February 26, 2004

Amaze Med. Supply v Eagle Ins. Co. (2004 NY Slip Op 50389(U))

https://www.beynensonlaw.com/case-law/amaze-med-supply-v-eagle-ins-co-2004-ny-slip-op-50389u/

Court: Appellate Term, Second Department
Decided: February 26, 2004
Citation: 2004 NY Slip Op 50389(U)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Provider's prima facie case
Legal questions: Claimant's prima facie case on motions (see the maps)

Cite as

Amaze Med. Supply v Eagle Ins. Co., 2004 NY Slip Op 50389(U) (App Term, 2d Dept, 2d & 11th Jud Dists 2004)

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.

The provider's own submissions raised factual issues about whether the billed equipment was prescribed or received by its assignor. Proper proof of claim generally establishes a prima facie case through a completed statutory form or its functional equivalent under 11 NYCRR 65-3.3 (d) and 65-3.5 (a), (f). But documents first submitted on the provider's summary judgment motion included a prescription that did not match the billed equipment and a delivery receipt for a different insured. Those discrepancies raised triable issues concerning certain benefits sought. The Appellate Term, Second Department, affirmed the order denying the provider's motion.

Reported in New York Official Reports at Amaze Med. Supply v Eagle Ins. Co. (2004 NY Slip Op 50389(U))

[*1]

Amaze Med. Supply v Eagle Ins. Co.

2004 NY Slip Op 50389(U)

Decided on February 26, 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This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on February 26, 2004

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS

PRESENT:PESCE, P.J., ARONIN and PATTERSON, JJ.
NO. 2002-1684 K C

AMAZE MEDICAL SUPPLY INC. a/a/o Mildred Mejia, Appellant,
against
EAGLE INSURANCE COMPANY, Respondent.

Appeal by plaintiff from an order of the Civil Court, Kings County (A. Schack, J.), entered October 7, 2002, denying its motion for summary judgment.

Order unanimously affirmed without costs.

Recovery of no-fault benefits requires a proper proof of claim, i.e. the completed statutory form (11 NYCRR 65-3.3 [d]) or its functional equivalent (11 NYCRR 65-3.5 [a], [f]; S & M Supply Inc. v Allstate Ins. Co., NYLJ, July 17, 2003 [App Term, 2d & 11th Jud Dists]; cf. Interboro Gen. Hosp. v Allcity Ins. Co., 149 AD2d 569, 570 [1989]), and an insured’s proof of a properly submitted claim generally suffices to establish its prima facie case in summary judgment (Amaze Med. Supply Inc. v Eagle Ins. Co., NYLJ, Dec. 29, 2003 [App Term, 2d & 11th Jud Dists]). Here, however, plaintiffs inclusion of additional documents for the first time upon its motion for summary judgment, namely, a physician’s prescription for medical equipment, which did not match the equipment for which benefits were sought, and a receipt for medical equipment delivered to an insured other than its assignor, raised a triable factual issue, whether certain of the no-fault benefits sought were for equipment that was not part of the prescribed course of treatment or for equipment other than what the patient actually received (see Amaze Med. Supply Inc. v Eagle Ins. Co., supra).
Decision Date: February 26, 2004

Legal questions

A question 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.

Claimant's prima facie case on motions

Open the full map

On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?

This decision: Insufficient for another reason (eligibility, timely submission, own papers defeat the claim)

Held that, although proof of a properly submitted claim generally suffices, the supplier's own added prescription and delivery receipt, which did not match the billed equipment or assignor, raised a triable issue defeating summary judgment.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followed

Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 19 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Cited by

Complete Orthopedic Supplies, Inc. v State Farm Ins. Co. (2007 NY Slip Op 27192)A fee schedule dispute remained triable because the insurer established neither a proper scheduled fee nor a comparable fee for the goods.
T&G Med. Supplies, Inc. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 50636(U))The supplier lacked standing because its assignor neither received the supplies nor incurred an obligation to pay for them.
Booth Chiropractic & Acupuncture PLLC v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51673(U))The provider's inconsistent treating-physician affidavits raised a triable issue and defeated its summary judgment motion.

Similar decisions

Amaze Med. Supply Inc. v General Assur. Co. (2005 NY Slip Op 50960(U))The insurer failed to raise a factual issue on IME nonappearance because it offered no competent proof that the requests were mailed.
Amaze Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 50211(U))The provider established entitlement to summary judgment by proving submission of complete claims that were not paid or denied within 30 days.
Amaze Medical Supply Inc. v Allstate Ins. Co. (2004 NY Slip Op 51636(U))The insurer's denials issued more than 30 days after submission precluded its medical-necessity defense.
Amaze Med. Supply Inc. v AIU Ins. Co. (2004 NY Slip Op 51629(U))The insurer's investigator affidavit raised a factual coverage issue despite an untimely denial of the medical-supply claim.
Amaze Med. Supply Inc. v State Farm Mut. Auto. Ins. Co. (2005 NYSlipOp 51315(U))The insurer's IME nonappearance defense failed because it did not establish mailing of the scheduling requests to the assignor.