February 5, 2014

Westchester Med. Ctr. v Allstate Ins. Co. (2014 NY Slip Op 00655)

https://www.beynensonlaw.com/case-law/westchester-med-ctr-v-allstate-ins-co-2014-ny-slip-op-00655/

Court: Appellate Division, Second Department
Decided: February 5, 2014
Citation: 2014 NY Slip Op 00655 · 114 AD3d 672
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Timeliness and preclusion Verification requests Provider's prima facie case
Legal questions: Claimant's prima facie case on motions (see the maps)

Cite as

Westchester Med. Ctr. v Allstate Ins. Co., 114 AD3d 672 (2d 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.

The provider obtained summary judgment because neither the insurer's asserted verification request nor its denial was sent within 30 days. The provider submitted sufficient evidence that the prescribed billing form was mailed to and received by the insurer and that payment was overdue under Insurance Law § 5106 (a) and 11 NYCRR 65-3.8 (a) (1) and (c). The insurer acknowledged receipt on November 4, but its purported verification letter was dated December 6 and its denial December 20. Those submissions raised no triable issue concerning timely handling of the claim. Applying 11 NYCRR 65-3.5 (b), the Appellate Division, Second Department, reversed the order denying the provider's motion and granted summary judgment on the complaint.

Reported in New York Official Reports at Westchester Med. Ctr. v Allstate Ins. Co. (2014 NY Slip Op 00655)

Westchester Med. Ctr. v Allstate Ins. Co.

2014 NY Slip Op 00655 [114 AD3d 672]

February 5, 2014

Appellate Division, Second Department

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

As corrected through Wednesday, March 26, 2014

Westchester Medical Center, as Assignee of Christine Tachaud, Appellant,
v
Allstate Insurance Company, Respondent.

—[*1] Joseph Henig, P.C., Bellmore, N.Y., for appellant.

McDonnell & Adels, PLLC, Garden City, N.Y. (Jannine A. Gordineer of counsel), for respondent.

In an action to recover no-fault benefits under a policy of automobile insurance, the plaintiff appeals from an order of the Supreme Court, Nassau County (Mahon, J.) dated September 6, 2012, which denied its motion for summary judgment on the complaint.

Ordered that the order is reversed, on the law, with costs, and the plaintiff’s motion for summary judgment on the complaint is granted.

The plaintiff made a prima facie showing of its entitlement to judgment as a matter of law by “demonstrating that the necessary billing documents were mailed to, and received by, [the defendant insurer] and that payment of no-fault benefits was overdue” (Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 106 AD3d 157, 164-165 [2013]; see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [a] [1]; [c]; Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33 [2d Dept 2013]), since “the prescribed statutory billing form had been mailed to and received by the defendant insurer, which failed either to pay or deny the claim within the requisite 30-day period” (Westchester Med. Ctr. v Hereford Ins. Co., 95 AD3d 1306, 1306 [2012]; see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33 [2013]). Contrary to the defendant’s contention, the papers submitted in support of the plaintiff’s motion were in sufficient evidentiary form to warrant the granting of summary judgment in favor of the plaintiff (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33 [2013]).

In opposition, the defendant failed to raise a triable issue of fact. The defendant acknowledged that it received the billing form on November 4, 2011. Neither the letter that the defendant describes as a request for a verification, dated December 6, 2011, nor its later denial of claim form dated December 20, 2011, was sent within the 30-day post-receipt-of-claim period (see id.; Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 106 AD3d at 164; see also 11 NYCRR 65-3.5 [b]; Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294, 300-301 [2007]).

Accordingly, the Supreme Court should have granted the plaintiff’s motion for summary judgment on the complaint. Mastro, J.P., Dickerson, Chambers and Roman, JJ., concur.

Legal questions

A question 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 showed its billing documents were mailed to and received by the insurer and payment was overdue, rejecting the insurer's argument that its papers were not in sufficient evidentiary form.

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

Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (this one included) are in the same category.

Cited in this decision

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

Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 02390) FollowedThe hospital's UB-04 form was not the functional equivalent of an NF-5 and did not support tolling before receipt of the NF-5.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430) FollowedA provider need not prove a claim's merits for summary judgment where the insurer failed to timely and properly deny the claim.
Westchester Med. Ctr. v Hereford Ins. Co. (2012 NY Slip Op 04156) FollowedThe provider proved mailing and receipt of its bill and the insurer's failure to pay or deny within 30 days; the insurer failed to raise a triable issue.

Cited by

A label shows how the later decision treated this one.

Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 05779) FollowedThe insurer's denial of a defective UB-04 submission did not excuse its failure to respond to the hospital's later NF-5 claim.

Similar decisions

Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 01319)The insurer raised a factual issue as to whether it mailed a proper denial 22 days after receiving requested verification.
New York Hosp. Med. Ctr. of Queens v Allstate Ins. Co. (2014 NY Slip Op 00640)The providers established receipt of their claim and nonpayment or improper denial within 30 days, warranting summary judgment.
Westchester Med. Ctr. v Lancer Ins. Co. (2012 NY Slip Op 02867)The insurer defeated the provider's summary judgment motion by proving timely verification requests and denial after verification was received.
Westchester Med. Ctr. v Country Wide Ins. Co. (2011 NY Slip Op 03838)The insurer raised a triable issue as to whether the hospital fully complied with its verification demand.
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.