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AMERICAN TRANSIT INSURANCE COMPANY v. ALEXANDRE DEMOURA M.D. PC

Docket 619605/2024, New York State, Nassau County, Supreme Court (Nov. 6, 2024)
Case TypeSpecial Proceedings - CPLR Article 75
Plaintiff AMERICAN TRANSIT INSURANCE COMPANY
Defendant ALEXANDRE DEMOURA M.D. PC D/B/A NEW YORK SPINE INSTITUTE A/A/O NAZMA BEGOM
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AFFIDAVIT Verification for Answer

Document AMERICAN TRANSIT INSURANCE COMPANY v. ALEXANDRE DEMOURA M.D. PC, 619605/2024, 5 (N.Y. Sup. Ct., Nassau County Dec. 13, 2024)
From my personal knowledge and observation, I am familiar with my own business practices and procedures with regard to the generation and maintenance of records and claims forms, as well as their mailing to insurance companies.
Having reviewed the records and claims forms generated regarding the services provided to Nazma Begom, I am fully familiar with the facts and circumstances of this matter.
The statements made within the annexed documents, to wit: Verified Answer and Counterclaims, are true and accurate.
As detailed in the attached documents, on December 8, 2021, the Defendant provided medical services to Nazma Begom with regard to the injuries sustained in the March 30, 2021 automobile accident.
These services were reasonable, necessary, and causally related to the injuries suffered by Nazma Begom as a result of the accident.
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ANSWER WITH COUNTER-CLAIM(S)

Document AMERICAN TRANSIT INSURANCE COMPANY v. ALEXANDRE DEMOURA M.D. PC, 619605/2024, 4 (N.Y. Sup. Ct., Nassau County Dec. 4, 2024)
This failure includes but is not limited to sending an examination request letter/request for additional verification within thirty days of receiving the first claim (Inwood Hill Med., P.C. v Allstate Ins. Co., 15 Misc.3d 143(A); 2007 NY Slip Op 51103(U) [App.
Term, 1st Dep., 2007]; Unitrin Advantage Ins. Co. v Better Health Care Chiropractic, P.C., 2016 NY Slip Op 30837(U) [Supreme Court, New York County, 2016]; Kemper Independence Ins. Co. v Adelaida Physical Therapy, P.C., 147 AD3d 437 [App.
That at the time of the accident there was an existing insurance policy issued by the Plaintiff containing Person Injury Protection benefits under the New York State No-Fault Law.
That Defendant-Assignees are entitled to payment of the bill, statutory interest at a rate of 2% per month (pursuant to 11 NYCRR §65-3.9(a)) until the amount due is paid in full, computed from thirty days after the date the claim was submitted to the Plaintiff.
Pursuant to 22 NYCRR 130-1.1, the undersigned, an attorney duly admitted to practice in the courts of the State of New York, certifies that, upon information and belief and reasonable inquiry, the contention contained in the annexed documents are not frivolous Dated: December 4, 2024
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SUMMONS + COMPLAINT Summons & Complaint

Document AMERICAN TRANSIT INSURANCE COMPANY v. ALEXANDRE DEMOURA M.D. PC, 619605/2024, 1 (N.Y. Sup. Ct., Nassau County Nov. 6, 2024)
This proceeding is brought pursuant to CPLR § 7511, Insurance Law § 5106(c) and 11 NYCRR § 65-4.10 (h) (l) (ii) for a De Novo review of the above captioned matter.
Prior to the occurrence, which forms the basis of this dispute Nazma Begom was allegedly injured and made a claim against a policy of insurance issued by Plaintiff, AMERICAN
Following the inception of the insurance policy, an accident occurred and Nazma Begom allegedly sustained injuries.
The plaintiff denied the claim based on outstanding verification requested for the treatment provided on December 8, 2021.
VINCENT F. GERBINO, Esq., an attorney admitted to practice in the Courts of the State of New York, affirms that the following statements are true under penalties of perjury:
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REPLY TO COUNTERCLAIM(S) Reply to Counterclaim

Document AMERICAN TRANSIT INSURANCE COMPANY v. ALEXANDRE DEMOURA M.D. PC, 619605/2024, 6 (N.Y. Sup. Ct., Nassau County Dec. 13, 2024)
VINCENT F. GERBINO, a partner duly admitted to practice in the Courts of the State of New York, replies to the counterclaim of the defendants, ALEXANDRE DEMOURA, M.D.
D/B/A NEW YORK SPINE INSTITUTE, upon information and belief, states as follows:
WHEREFORE, Plaintiff, AMERICAN TRANSIT INSURANCE COMPANY, hereby demands judgment dismissing the counterclaim of the defendant, ALEXANDRE DEMOURA, M.D.
D/B/A NEW YORK SPINE INSTITUTE, together with the costs and disbursements of this action.
Dated: Melville, New York December 12, 2024
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EXHIBIT(S) - B Exhibit B

Document AMERICAN TRANSIT INSURANCE COMPANY v. ALEXANDRE DEMOURA M.D. PC, 619605/2024, 3 (N.Y. Sup. Ct., Nassau County Nov. 6, 2024)
2012]) Authority for the review of the resulting awards is derived from Insurance Law § 5106 (c) and 11 NYCRR § 65-4.10, and disposition of an appeal taken therefrom is shaped by the procedures and standards delineated in the subject regulation.
Such awards may be vacated or modified solely by appeal to a master arbitrator (see, 11 NYCRR § 65-4.10 [a]), and the governing criteria include the substantive grounds specified in Article 75 of the CPLR.
2006]), and, generally, the assailed award must be upheld where the arbitrator “ ‘offer[s] even a barely colorable justification for the outcome reached’ (Matter of Andros Cia Maritima, S.A. [Marc Rich & Co., A.G.], 579 F.2d 691, 704 [2d Cir 1978]).” (Wien & Malkin LLP v Helmsley-Spear, Inc., 6 NY3d 471, 479 [2006], cert dsmd 548 US 940 [2006]) The Appellant failed to make the showing required for vacatur or modification.
In this regard, the Lower Arbitrator found that the Applicant substantially complied with the Appellant’s requests for additional verification by providing all items within its possession and control.
However, for all arbitration requests filed on or after April 5, 2002, if the benefits and interest awarded thereon is equal to or less than the respondent’s written offer during the conciliation process, then the attorney’s fee shall be based upon the provisions of 11 NYCRR 65-4.6(b).
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EXHIBIT(S) - A Exhibit A

Document AMERICAN TRANSIT INSURANCE COMPANY v. ALEXANDRE DEMOURA M.D. PC, 619605/2024, 2 (N.Y. Sup. Ct., Nassau County Nov. 6, 2024)
Dear Parties: Israel Purdy, LLP 11 Grace Avenue Suite 111 Great Neck, NY 11021 By: EMAIL American Transit Insurance Company One Metro Tech Center, 7th Fl.
Summary of Issues in Dispute Applicant is seeking reimbursement for a Cervical Discectomy and related procedures, undergone on December 08, 2021 by the Assignor, a 50-year-old female passenger who sustained injuries in a motor vehicle accident on March 30, 2021.
Findings, Conclusions, and Basis Therefor The decision below is based upon a review of the documents that have been submitted electronically, as well as the arguments of counsel and/or representatives appearing via video conference on behalf of the parties.
Applicant has established a prima facie entitlement to reimbursement, as a matter of law, by submitting evidentiary proof that the prescribed statutory billing forms, setting forth the fact and the amount of the loss sustained, have been mailed and received, and that payment of no-fault benefits is overdue.
Once the Applicant has established a prima facie case, the burden shifts to Respondent to timely request additional verification, deny or pay the claim.
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