April 15, 2014

Aetna Health Plans v Hanover Ins. Co. (2014 NY Slip Op 02541)

https://www.beynensonlaw.com/case-law/aetna-health-plans-v-hanover-ins-co-2014-ny-slip-op-02541/

Court: Appellate Division, First Department
Decided: April 15, 2014
Citation: 2014 NY Slip Op 02541 · 116 AD3d 538
Posture: Motion to dismiss (CPLR 3211)
Later history: Affirmed by Aetna Health Plans v Hanover Ins. Co. (2016 NY Slip Op 04658)
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Assignments and standing Priority, other coverage

Cite as

Aetna Health Plans v Hanover Ins. Co., 116 AD3d 538 (1st Dept 2014)

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.

A health insurer cannot recover no-fault benefits as an injured claimant's assignee under 11 NYCRR 65-3.11 (a). The regulation permits payment to the applicant or, upon assignment, providers of health care services; the plaintiff was a health insurer rather than a provider. The limited interinsurer arbitration provisions of Insurance Law §§ 5105 and 5106 (d) did not apply to a health insurer, so it could not maintain a subrogation claim against the no-fault insurer. Its contract claim also failed for lack of privity or a showing of intended third-party beneficiary status. The Appellate Division, First Department, affirmed dismissal of the complaint and denial of the health insurer's motion for summary judgment on liability.

Reported in New York Official Reports at Aetna Health Plans v Hanover Ins. Co. (2014 NY Slip Op 02541)

Aetna Health Plans v Hanover Ins. Co.

2014 NY Slip Op 02541 [116 AD3d 538]

April 15, 2014

Appellate Division, First Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, May 28, 2014

Aetna Health Plans, as Assignee of Luz Herrera, Appellant,
v
Hanover Insurance Company, Respondent.

—[*1] Shayne, Dachs, Sauer & Dachs, LLP, Mineola (Jonathan A. Dachs of counsel), for appellant.

Crisci, Weiser & McCarthy, New York (Jayashri C. Srinivasan Cuffey of counsel), for respondent.

Order, Supreme Court, Bronx County (Mary Ann Brigantti-Hughes, J.), entered on or about January 7, 2013, which granted defendant’s cross motion to dismiss the complaint, and denied plaintiff’s motion for summary judgment on the issue of liability, unanimously affirmed, with costs.

11 NYCRR 65-3.11 (a) provides, in relevant part, for the payment of no-fault benefits “directly to the applicant . . . or, upon assignment by the applicant . . . to [the] providers of health care services.” Plaintiff Aetna Health Plans is not a “health care provider” under the statute, but rather a health care insurer (see A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co., 101 AD3d 53, 62 [2d Dept 2012] Craig Antell, D.O., P.C. v New York Cent. Mut. Fire Ins. Co., 11 Misc 3d 137[A], 2006 NY Slip Op 50521[U] [App Term, 1st Dept 2006]).

While the No-Fault Law provides a limited window of arbitration between no-fault insurers (see Insurance Law §§ 5105, 5106 [d] Eagle Ins. Co. v ELRAC, Inc., 291 AD2d 272 [1st Dept 2002]), the statutory language does not pertain to a health insurer such as Aetna. Thus, Aetna cannot maintain a claim against defendant under the principle of subrogation (see Health Ins. Plan of Greater N.Y. v Allstate Ins. Co., 2007 NY Slip Op 33925[U] [Sup Ct, NY County 2007]). Nor may Aetna assert a breach of contract claim against Hanover, [*2]since it is not in privity of contract with Hanover, and there has been no showing that it was an intended third-party beneficiary of the contract. Concur—Tom, J.P., Acosta, Freedman and Kapnick, JJ. [Prior Case History: 2013 NY Slip Op 33221(U).]

Cited in this decision

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

A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co. (2012 NY Slip Op 06902) FollowedAn insurer's independent contractor defense is subject to preclusion if not asserted in a timely denial of claim.
Craig Antell, D.O., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 50521(U)) FollowedA billing provider cannot receive assigned no-fault benefits for services performed by an independent contractor rather than itself or its employees.

Cited by

A label shows how the later decision treated this one.

Aetna Health Plans v Hanover Ins. Co. (2016 NY Slip Op 04658) AffirmedA health insurer cannot obtain direct reimbursement from a no-fault insurer as an assignee under 11 NYCRR 65-3.11 (a).
Matter of Fiduciary Ins. Co. v American Bankers Ins. Co. of Florida (2015 NY Slip Op 06343) FollowedAn arbitrator may decide whether a carrier is an insurer subject to mandatory loss-transfer arbitration despite its nonappearance.

Similar decisions

A.B. Med. Servs. PLLC v Nationwide Mut. Ins. Co. (2004 NY Slip Op 24506)The providers' billing manager affidavit failed to establish submission of properly completed claim forms.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 02731)The insurer proved exhaustion of policy limits before it became obligated to pay the provider's claim.
A.B. Med. Servs., PLLC v New York Cent. Mut. Fire Ins. Co. (2009 NY Slip Op 50331(U))The insurer's evidence established a founded belief that the assignors' injuries did not arise from an insured incident.
A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2005 NY Slip Op 25032)An insurer may assert a lack-of-coverage defense despite an untimely denial of no-fault claims.
A.T. Med., P.C. v State Farm Ins. Co. (2008 NY Slip Op 50875(U))The provider's summary judgment motion was barred by an injunction issued in the insurer's separate action against health care providers.