100 A.D.2d 570 | N.Y. App. Div. | 1984
In an action for a declaratory judgment, inter alia, in effect adjudicating that certain alterations made by plaintiff to motor vehicle no-fault benefits application forms were valid, plaintiff appeals from a judgment of the Supreme Court, Queens County (Dunkin, J.), dated August 22, 1983, which declared that the alterations were invalid as violative of the regulations of the Department of Insurance and inconsistent with the requirements of the Insurance Law. f Judgment affirmed, with costs. 11 On July 31, 1982, plaintiff, while driving an automobile owned by him and insured by defendant, was involved in an automobile accident. On August 2, 1982, plaintiff applied to defendant for no-fault insurance benefits using a form prescribed by the Department of Insurance (11 NYCRR Appendix 13-A). The prescribed form contains the following provisions:
“authorization for release of work AND OTHER LOSS INFORMATION
“THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE AUTOMOBILE INSURANCE REPARATIONS ACT (NO-FAULT LAW)
NAME (PRINT OR TYPE) SOCIAL SECURITY NO.
SIGNATURE DATE
“DO NOT DETACH
“AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION
“THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE AUTOMOBILE INSURANCE REPARATIONS ACT (NO-FAULT LAW).
NAME (PRINT OR TYPE)
SIGNATURE DATE
“(IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP)”.
Plaintiff signed these authorizations, but added restrictive clauses authorizing the release of the relevant information “only to my attorney, Stanley S. Hausen”. 11 After defendant refused to pay benefits unless plaintiff signed the authorizations as set forth in the prescribed form, plaintiff commenced this declaratory judgment action. U Special Term held that plaintiff’s alterations of the form not only violated the regulations promulgated by the Superintendent of the Department of Insurance, but also made “meaningful verification of no fault claims impossible”. We affirm. 11 The relevant authorizations are contained in the “Application for Motor Vehicle No-Fault Benefits (NYS Form N-F 2)” which is prescribed for use by all no-fault insurers (11 NYCRR 65.15 [c]