September 30, 2024
Health E. Ambulatory Surgical Ctr. v Country-Wide Ins. Co. (2024 NY Slip Op 51346(U))
https://www.beynensonlaw.com/case-law/health-e-ambulatory-surgical-ctr-v-country-wide-ins-co-2024-ny-slip-op-51346u/
- Decided
- September 30, 2024
- Citation
- 2024 NY Slip Op 51346(U)
- Posture
- Trial
- Outcome
- Insurer prevailed
- Later history
- Reversed by Health E. Ambulatory Surgical Ctr. v Country-Wide Ins. Co. (2025 NY Slip Op 06648)
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 Health E. Ambulatory Surgical Ctr. v Country-Wide Ins. Co. (2024 NY Slip Op 51346(U))
[*1]| Health E. Ambulatory Surgical Ctr. v Country-Wide Ins. Co. |
| 2024 NY Slip Op 51346(U) |
| Decided on September 30, 2024 |
| Appellate Term, First 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| This opinion is uncorrected and will not be published in the printed Official Reports.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 September 30, 2024
SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT
PRESENT: Hagler, P.J., Brigantti, Tisch, JJ.
570101/24
against
Country-Wide Insurance Company, Defendant-Appellant.
Defendant appeals from a “decision and order” of the Civil Court of the City of New York, Bronx County (Myrna Socorro, J.), entered on or about May 15, 2020, and a judgment (same court and Judge), entered March 18, 2022, after a nonjury trial, in favor of plaintiff and awarding it damages in the principal sum of $19,646.13.
Per Curiam.
Judgment (Myrna Socorro, J.), entered March 18, 2022, reversed, with $30 costs, and complaint dismissed. Appeal from “decision and order” (Myrna Socorro, J.), entered on or about May 15, 2020, dismissed, without costs, as subsumed in the appeal from the judgment.
In this first-party no-fault action, which came on for trial after having been marked “final,” the trial transcript consists of barely nine pages of colloquy between the court and respective counsel. No witnesses were sworn or evidence received. Instead, plaintiff-provider referenced admissions made by defendant-insurer in defendant’s prior motion for summary judgment, regarding, inter alia, its receipt of plaintiff’s claim. Following these abbreviated proceedings, a judgment was entered in plaintiff’s favor in the principal sum of $19,646.13.
We reverse. The sole evidence relied upon by plaintiff, while sufficient to establish defendant’s receipt of the claim (see generally Fair Price Med. Supply, Inc. v St. Paul Travelers Ins. Co., 16 Misc 3d 8, 2007 NY Slip Op 27173 [App Term, 1st Dept 2007]), also established that defendant timely sought verification, which was not provided. As a result, plaintiff failed to establish, prima facie, that the claim was overdue i.e., was not “denied or paid” within the prescribed 30—day period (see 11 NYCRR 65-3.8[c]; Insurance Law § 5106[a]; Viviane Etienne Med. Care, P.C. v. Country—Wide Ins. Co., 25 NY3d 498, 507 [2015]). Therefore, the complaint should have been dismissed.
All concur.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
Clerk of the CourtDecision Date: September 30, 2024
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.
What must a no-fault claimant prove at trial to make out its prima facie case for overdue benefits?
This decision: Insufficient: claimant did not prove at trial that payment was overdue (unpaid, or not paid or denied within 30 days)
Held the provider failed to establish at trial that the claim was overdue because the insurer's admissions it relied on also showed the insurer timely sought verification that was never provided.
Of the 13 decisions on this question in the First Department courts and the Court of Appeals, 1 (this one included) is in the same category.
Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?
This decision: Timely requests went unanswered; the claim is not overdue and the action is premature
Held the claim was not overdue, and dismissed the complaint, because the provider's own evidence showed the insurer timely requested verification that was not provided.
Of the 38 decisions on this question in the First Department courts and the Court of Appeals, 23 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- Fair Price Med. Supply, Inc. v St. Paul Travelers Ins. Co. (2007 NY Slip Op 27173)The insurer's verified interrogatory answers established receipt and partial payment of the claims and defeated its proof-of-billing objection.
- Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2015 NY Slip Op 04787) FollowedA provider establishes entitlement to summary judgment on overdue no-fault claims with admissible proof of mailing and receipt of statutory claim forms.
Cited by
A label shows how the later decision treated this one.
- Health E. Ambulatory Surgical Ctr. v Country-Wide Ins. Co. (2025 NY Slip Op 06648) ReversedAn insurer's admission in its motion papers that it received the claim may establish a provider's prima facie case at trial.
Similar decisions
- Healthway Med. Care, P.C. v Country Wide Ins. Co. (2015 NY Slip Op 51654(U))The insurer established late notice of the accident, and the provider offered no proof of timely notice or a reasonable justification.
- PR Med., P.C. v Praetorian Ins. Co. (2016 NY Slip Op 50338(U))The insurer's letter delaying payment pending IMEs did not toll the 30-day period, and its medical-necessity defense was precluded.
- J.C. Healing Touch Rehab, P.C. v Amica Mut. Ins. Co. (2014 NY Slip Op 50969(U))The provider failed to establish either an untimely denial or a timely denial that was legally insufficient.
- D.S. Chiropractic, P.C. v Country-Wide Ins. Co. (2010 NY Slip Op 50649(U))The provider's action was premature because requested verification remained outstanding despite follow-up requests mailed on the 30th day.
- Boro Med. Supplies, Inc. v Country Wide Ins. Co. (2008 NY Slip Op 52698(U))The insurer's unsigned affidavit failed to prove a timely denial, precluding its defense that the provider submitted the claim late.