March 1, 2011
New York Hosp. Med. Ctr. of Queens v Country Wide Ins. Co. (2011 NY Slip Op 01628)
https://www.beynensonlaw.com/case-law/new-york-hosp-med-ctr-of-queens-v-country-wide-ins-co-2011-ny-slip-op01628/
- Decided
- March 1, 2011
- Citation
- 2011 NY Slip Op 01628 · 82 AD3d 723
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Later treatment
- Distinguished in 1 later decision (see Cited by)
- Issues
- Verification requests
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.
Reported in New York Official Reports at New York Hosp. Med. Ctr. of Queens v Country Wide Ins. Co. (2011 NY Slip Op 01628)
| New York Hosp. Med. Ctr. of Queens v Country Wide Ins. Co. |
| 2011 NY Slip Op 01628 [82 AD3d 723] |
| March 1, 2011 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| New York Hospital Medical Center of Queens, as Assignee of
Brian Quintero, et al., Appellants, v Country Wide Insurance Company, Respondent. |
—[*1] Joseph Henig, P.C., Bellmore, N.Y., for appellants.
Jaffe & Koumourdas, LLP, New York, N.Y. (Jean H. Kang of counsel), for respondent.
In an action to recover assigned first-party no-fault benefits for medical services rendered, the plaintiffs appeal, as limited by their brief, from so much of an order of the Supreme Court, Nassau County (Murphy, J.), entered July 14, 2010, as denied that branch of their motion which was for summary judgment on the first cause of action.
Ordered that the order is reversed insofar as appealed from, on the law, with one bill of costs payable to the plaintiff New York Hospital Medical Center of Queens, and that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action is granted.
The plaintiffs established their prima facie entitlement to judgment as a matter of law on the first cause of action by submitting, inter alia, the requisite billing forms, the affidavits from its third-party biller, the certified mail receipts, and the signed return-receipt card referencing the patient and the forms, which demonstrated that the plaintiff New York Hospital Medical Center of Queens (hereinafter the plaintiff) mailed the necessary billing documents to the defendant, that the defendant received them, and that the payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [a] [1]; Westchester Med. Ctr. v GMAC Ins. Co. Online, Inc., 80 AD3d 603 [2011]; Westchester Med. Ctr. v Countrywide Ins. Co., 45 AD3d 676 [2007]; New York & Presbyt. Hosp. v Countrywide Ins. Co., 44 AD3d 729, 730 [2007]; Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 34 AD3d 532 [2006], affd 9 NY3d 312 [2007]).
In opposition, the defendant failed to raise a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]). The defendant’s verification requests, dated April 22, 2008, and May 22, 2008, respectively, requested “Rev. 01/04 NF5 & Assignment of Benefit Forms signed (No Stamps).” The plaintiff responded by providing exactly what was requested of it. The defendant cannot now complain that the NF5 or the assignment of benefits forms provided by the plaintiff were “outdated,” as its verification requests only sought the January 2004 version of the NF5 form and its accompanying assignment. Contrary to the Supreme Court’s conclusion, the affidavit of the defendant’s representative was insufficient to raise a triable issue of fact, as the plaintiff’s documented responses demonstrate that it [*2]complied with the defendant’s verification requests.
The defendant’s remaining contentions are without merit.
Accordingly, the Supreme Court should have granted that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action. Dillon, J.P., Covello, Florio and Hall, JJ., concur.
Legal questions (4)
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.
Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?
This decision: Defense rejected because the provider supplied the verification or justified noncompliance
Held the hospital complied with the verification requests by supplying exactly the forms requested, so the insurer could not object that they were outdated and raised no triable issue.
Of the 385 decisions on this question in the Second Department courts and the Court of Appeals, 9 (this one included) are in the same category.
Could the insurer contest the validity of the provider’s assignment of benefits, or had it waived that defense?
This decision: Insurer barred from contesting the assignment because it did not timely object, verify, deny or plead on that ground
Held the insurer could not object that the NF-5 and assignment of benefits forms supplied were outdated, because its verification requests sought exactly those January 2004 forms and the hospital provided what was requested.
Of the 96 decisions on this question in the Second Department courts and the Court of Appeals, 48 (this one included) are in the same category.
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 (rules on the question, but another ground decided the case)
Held the hospital established its prima facie case through billing forms, biller affidavits, certified mail receipts and a signed return-receipt card showing mailing, receipt and overdue payment.
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.
Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?
This decision: The provider's or claimant's proof established mailing of its claim form, NF-2 or verification response (rules on the question, but another ground decided the case)
Held the certified mail receipts and signed return-receipt card referencing the patient and forms, with the biller's affidavits, showed the hospital mailed the bills and the insurer received them.
Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 106 (this one included) are in the same category.
Cited in this decision
- Westchester Med. Ctr. v GMAC Ins. Co. Online, Inc. (2011 NY Slip Op 00217)The insurers' verification letters failed to toll the payment period, and their untimely denial precluded the residence-misrepresentation defense.
- Westchester Med. Ctr. v Countrywide Ins. Co. (2007 NY Slip Op 09024)The insurer failed to prove mailing of verification requests and waived defenses based on incomplete assignment forms.
- New York & Presbyt. Hosp. v Countrywide Ins. Co. (2007 NY Slip Op 07675)The insurer raised verification and billing-date issues on one claim, but failed to rebut proof of receipt of verification on another.
- Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2006 NY Slip Op 08214)An insurer waives claim-form and assignment defenses by failing to timely object to form adequacy or seek assignment verification.
- Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067)An insurer that fails to timely seek verification of an assignment cannot later contest its validity when the underlying claim is covered.
Cited by
A label shows how the later decision treated this one.
- Lenox Hill Hosp. v Allstate Ins. Co. (2011 NY Slip Op 50800(U)) DistinguishedThe hospitals failed to establish that their billing documents were business records and were denied summary judgment.
- 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.
- Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 02390)The 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.
- NYU Hosp. for Joint Diseases v Country Wide Ins. Co. (2011 NY Slip Op 04219)The insurer's denial was fatally defective because it omitted required information and named the assignor as the benefits applicant.
- Dynamic Med. Imaging, P.C. v State Farm Fire & Cas. Co. (2011 NY Slip Op 21210)EUO notices alone do not conclusively establish a nonappearance defense for dismissal under CPLR 3211 (a) (1).
Similar decisions
- Wyckoff Hgts. Med. Ctr. v Country-Wide Ins. Co. (2010 NY Slip Op 02552)The hospital's completed NF-5 submitted within 45 days after services satisfied the policy's written notice requirement.
- 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.
- New York Hosp. Med. Ctr. of Queens v Statewide Ins. Co. (2011 NY Slip Op 51863(U))The hospital's third-party affidavit failed to establish its claim forms as business records proving the services rendered.
- 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.
- Hospital for Joint Diseases v Countrywide Ins. Co. (2004 NY Slip Op 06513)The insurer raised factual issues over when the providers mailed their claims and whether earlier denials properly disposed of them.