February 1, 2005

A & S Med. P.C. v Allstate Ins. Co. (2005 NY Slip Op 00505)

https://www.beynensonlaw.com/case-law/a-s-med-p-c-v-allstate-ins-co-2005-ny-slip-op-00505/

Court: Appellate Division, First Department
Decided: February 1, 2005
Citation: 2005 NY Slip Op 00505 · 15 AD3d 170
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Contrasted (cf., but see) in 1 and followed in 2 later decisions (see Cited by)
Issues: Timeliness and preclusion Medical necessity

Cite as

A & S Med. P.C. v Allstate Ins. Co., 15 AD3d 170 (1st Dept 2005)

Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.

Summary

Editorial summary by Beynenson Law, not part of the court’s decision.

An insurer must timely respond to a provider's first assigned claim despite an earlier blanket denial sent to the insured. The insurer denied further orthopedic benefits based on an IME but did not respond within 30 days to the provider's subsequent claim for orthopedic services. It later rejected the portion covering treatment after the cutoff. Under Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3), the earlier denial to the insured did not excuse that failure or permit silent reliance on the cutoff. The Appellate Division, First Department, affirmed the Appellate Term's order granting the provider summary judgment because the untimely response precluded the medical-necessity defense.

Reported in New York Official Reports at A & S Med. P.C. v Allstate Ins. Co. (2005 NY Slip Op 00505)

A & S Med. P.C. v Allstate Ins. Co.

2005 NY Slip Op 00505 [15 AD3d 170]

February 1, 2005

Appellate Division, First Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, April 20, 2005

A & S Medical P.C., as Assignee of Reyna Martinez, Respondent,
v
Allstate Insurance Company, Appellant.

—[*1]

Order of the Appellate Term of the State of New York, First Department, entered on or about June 18, 2003, which, in an action by a health provider against a no-fault insurer to recover on an assigned no-fault claim, reversed an order, Civil Court, Bronx County (Wilma Guzman, J.), entered October 24, 2001, denying plaintiff’s motion for summary judgment, and, inter alia, granted the motion, unanimously affirmed, without costs.

Plaintiff submitted a claim to defendant for orthopedic services it provided to its assignor from November 4, 1998 to February 8, 1999. More than 30 days later, and after plaintiff had commenced the instant action alleging that defendant had neither paid nor denied the claim within 30 days as required by Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3), defendant rejected a portion of the claim, explaining that it had previously denied all further orthopedic benefits effective January 26, 1999, and that it was accordingly denying the claim insofar as it sought benefits for services provided after that date. It appears that on January 19, 1999, defendant had sent plaintiff’s assignor a denial of claim form advising that all further orthopedic benefits would be denied effective January 26, 1999, based on an independent medical examination showing no further need for treatment. Appellate Term rejected defendant’s argument that the January 19, 1999 denial of claim form it had sent to plaintiff’s assignor is imputable to plaintiff (citing Atlantis Med. v Liberty Mut. Ins. Co., 2002 NY Slip Op 40043U [Dist Ct, Nassau County 2002], and held that defendant’s failure to respond to plaintiff’s claim within the statutory 30-day time limit precluded defendant from defending against the claim on the ground that any treatment after January 26, 1999 was unnecessary (citing Presbyterian Hosp. v Maryland Cas. Co., 90 NY2d 274 [1997]; Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]; Country-Wide Ins. Co. v Zablozki, 257 AD2d 506 [1999], lv denied 93 NY2d 809 [1999]).

We hold that the No-Fault Law itself (Insurance Law art 51), and the regulations promulgated thereunder for settlement of claims (11 NYCRR 65.15), require that “When a provider of medical services [first] submits a claim as assignee of an insured, neither the statute nor the regulations contemplate the insurer simply sitting mute and failing to act upon the claim, silently and secretly relying upon an earlier [blanket] denial issued directly to the insured” (Atlantis Med., 2002 NY Slip Op 40043U at *9; see also Aurora Chiropractic, P.C. v Farm & Cas. Ins. [*2]Co. of Conn., 4 Misc 3d 1026 [A], 2004 NY Slip Op 51066[U], *2-3 [2004]; compare Hospital for Joint Diseases v Allstate Ins. Co., 5 AD3d 441 [2d Dept 2004]). Concur—Mazzarelli, J.P., Saxe, Friedman, Sullivan and Williams, JJ. [See 196 Misc 2d 322.]

Cited in this decision

Aurora Chiropractic, P.C. v Farm & Cas. Ins. Co. of Ct. (2004 NY Slip Op 51066(U))The insurer's blanket IME cutoff did not excuse timely denials of later provider claims, leaving no meritorious defense to vacate default.
Hospital for Joint Diseases v Allstate Ins. Co. (2004 NY Slip Op 01546)Resubmission of a previously denied no-fault claim does not restart the insurer's 30-day period to deny it.

Cited by

A label shows how the later decision treated this one.

Island Life Chiropractic Pain Care, PLLC v 21st Century Ins. Co. (2021 NY Slip Op 21340) Contrasted (cf., but see)An untimely EUO no-show denial of one claim does not waive the defense against later claims that are individually timely denied.
Summit Psychological, P.C. v General Assur. Co. (2005 NY Slip Op 25263) FollowedThe insurer failed to establish timely mailing of its denials or proper mailing of preclaim IME requests.
Shtarkman v Allstate Ins. Co. (2005 NYSlipOp 51028(U)) FollowedAn insurer's blanket denial issued before receipt of a provider's claim does not constitute a valid denial of that claim.
A.B. Med. Servs., PLLC v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 25089)A provider retains the burden of proving coverage after an insurer produces admissible evidence of a founded belief that a collision was staged.
Metropolitan Radiological Imaging v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 25063)An insurer moving to compel no-fault discovery must supply its denial or verification demand, absent a compelling reason for omission.
Precision Diagnostic Imaging, P.C. v Travelers Ins. Co. (2005 NY Slip Op 25180)A radiology provider's reliance on referrals does not exempt its services from the medical-necessity requirement for no-fault reimbursement.
CPT Med. Serv., P.C. v Utica Mut. Ins. (2006 NY Slip Op 26098)The insurer's post-assignment EUO transcripts were excluded at trial as hearsay against the provider assignee.
Triangle R Inc. v Praetorian Ins. Co. (2010 NY Slip Op 52041(U))An insurer need not pay or deny a no-fault claim until it receives all relevant requested verification.
Total Chiropratic P.C. v Mercury Cas. Ins. Co. (2021 NY Slip Op 50142(U))The provider's claims were barred by an unvacated default declaratory judgment determining coverage against both provider and assignor.
American Tr. Ins. Co. v Nexray Med. Imaging PC (2023 NY Slip Op50538(U))A Workers' Compensation Board rejection does not restart the insurer's 30-day period to deny a claim for lack of medical necessity.

Similar decisions

Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co. (2005 NY Slip Op 02235)The insurer failed to prove mailing of its denial, and the denial was incomplete even if timely.
A.B. Med. Servs. PLLC v Nationwide Mut. Ins. Co. (2004 NY Slip Op 24506)The providers' billing manager affidavit failed to establish submission of properly completed claim forms.
A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 51036(U))The insurer failed to establish tolling because it did not prove mailing of its follow-up verification request.
A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2005 NY Slip Op 25032)An insurer may assert a lack-of-coverage defense despite an untimely denial of no-fault claims.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 05602)The insurer proved a timely denial but failed to establish that the provider's treatment was unrelated to the accident.