May 18, 2015

Compas Med., P.C. v Hartford Ins. Co. (2015 NY Slip Op 50784(U))

https://www.beynensonlaw.com/case-law/compas-med-p-c-v-hartford-ins-co-2015-ny-slip-op50784u/

Court: Appellate Term, Second Department
Decided: May 18, 2015
Citation: 2015 NY Slip Op 50784(U)
Posture: Summary judgment
Outcome: Split result
Issues: Timeliness and preclusion Provider's prima facie case
Legal questions: Claimant's prima facie case on motions · Proof of mailing (see the maps)

Cite as

Compas Med., P.C. v Hartford Ins. Co., 2015 NY Slip Op 50784(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015)

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 obtained summary judgment on the fourth, fifth and tenth causes of action because the insurer failed to deny those claims timely. The provider established submission and nonpayment of those claims. The insurer's conclusory assertion that it had not received the fourth claim did not rebut the presumption of receipt, and the insurer admitted that claim was not timely denied. The fifth and tenth denials were also untimely. The Appellate Term, Second Department, modified the order, insofar as appealed from, to grant the provider judgment on those three causes and deny the insurer's cross motion on the fifth and tenth. It upheld dismissal of the first through third and sixth through ninth causes, for which the insurer established timely mailing of denials.

Reported in New York Official Reports at Compas Med., P.C. v Hartford Ins. Co. (2015 NY Slip Op 50784(U))

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

Compas Medical, P.C. as Assignee of VENETTE PIERRE LOUIS, Appellant,
against
Hartford Insurance Company, Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (James E. d’Auguste, J.), entered December 4, 2012. The order, insofar as appealed from, denied plaintiff’s motion for summary judgment and granted the branches of defendant’s cross motion seeking summary judgment dismissing the 1st through 3rd and 5th through 10th causes of action.

ORDERED that the order, insofar as appealed from, is modified by providing that the branches of plaintiff’s motion seeking summary judgment on the 4th, 5th and 10th causes of action are granted, and the branches of defendant’s cross motion seeking summary judgment dismissing the 5th and 10th causes of action are denied; as so modified, the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The court denied plaintiff’s motion for summary judgment and, insofar as is relevant to this appeal, granted the branches of defendant’s motion seeking summary judgment dismissing the first through third and fifth through tenth causes of action. With respect to the claim underlying the fourth cause of action, which defendant alleged it had never received, the court found that issues of fact exist.

With respect to the claims underlying the first through third and sixth through ninth causes of action, contrary to plaintiff’s argument on appeal, the affidavits submitted by defendant were sufficient to demonstrate that the denial of claim forms had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). However, with respect to the claims underlying the 5th and 10th causes of action, plaintiff correctly argues that defendant’s denial of claim forms were not timely mailed. Accordingly, the branches of defendant’s cross motion seeking summary judgment dismissing those causes of action should have been denied.

Plaintiff is entitled to summary judgment on the 4th, 5th and 10th causes of action. Plaintiff’s moving papers established, prima facie, the submission to defendant of the claim forms underlying those causes of action (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16), and that defendant had not paid the claims. With respect to the claim underlying the fourth cause of action, defendant’s conclusory allegation that it had not received the bill failed to rebut the presumption of receipt (cf. Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co., 44 Misc 3d 59 [App Term, 2d, 11th & 13th Jud Dists 2014]). Since defendant admitted that it did not timely deny the claim underlying the 4th cause of action, and the record demonstrates that the claims underlying the 5th and 10th causes of action were not timely denied, the branches of plaintiff’s motion seeking summary judgment on those causes of action should have been granted (see Viviane Etienne Med. Care, P.C. v [*2]Country-Wide Ins. Co., 114 AD3d 33 [2013]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d, 11th & 13th Jud Dists 2011]).

Accordingly, the order is modified by providing that the branches of plaintiff’s motion seeking summary judgment on the 4th, 5th and 10th causes of action are granted and the branches of defendant’s cross motion seeking summary judgment dismissing the 5th and 10th causes of action are denied.

Pesce, P.J., Aliotta and Solomon, JJ., concur.

Decision Date: May 18, 2015

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.

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: Claimant's proof held to make out its prima facie case

Held the provider's moving papers established submission of three claims and nonpayment, and the claims were not timely denied, entitling it to summary judgment on those causes of action.

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, 511 (this one included) are in the same category.

Proof of mailing

Open the full map

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

This decision: Different mailing results for different documents or claims in one decision

Held the insurer proved timely mailing of denials for most claims but not for two, and the provider's mailing proof created a presumption of receipt that a conclusory non-receipt allegation failed to rebut.

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

Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 55 (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)The insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345)An insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 24145) Contrasted (cf., but see)The provider's mail-record affidavit raised a triable issue as to whether the insurer mailed its verification requests.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430)A provider need not prove a claim's merits for summary judgment where the insurer failed to timely and properly deny the claim.
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

Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51239(U))The provider's mailing affidavit raised a factual issue over receipt of verification, and the insurer failed to prove fee-schedule payment.
Compas Med., P.C. v Farm Family Cas. Ins. Co. (2015 NY Slip Op 51704(U))The insurer lacked personal-knowledge proof of EUO nonappearance, while disputed billing receipt and deficient proof defeated the provider's motion.
Compas Med., P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51228(U))The insurer failed to establish a timely denial of the fourth claim but proved full fee-schedule payment of the first and fifth claims.
Compas Med., P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50249(U))Seven provider claims were dismissed for IME nonappearance or unanswered verification; neither side established summary judgment on two others.
Compas Med., P.C. v Nationwide Ins. (2014 NY Slip Op 51824(U))The insurer rebutted presumed receipt of one claim, leaving a factual issue, and proved IME and EUO nonappearances on the remaining claims.