March 3, 2011

Quality Health Prods. v Country-Wide Ins. Co. (2011 NY Slip Op 50328(U))

https://www.beynensonlaw.com/case-law/quality-health-prods-v-country-wide-ins-co-2011-ny-slip-op-50328u/

Court: Appellate Term, Second Department
Decided: March 3, 2011
Citation: 2011 NY Slip Op 50328(U) · 30 Misc 3d 143
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Provider's prima facie case Timeliness and preclusion
Legal questions: Claimant's prima facie case on motions (see the maps)

Cite as

Quality Health Prods. v Country-Wide Ins. Co., 30 Misc 3d 143 (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011)

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 failed to establish that its unpaid claim was denied late or that the denial's basis lacked legal merit. Its summary judgment papers included only part of the denial form, omitting both the denial date and the stated reason. The provider's affiant also did not identify when the denial was received. Proof of nonpayment alone therefore did not establish prima facie entitlement: the provider showed neither a denial outside 30 days nor a conclusory, vague, or legally meritless basis. The Appellate Term, Second Department, affirmed denial of the provider's motion on a different ground and did not consider the sufficiency of the insurer's opposition.

Reported in New York Official Reports at Quality Health Prods. v Country-Wide Ins. Co. (2011 NY Slip Op 50328(U))

[*1]

Quality Health Prods. v Country-Wide Ins. Co.

2011 NY Slip Op 50328(U) [30 Misc 3d 143]

Decided on March 3, 2011

Appellate Term, Second Department

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

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on March 3, 2011

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., GOLIA and STEINHARDT, JJ
2009-1770 K C.

Quality Health Products as Assignee of Darek Rudnik, Appellant,
against
COUNTRY-WIDE INS. CO., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Noach Dear, J.), entered June 3, 2009. The order denied plaintiff’s motion for summary judgment.

ORDERED that the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant opposed plaintiff’s motion for summary judgment, arguing that it had timely denied plaintiff’s claims on the ground of lack of medical necessity based upon a peer review report. The Civil Court denied plaintiff’s motion. This appeal by plaintiff ensued.

Plaintiff established that defendant did not pay plaintiff’s claim. However, plaintiff failed to establish that the claim was not denied within 30 days (see New York & Presbyt. Hosp. v Allstate Ins. Co., 31 AD3d 512 [2006]; see also Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]). Plaintiff attached a copy of a portion of defendant’s denial of claim form to its motion papers, but this copy did not establish that defendant did not deny the claim within 30 days, since the date of the denial of claim form was not contained in the portion of the form annexed to plaintiff’s papers. Moreover, plaintiff’s affiant did not provide the date on which the denial of claim form was received by plaintiff. Furthermore, the reason for defendant’s denial of the claim was also not included in the annexed portion of the form. As plaintiff failed to show that the claim was not denied within 30 days or that the basis for the denial was conclusory, vague or had no merit as a matter of law, it failed to make a prima facie showing of its entitlement to judgment as a matter of law (see Westchester Med. Ctr., 78 AD3d 1168). As a result, we need not consider the sufficiency of defendant’s paper’s submitted in opposition to the motion (see Westchester Med. Ctr., 78 AD3d 1168). Accordingly, the [*2]
order denying plaintiff’s motion for summary judgment is affirmed, albeit on a different ground.

Pesce, P.J., Golia and Steinhardt, JJ., concur.
Decision Date: March 03, 2011

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

Held the provider failed its prima facie showing because the annexed portion of the insurer's denial form omitted its date and stated reason and the affiant gave no receipt date, so it did not show the claim went undenied for 30 days.

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

Cited in this decision

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

New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 05602)The insurer proved a timely denial but failed to establish that the provider's treatment was unrelated to the accident.
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.

Cited by

Jae Ook Park v GEICO Gen. Ins. Co. (2011 NY Slip Op 52379(U))The provider failed to establish its prima facie case because it did not show an untimely or legally insufficient denial.

Similar decisions

Quality Custom Med. Supply, Inc. v American Country Ins. Co. (2019 NY Slip Op 51165(U))The insurer's peer review established lack of medical necessity, and the provider submitted no medical evidence rebutting its conclusions.
Quality Health Prods., Inc. v Auto One Ins. Co. (2008 NY Slip Op 51530(U))The insurer failed to establish continued EUO tolling after receiving verification, rendering its denial untimely and precluding fraudulent billing.
New Quality Med., P.C. v Allstate Ins. Co. (2016 NY Slip Op 50871(U))The insurer failed to raise a triable issue as to timely denial of the provider's no-fault claim.
Healthway Med. Care, P.C. v Country Wide Ins. Co. (2015 NY Slip Op 51654(U))The insurer established late notice of the accident, and the provider offered no proof of timely notice or a reasonable justification.
Quality Psychological Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50063(U))The insurer's psychologist's peer review was inadmissible, and the provider failed to establish entitlement to summary judgment.