June 7, 2019

Golden Star Acupuncture, P.C. v Erie Ins. Co. of NY (2019 NY Slip Op 50920(U))

https://www.beynensonlaw.com/case-law/golden-star-acupuncture-p-c-v-erie-ins-co-of-ny-2019-ny-slip-op50920u/

Court: Appellate Term, Second Department
Decided: June 7, 2019
Citation: 2019 NY Slip Op 50920(U)
Posture: Summary judgment
Outcome: Split result
Issues: EUO no-show Provider's prima facie case Discovery and procedure
Legal questions: Claimant's prima facie case on motions · No-show defense: insurer's proof · Proof of mailing (see the maps)

Cite as

Golden Star Acupuncture, P.C. v Erie Ins. Co. of NY, 2019 NY Slip Op 50920(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2019)

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 insurer failed to prove EUO nonappearance, and the provider failed to establish entitlement to summary judgment on the appealed claims. Although EUO letters were properly mailed to one assignor, defense counsel's legal assistant did not establish personal knowledge of nonappearance. The provider's owner's affidavit did not establish untimely denials or timely denials that were conclusory, vague or legally meritless under Insurance Law § 5106 (a). Considering the provider's untimely opposition was within the Civil Court's discretion because the insurer could reply. The Appellate Term, Second Department, modified the order, insofar as appealed from, to deny the provider's cross motion on that assignor's claims and otherwise affirmed, leaving denial of the insurer's motion intact.

Reported in New York Official Reports at Golden Star Acupuncture, P.C. v Erie Ins. Co. of NY (2019 NY Slip Op 50920(U))

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

Golden Star Acupuncture, P.C., as Assignee of Rhonda Cobin and Jose Ramos, Respondent,
against
Erie Insurance Co. of NY, Appellant.

Robyn M. Brilliant, P.C. (Robyn M. Brilliant of counsel), for appellant. Zara Javakov, P.C. (Zara Javakov of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin Kelly Sheares, J.), entered June 2, 2017. The order, insofar as appealed from, denied the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims as assignee of Rhonda Cobin and granted the branch of plaintiff’s cross motion seeking summary judgment on that portion of the complaint.

ORDERED that the order, insofar as appealed from, is modified by providing that the branch of plaintiff’s cross motion seeking summary judgment on so much of the complaint as sought to recover upon claims as assignee of Rhonda Cobin is denied; as so modified, the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from so much of an order of the Civil Court as denied the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims as assignee of Rhonda Cobin and granted the branch of plaintiff’s cross motion seeking summary judgment on that portion of the complaint. Contrary to the determination of the Civil Court, the proof submitted by defendant was sufficient to establish the proper mailing of the examination under oath (EUO) scheduling letters sent to Cobin (see St. Vincent’s Hosp. of [*2]Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). However, the affidavit of defense counsel’s legal assistant failed to establish that he possessed personal knowledge that Cobin had not appeared for the EUOs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Consequently, defendant failed to make a prima facie showing that it was entitled to summary judgment dismissing the claims submitted by plaintiff as assignee of Cobin. We note that the Civil Court did not improvidently exercise its discretion in considering the papers submitted by plaintiff in opposition to defendant’s motion, even though the opposition papers had been untimely served pursuant to the parties’ stipulation, as defendant was able to submit reply papers (see Hsu v Shields, 111 AD3d 674 [2013]; Kavakis v Total Care Sys., 209 AD2d 480 [1994]).

Plaintiff failed to demonstrate its prima facie entitlement to summary judgment, as the affidavit of plaintiff’s owner submitted in support of its cross motion failed to establish that the claims at issue had not been timely denied (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]), or that defendant had issued timely denial of claim forms that were conclusory, vague or without merit as a matter of law (see Insurance Law § 5106 [a]; 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]).

Accordingly, the order, insofar as appealed from, is modified by providing that the branch of plaintiff’s cross motion seeking summary judgment on so much of the complaint as sought to recover upon claims as assignee of Rhonda Cobin is denied.

PESCE, P.J., ALIOTTA and ELLIOT, JJ., concur.

ENTER:
Paul Kenny
Chief Clerk
Decision Date: June 07, 2019

Legal questions (3)

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.

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: claimant did not prove the claim was overdue (not paid or timely denied)

Held the provider's owner's affidavit failed to show the claims had not been timely denied or that timely denials were conclusory, vague or without merit, so its cross motion was denied.

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

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.

No-show defense: insurer's proof

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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 nonappearance by someone with personal knowledge

Held the EUO scheduling letters properly mailed, but the defense counsel's legal assistant's affidavit did not show personal knowledge of the nonappearances, so the insurer made no prima facie showing.

Defense provedMailing not provedNonappearance not provedRequests not compliantTriable issueNo-show excusedThis decisionCites it or cited by itCited or followed

Of the 851 decisions on this question in the Second Department courts and the Court of Appeals, 79 (this one included) are in the same category.

Proof of mailing

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Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?

This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)

Held the insurer's proof sufficient to establish proper mailing of the EUO scheduling letters, reversing the lower court on that point, though the insurer's motion failed on proof of nonappearance.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 806 (this one included) are in the same category.

Cited in this decision

A label shows how this decision treated the case it cites.

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.
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)The 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))The provider failed to establish summary judgment entitlement because nonpayment alone did not show an absent or legally insufficient denial.

Similar decisions

Wellness Plaza Acupuncture, P.C. v Erie Ins. (2017 NY Slip Op 51729(U))The provider failed to establish its prima facie case, and the insurer failed to prove timely mailing of EUO nonappearance denials.
Body Acupuncture Care, P.C. v Erie Ins. Co. of N.Y. (2019 NY Slip Op 51695(U))The insurer proved timely IME notices sent to the address on the assignor's sworn application, two nonappearances, and timely denials.
Sovereigh Acupuncture, P.C. v American Commerce Ins. Co. (2017 NY Slip Op 50922(U))The insurer's EUO defense failed because scheduling was late for some claims and the insurer rescheduled each EUO before its date.
Acupuncture Healthcare Plaza I, P.C. v Allstate Ins. Co. (2017 NY Slip Op 50939(U))The insurer's untimely follow-up EUO notice rendered its denial untimely and precluded the nonappearance defense.
Corona Hgts. Med., P.C. v Lancer Ins. Co. (2011 NY Slip Op 51293(U))The insurer established timely mailing of EUO notices and denials and the provider's failure to appear for the scheduled EUOs. The motion papers demonstrated mailing through the standard office practices of the law firm conducting the EUOs and the insurer's own denial-mailing procedures.