September 29, 2004
A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51104(U))
https://www.beynensonlaw.com/case-law/a-b-med-servs-pllc-v-state-farm-mut-auto-ins-co-2004-ny-slip-op-51104u/
- Decided
- September 29, 2004
- Citation
- 2004 NY Slip Op 51104(U)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
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.
Reported in New York Official Reports at A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51104(U))
| A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. |
| 2004 NY Slip Op 51104(U) |
| Decided on September 29, 2004 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS
PRESENT:PESCE, P.J., ARONIN and PATTERSON, JJ.
x
against
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Respondent.
Appeal by plaintiffs from so much of an order of the Civil Court, Kings County
(D. Silber, J.), entered on September 19, 2003, as denied their cross motion for summary judgment.
Order insofar as appealed from unanimously affirmed without costs.
Plaintiffs health care providers established their prima facie entitlement to summary judgment for assigned no-fault benefits by the submission of evidentiary proof that the statutory claims forms were mailed to defendant and that defendant failed to pay or deny the claims within the prescribed 30-day period (see Insurance Law § 5106 [a]; 11 NYCRR 65.15 [g] [3]; New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co., 8 AD3d 640 [2004]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128 [A], 2003 NY Slip Op 51701 [U] [App Term, 2d & 11th Jud Dists]). Moreover, defendant’s requests for examinations under oath did not toll the 30-day period in the [*2]absence of provisions in the applicable insurance regulations requiring a claimant to submit to examinations under oath (see Melbourne Med., P.C. v Utica Mut. Ins. Co., ___ Misc 3d ___, 2004 NY Slip Op 24221 [U] [App Term, 2d & 11th Jud Dists]; S & M Supply v Nationwide Mut. Ins. Co., 3 Misc 3d 138 [A], 2004 NY Slip Op 50557 [U] [App Term, 2d & 11th Jud Dists]; A.B. Med. Servs. v Eagle Ins. Co., 3 Misc 3d 8 [App Term, 9th & 10th Jud Dists 2003]).
However, defendant is not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, despite the untimely denial of the claims (see Matter of Metro Med. Diagnostics v Eagle Ins. Co., 293 AD2d 751 [2002]). The affidavit submitted by defendant’s special investigator was sufficient to demonstrate that defendant’s denial was based upon a “founded belief that the alleged injur[ies] do[] not arise out of an insured incident” (Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]). Accordingly, since defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage (see id.), plaintiffs’ motion for summary judgment was properly denied.
Decision Date: September 29, 2004
Legal questions (2)
Questions of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.
Did the insurer show the claimed injuries did not arise from a covered accident (staged, intentional, or unrelated)?
This decision: Founded belief shown; the question must be tried
Held the special investigator's affidavit showed a founded belief that the collision furthered an insurance fraud scheme, raising a triable issue of lack of coverage that required denial of the providers' motion.
Of the 234 decisions on this question in the Second Department courts and the Court of Appeals, 102 (this one included) are in the same category.
On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?
This decision: Claimant's proof held to make out its prima facie case (rules on the question, but another ground decided the case)
Held the providers established their prima facie case by evidentiary proof that the claim forms were mailed and that the insurer failed to pay or deny within 30 days.
Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (this one included) are in the same category.
Cited in this decision
- New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 05626)The insurer failed to establish mailing of assignment-verification requests and could not defeat the hospitals' summary judgment motion.
- Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359)The hospitals established entitlement to summary judgment by proving that statutory billing forms were mailed and received and payment was overdue.
- Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U))A provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
- Melbourne Med., P.C. v Utica Mut. Ins. Co. (2004 NY Slip Op 24221)EUO requests do not toll the claim determination period when the governing no-fault regulations do not authorize EUO verification.
- S & M Supply, Inc. v Nationwide Mut. Ins. Co. (2004 NY Slip Op 50557(U))An EUO request does not toll the payment or denial period under the former regulation that did not require an injured person to submit to an EUO. The provider established submission of a complete proof of claim and nonpayment or denial within 30 days under Insurance Law § 5106 (a) and former 11 NYCRR 65.15.
- A.B. Med. Servs. v Eagle Ins. Co. (2003 NY Slip Op 23978)The insurer's investigator's affidavit failed to raise a triable issue that the collision was staged.
Cited by
- American Tr. Ins. Co. v Nexray Med. Imaging PC (2023 NY Slip Op 50506(U))The insurer's challenge to the arbitrator's finding of insufficient causation evidence raised a factual issue, not an error of law.
Similar decisions
- Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51251(U))The insurer raised a triable insurance fraud coverage defense despite ineffective EUO requests and an untimely denial.
- GPM Chiropractic, P.C. v State Farm Mut. Ins. Co (2005 NYSlipOp 50861(U))The insurer's investigator affidavit raised a triable staged-collision coverage issue despite an untimely denial.
- A.B. Med. Servs. PLLC v GMAC Ins. (2005 NYSlipOp 51079(U))The insurer's claims representative supplied facts supporting a founded belief that the alleged injuries did not arise from an insured incident.
- New Century Chiropractic, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 52236(U))The insurer's investigator established a founded belief that the injuries did not arise from an insured incident, raising a coverage issue.
- A.B. Med. Servs. v Allstate Ins. Co. (2004 NY Slip Op 50373(U))The providers' billing affidavit failed to establish their prima facie case because it did not identify which of three providers it covered.