnusualCircumslances) oAvs.· EPSDTID. RENDERING
, DIAGNOSiS
MM OD YY MM DO YY SEllV1CE
EMG CPT/HCPÇ$ I MODIFIER POINTER SCHARGES u s OUAL. PROviOERID.
;11 f6 5 . Ï 16 15 11 99203 25 àBÖD . 104,308 1 1205111572
' NPI C
11.. 16 10 11 16 15 11 97813 . ABCD 22 48 .1 __ 120517157 ?
11 16 15 11 16 15 . 11 97814 AECD 19 .54 1 1205111572
li io :d i io . (5 I i ACUNE . AtM..,U . O UU RU,DWH O
, , . ____________________
16 $ 1 GB-21 ABCD 0 00 1 1205111572 -
, ---_ _____--___--_....
. 16 b 11 GB-30 . . ABCD 0. 00 1 . 1205111572 .
I . NPI
| I
25. FEOF MBER SSN 26 MgpccOUNT NO- 27. T IG M ? 28. TOTALCHAR46 29. AMOUNTP 30. RsvdlorNUCCuse
EINX
YES NO s S 7
2. 160BqBRANFCEN FRAt! WOP.fPISNGTURE, F C 33· 8
u NGDEGR E C DENTA HUbUÚCTUR . PC
(I certilythatIne statementson thereverse
1762 MCDONALD AVE 1762 MCDONALD AVE.
aovumING ed de a partthDS/23/16
BROOKLYN NY 11230-6907 BROOKLYN, NY 11230-6907
1205111572 1205111572
SIGNED OATE . . . . .... . ... .. .
JUCC Manual
Instruction availableat:www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB 0938-1197 FORM 1500 (02-12)
wr c ennec.n
Preview
0208227171098 INDEX NO. 652678/2018 FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018 CIVIL COURT OF THE CITY OF NEW YORK COUNTY OF QUEENS Index #: Grand Central Acupuncture, PC 705180 A/A/O XXXXXXXXXXXXXX, Plaintiff, SUMMONS -against- Plaintiff designates QUEENS County as the place of trial. Liberty Mutual Fire Insurance Company, Defendant. The basisof the venue ispursuant to CPLR 503 and Insurance Law 1212 To the above named defendant(s) YOU ARE HEREBY SUMMONED to appear in the CivilCourt of the City of New York, County of Queens at the office of the Clerk of the said Court at 89-17 Sutphin Blvd. in the County of Queens, City and State of New York, within the time provided by law as noted below and to your file answer to the c06-plaint with the clerk: Upon your failure to answer, judgment willbe taken against you for the sum of $2,533.60 with interest, together with costs of this action. Dated: Brooklyn, New York . .. June 6, 2017 RTF4F ITFI IS_ESQ. GITELIS LAW FIRM, P.C. ttorneys for Plaintiff ' 2nd g16 004 Coney Island Avenue, FlOOr Brooklyn, NY 11223 1(718) 871-5070 Plaintiff'saddress: 1762 McDonald Avenue Brooklyn NY 11230 Fileno. 43038 Defendant's Address: 1225 RXR Plaza, Suite 515 Uniondale NY 11556 NOTE: The law provides that: (a) Ifthis summons isserved by itsdelivery to you perscñaily within the State of New York, you must appear and answer within TWENTY days after such service; or (b) Ifthis summons is served by any means other then personal dê|ivery to you within the State of New York, you mustappear and answer within THIRTY days after proof of service thereof isfiled with the clerk of this Court. 0208227171098 INDEX NO. 652678/2018 FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018 CIVIL COURT OF THE CITY OF NEW YORK COUNTY OF QUEENS Grand Central Acupuncture, PC Index #: A/A/O XXXXXXXXXXXXXX Plaintiff, COMPLAINT -against- Liberty Mutual Fire Insurance Company, Defendant. Plaintiff, complaining of the Defendant, shows to the court and alleges: AS AND FOR A FIRST CAUSE OF ACTION 1. Defendant isan insurance company authorized to do business in the State of New York. DV 2. That the Plaintiffsassignor was injured in an automobile accident on 11/15/2015. DM- 3. That at the time of the accident there a an insurance benefits under the existing policy containing New York State No-Fault law issued by the Defendant. DV 4. That one of the No-Fault benefits was payment of health service expenses. of 5. That Grand Central Acupuncture, PC isa health service provider authorized to practice in the State of New York. gvd.. 6. That Grand Central Acupuncture, PC isthe assignee of XXXXXXXXXXXX as indicated by a copy of the assignment attached hereto. DE6 7. That as a result of the aforesaid accident, the assignor was entitled to receive No-Fault benefits. %Ai. 8. The plaintiff-assignee rendered health service to the Plaintiffsassignor inconnection with personal injuries sustained in said accident. 011 9. The Plaintiff-assignee submitted to the defendant a billand claim for payment in theamount of $2,630.36 as annexed hereto. DLB 10. That said billtogether with proper verification was submitted to the defeñdani on or about 5/23/2016. 0Ak 11. That there has been a partial payment made in the amount of $ 96.76. evd- 12. That the Defendant has assigned claim or filenumber AOS-228-057944-40 to thismatter. plf? 13. That the sum of $2,533.60 remains unpaid and outstanding. 14. That Plaintiff assignee isentitled to interestat the rate of 2% compounded per month untilthe amount due is paid in computed full, from thirtydays afterthe date the claim was submitted to Defendant, pursuant to New York State Insurance Law 5106. AS AND FOR A SECOND CAUSE OF ACTION 01) 15. Plaintiff-assignee duly stated an account to the Defendant in the above amount and the same was retained without objection. 0208227171098 INDEX NO. 652678/2018 FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018 f 16. By reason thereof an account was taken and stated between the parties thereto. 17. That this transaction is one in which no credit was extended to the Defendant and istherefore not 010 transaction." a "consumer credit AS AND FOR A THIRD CAUSE OF ACTION o16 18. elaintiffhasretained a law firm to collect No-Fault benefits and is entitledto legal fees to be paid by Defendant. D 19. That the law firm retained by the plaintiffhas necessarily rendered legal services to the Plaintiffin this action and isentitled to statutory legal fees. WHEREFORE, Plaintiffdemands judgment against the Defendant, as recited in the complaint, together with interest, cost and disbursement of thisaction. Dated: Brooklyn, New York June 6, 2017 STEVE GITELIS, ESQ. GITELIS LAW FlRM, P.C. 2nd 2004 Coney island Avenue, Brooklyn, NY 11223 1(718) 871-5070 0208227171098 INDEX NO. 652678/2018 FILED: NEW YORK COUNTY CLERK 08/24/2018 08:34 AM NYSCEF DOC. NO. 18 RECEIVED NYSCEF: 08/24/2018 Liberty Mutual Insu rance Company , P.O. Box 1052 Montgomeryville, PA 18936-1052 HEALTH INSURANCE CLAIM FORM , . e PPROVEDBY,NATIONALUNIFORMCLA1MCOMMITTEE (NUCC)02/12 O PICA PICA 1. MEDICARE MEDICAID TRICARE CHAMPVA GROUP FECA DIHER 1a. INSURED'SI.D. NUMBER (FoaProgramin Item)) ++ HEALTHPLAN ^^ BLKLUNG · madicatenQueatcas -] n oo,/ooon [--] semsenon Q pon oon SEX poi) 03294757802 2. PATIENT'SNAME(LastName.FirstName,MiddleInitial) 3. PATIENTSgI 4. INSUREDSNAME(LastName.FirstName.MiddleInitial) XX F XXXXXXXXXXXXXXXX xxxxxxxxxxxxxxxxxxxxx 5. PATIENTSADDRESS(No..Street) 6. PATIENTRELATIONSHIP TOINSURED 7. INSUREOSADDRESS(No..Street) 2xxxxxxxxxxxxxxx Spouse CN1d Other 2xxxxxxxxxxxxxxxxxxx SenÜ CITY STATE 8. RESERVEDFORNUCCUSE CITY STATE No BROOKLYN NY o BROOKLYN ZIPCODE TELEPHONE(includeAreaCode) ZIPCODE TELEPHONE(includeAreaCode) 11214 34)7 713 6564 11214 ×××××××××××××. ( 9. OTHERINSUREDSNAME(LastName.FirstName,MiddleInitial) 10. ISPATIENT'SCONDITION RELATEDTO: 11. INSUREDSPOLICYGROUPOR F EA NUMBER AOS228057944405 a. OTHERINSUREO·S POLICYOR GROUPNUMBER a. EMPLOYMENT?(Currentor Previous) DATEOFBIRTH a. INSURED·S SEx YES XXXXXXXXXXXXXX M b. RESERVEDFORNUCCUSE b. AUTOACCIDENT? PLAC b. OTHERCLAIM10(Designatedby NUCC) te) YES NO c. RESERVEOFORNUCCUSE c. OWER ACCIDENT? c. INS P NAM R PROGRAM N ME tua nsurance ompany d INSURANCEPLANNAMEOR PROGRAM NAME 101 CLA(MCODES(Designated by NUCC) d. IS THEREANOTHER HEALTHBENEFlTPLAN YES NO H yes,completeitems9, 9aand9d. READBACKOFFORMBEFORECOMPLETING & SIGNINGTHISFORM. 13.INSUREDSORAUTHORIZED PERSONSSIGNATURE I authorite 12. PATIENT'SORAUTHORIZED PERSONSSIGNATURE I authorizethereleaseof any medicalor otherinlormation necessary paymentof medicalbenefitsto the undersignedphysicianor supplierfor to processthis claim.I alsorequestpaymentof governrnent benefitseitherto myseltor to thepartywhoacceptsassignment servicesdescribedcetow. below. Signature On File 11 16 2015 Signature On File SIGNED __ ____ DATE SIGNED 14. DATEOF CURRENTIU ESS.INJURY,or PREGNANCY MM Di OUAL. ,431 (LMP) OUAL. , d 15. OTHERD up &5 2015 . 16. DATESPATIENTUNABLETOWORKINCURRENTOCCUPATION FROM MM , oD YY TO MM I DD , YY 17. NAMEOF REFERRING PROVIDER OR OTHERSOURCE .· 18. HOSPITALiZATION DATESRELATEDTOCURRENTSERVICES da MM YY MM i DD : YY OD .. 17b. NP1 FROM s TO 19. AbDITlÖNALCLAIMINFORMATION (Designatedby NUCC) 20. OUTSIDELAB? SCHARGES ÜYES NO 0 21. DIAGNOSISOR NATUREOF ILLNESSOR INJURY.RelateA·L10servicetinebelow(24E 22. RESUBMISSION S13.9xxA S23.3xxA S33.5xx iCDind.|S43.402A CODe ORIGINALREF.NO. AI . . R / C. f 0. NUMBER 23. PRIORAUTHORIZATION E. { F. I G. I H. L i. L-..DATE(S)OFSERVICEJ. I 24. A. B. - C. K. | 0. PROCEDURES. - L I SERVICES.ORSUPPLIES E. F. G. H. I. J. 2 From To EOF (ExclainUnusualCircumslances) oAvs.· EPSDTID. RENDERING , DIAGNOSiS MM OD YY MM DO YY SEllV1CE EMG CPT/HCPÇ$ I MODIFIER POINTER SCHARGES u s OUAL. PROviOERID. ;11 f6 5 . Ï 16 15 11 99203 25 àBÖD . 104,308 1 1205111572 ' NPI C 11.. 16 10 11 16 15 11 97813 . ABCD 22 48 .1 __ 120517157 ? 11 16 15 11 16 15 . 11 97814 AECD 19 .54 1 1205111572 li io :d i io . (5 I i ACUNE . AtM..,U . O UU RU,DWH O , , . ____________________ 16 $ 1 GB-21 ABCD 0 00 1 1205111572 - , ---_ _____--___--_.... . 16 b 11 GB-30 . . ABCD 0. 00 1 . 1205111572 . I . NPI | I 25. FEOF MBER SSN 26 MgpccOUNT NO- 27. T IG M ? 28. TOTALCHAR46 29. AMOUNTP 30. RsvdlorNUCCuse EINX YES NO s S 7 2. 160BqBRANFCEN FRAt! WOP.fPISNGTURE, F C 33· 8 u NGDEGR E C DENTA HUbUÚCTUR . PC (I certilythatIne statementson thereverse 1762 MCDONALD AVE 1762 MCDONALD AVE. aovumING ed de a partthDS/23/16 BROOKLYN NY 11230-6907 BROOKLYN, NY 11230-6907 1205111572 1205111572 SIGNED OATE . . . . .... . ... .. . JUCC Manual Instruction availableat:www.nucc.org PLEASE PRINT OR TYPE APPROVED OMB 0938-1197 FORM 1500 (02-12) wr c ennec.n