September 16, 2022
Parisien v Tri State Consumers Ins. Co. (2022 NY Slip Op 50920(U))
https://www.beynensonlaw.com/case-law/parisien-v-tri-state-consumers-ins-co-2022-ny-slip-op-50920u/
- Decided
- September 16, 2022
- Citation
- 2022 NY Slip Op 50920(U)
- Posture
- Summary judgment
- Outcome
- Split result
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 Parisien v Tri State Consumers Ins. Co. (2022 NY Slip Op 50920(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
Tri State Consumers Ins. Co., Respondent.
The Rybak Firm, PLLC (Damin J. Toell and Richard Rozhik of counsel), for appellant. Law Office of Jason Tenenbaum, P.C. (Shaaker Bhuiyan of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Robin S. Garson, J.), entered October 2, 2019. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.
ORDERED that the order is modified by providing that the branches of defendant’s cross motion seeking summary judgment dismissing the first and third through tenth causes of action are denied, and the branch of plaintiff’s motion seeking summary judgment on the first cause of action is granted; as so modified, the order is affirmed, without costs.
In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court denying plaintiff’s motion for summary judgment and granting defendant’s cross motion for summary judgment dismissing the complaint.
Defendant denied the claim underlying the first cause of action on the ground that written instructions for physical therapy should have been included in plaintiff’s assignor’s medical records for services billed under CPT code 97001 of the workers’ compensation fee schedule. However, as plaintiff argues, defendant did not request any additional verification from plaintiff seeking the information it felt it required in order to review this claim. Consequently, defendant was not entitled to summary judgment dismissing the first cause of action, and, under the circumstances presented, the branch of plaintiff’s motion seeking summary judgment on that [*2]cause of action should have been granted (see Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co., 57 Misc 3d 145[A], 2017 NY Slip Op 51452[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2017], affd 175 AD3d 455 [2019]).
With respect to the second cause of action, contrary to plaintiff’s contention, plaintiff’s conclusory assertion that it never received the check defendant had mailed to pay this claim was insufficient to raise a triable issue of fact (see Matter of Rodriguez v Wing, 251 AD2d 335 [1998]).
With respect to the third through tenth causes of action, plaintiff correctly argues that defendant failed to show, as a matter of law, that the independent medical examination (IME) scheduling letters were properly addressed and generated pursuant to the standard practices and procedures of its IME scheduling vendor (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Moreover, the affirmation from the doctor who was scheduled to perform the IMEs did not establish that he possessed personal knowledge of the nonappearance of plaintiff’s assignor for the IMEs. In addition, defendant failed to establish, as a matter of law, that the amounts charged in these claims were improperly billed or in excess of the amounts permitted by the workers’ compensation fee schedule. Therefore, defendant failed to establish its entitlement, as a matter of law, to summary judgment dismissing the third through tenth causes of action (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]; Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 52 Misc 3d 128[A], 2016 NY Slip Op 50922[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]; Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]).
However, plaintiff failed to establish its prima facie entitlement to summary judgment upon the third through tenth causes of action, as plaintiff did not establish either that defendant failed to timely deny the claims (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]), or that defendant issued timely denial of claim forms that were conclusory, vague or without merit as a matter of law (see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]). Thus, the branches of plaintiff’s motion seeking summary judgment on these causes of action were properly denied.
Accordingly, the order is modified by providing that the branches of defendant’s cross motion seeking summary judgment dismissing the first and third through tenth causes of action are denied, and the branch of plaintiff’s motion seeking summary judgment on the first cause of action is granted.
ALIOTTA, P.J., GOLIA and BUGGS, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: September 16, 2022
Legal questions (4)
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.
On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?
This decision: Insufficient: claimant did not prove the claim was overdue (not paid or timely denied)
Held the provider failed its prima facie burden on the third through tenth causes of action because it did not show the claims were not timely denied or that timely denials were conclusory, vague or meritless.
Of the 1,063 decisions on this question in the Second Department courts and the Court of Appeals, 247 (this one included) are in the same category.
Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?
This decision: The insurer's proof did not establish mailing of its denial, verification request or IME/EUO notice
Held the insurer failed to show the IME scheduling letters were properly addressed and generated under its scheduling vendor's standard office practices and procedures.
Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 257 (this one included) are in the same category.
Did the insurer prove its IME/EUO no-show defense: mailed, compliant scheduling requests and the claimant’s nonappearance?
This decision: Insurer failed to prove the scheduling letters were mailed or properly addressed
Held the IME no-show defense unproved because mailing of the scheduling letters was not shown and the scheduled doctor's affirmation showed no personal knowledge of the nonappearance.
Of the 851 decisions on this question in the Second Department courts and the Court of Appeals, 114 (this one included) are in the same category.
Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?
This decision: Insurer's proof did not establish the excess as a matter of law; question left for trial
Held the insurer failed to establish as a matter of law that the charges on the third through tenth claims were improperly billed or exceeded the fee schedule.
Of the 284 decisions on this question in the Second Department courts and the Court of Appeals, 85 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (2017 NY Slip Op 51452(U)) FollowedAn insurer must request missing documentation for a By Report claim before denying it for lack of that documentation.
- Bronx Acupuncture Therapy, P.C. v Hereford Ins. Co. (2019 NY Slip Op 06059)An insurer that fails to request verification cannot deny a moxibustion claim under CPT code 97039 for insufficient information.
- St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
- Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 09604) FollowedAn insurer may deny benefits retroactively to the date of loss for failure to attend reasonably required IMEs under 11 NYCRR 65-1.1.
- Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 50922(U)) FollowedThe insurer failed to establish the assignor's IME nonappearance or receipt of notice of both scheduled IMEs. The provider appealed from summary judgment dismissing its assigned no-fault claims.
- Rogy Med., P.C. v Mercury Cas. Co. (2009 NY Slip Op 50732(U)) FollowedThe insurer's peer review report was not competent evidence, and its fee-schedule proof was insufficient.
- 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.
- Westchester Med. Ctr. v Nationwide Mut. Ins. Co. (2010 NY Slip Op 08933) FollowedThe provider failed to establish entitlement to summary judgment because the insurer partially paid and denied the claim within 30 days.
- Ave T MPC Corp. v Auto One Ins. Co. (2011 NY Slip Op 51292(U)) FollowedThe provider failed to establish summary judgment entitlement because nonpayment alone did not show an absent or legally insufficient denial.
Similar decisions
- Parisien v 21st Century Ins. Co. (2019 NY Slip Op 50275(U))The insurer's late EUO follow-up letter defeated summary judgment on one claim, while disputed receipt defeated summary judgment on another.
- Parisien v Travelers Ins. Co. (2022 NY Slip Op 50553(U))The insurer established the provider's failure to attend two duly scheduled EUOs and timely denials on that ground.
- Parisien v Ameriprise Ins. (2020 NY Slip Op 50990(U))The insurer proved the provider's EUO nonappearances, including one at a location changed at the provider's request, and a timely denial.
- Parisien v Allstate Ins. Co. (2019 NY Slip Op 51154(U))The insurer failed to establish timely mailing of its denials, but the provider also failed to establish entitlement to summary judgment.
- Parisien v Maya Assur. Co. (2018 NY Slip Op 50766(U))The insurer failed to prove mailing of IME scheduling letters, and the provider failed to establish entitlement to summary judgment.