June 30, 2009

West Tremont Med. Diagnostics P.C. v Utica Mut. Ins. Co. (2009 NY Slip Op 51325(U))

https://www.beynensonlaw.com/case-law/west-tremont-med-diagnostics-p-c-v-utica-mut-ins-co-2009-ny-slip-op51325u/

Court: Appellate Term, First Department
Decided: June 30, 2009
Citation: 2009 NY Slip Op 51325(U) · 24 Misc 3d 129(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Staged accidents, lack of coverage Timeliness and preclusion Policy issues
Legal questions: No covered accident (founded belief) (see the maps)

Cite as

West Tremont Med. Diagnostics P.C. v Utica Mut. Ins. Co., 24 Misc 3d 129(A), 2009 NY Slip Op 51325(U) (App Term, 1st Dept 2009)

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 insurer failed to establish a founded belief supporting its staged-accident defense, and its policy-exclusion defense was precluded. The Appellate Term, First Department, affirmed the order granting the provider summary judgment for first-party no-fault benefits. Under Central Gen. Hosp. v Chubb Group of Ins. Cos., the insurer's submission did not establish a founded belief that the alleged injury did not arise from an insured incident. Any policy-exclusion defense was precluded because the insurer failed to deny the claims timely.

Reported in New York Official Reports at West Tremont Med. Diagnostics P.C. v Utica Mut. Ins. Co. (2009 NY Slip Op 51325(U))

[*1]

West Tremont Med. Diagnostics P.C. v Utica Mut. Ins. Co.

2009 NY Slip Op 51325(U) [24 Misc 3d 129(A)]

Decided on June 30, 2009

Appellate Term, First 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This opinion is uncorrected and will not be published in the printed Official Reports.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 June 30, 2009

APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT

PRESENT: McKeon, P.J., Heitler, Shulman, JJ
570034/09.,

West Tremont Medical Diagnostics P.C. a/a/o Jesus Rodriguez, Plaintiff-Respondent,
against
Utica Mutual Insurance Company, Defendant-Appellant.

Defendant appeals from an order of the Civil Court of the City of New York, Bronx County (Mitchell J. Danziger, J.), entered February 9, 2007, which granted plaintiff’s motion for summary judgment.

Per Curiam.

Order (Mitchell J. Danziger, J.), entered February 9, 2007, affirmed, without costs.

In this action to recover first party no-fault benefits, defendant’s submission in support of its staged accident defense was insufficient to establish a “founded belief that the alleged injury [did] not arise out of an insured incident” (Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]; see Vista Surgical Supplies, Inc. v Utica Mut. Ins. Co., 2009 NY Slip Op 50493[U] [2009]). To the extent that defendant purports to rely upon a policy exclusion, any such defense is precluded in view of defendant’s failure to timely deny the claims (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d at 199).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
Decision Date: June 30, 2009

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.

No covered accident (founded belief)

Open the full map

Did the insurer show the claimed injuries did not arise from a covered accident (staged, intentional, or unrelated)?

This decision: Insurer's proof did not raise an issue or failed at trial; provider prevails on it

Affirmed summary judgment for the provider because the insurer's submission on its staged-accident defense was insufficient to establish even a founded belief that the injury did not arise from an insured incident.

Defense establishedTriable issueInsurer's motion failsDefense not shownThis decision

Of the 29 decisions on this question in the First Department courts and the Court of Appeals, 7 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Cited in this decision

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

Vista Surgical Supplies, Inc. v Utica Mut. Ins. Co. (2009 NY Slip Op 50493(U)) FollowedThe insurer's evidence failed to establish a founded belief that the assignor's injuries arose from a staged accident.

Similar decisions

Inwood Hill Med. P.C. v Utica Mut. Ins. Co. (2007 NY Slip Op 51309(U))The insurer's late denials precluded its statutory, policy-condition, exclusion, and fraudulent-billing defenses.
Amaze Med. Supply, Inc. v Utica Mut. Ins. Co. (2009 NY Slip Op 52690(U))The insurer's submissions supported a founded belief that the alleged injuries did not arise out of an insured incident.
A.B. Med. Servs., PLLC v Utica Mut. Ins. Co. (2008 NY Slip Op 51859(U))The insurer's investigators established a founded belief that the assignor's injuries did not arise from an insured incident.
Advanced Med., P.C. v Utica Mut. Ins. Co. (2009 NY Slip Op 51023(U))The insurer supported a founded belief that the injuries did not arise from an insured incident despite failing to prove timely denials.
A.B. Chiropractic, P.C. v Utica Mut. Ins. Co. (2009 NY Slip Op 51022(U))The insurer raised a factual issue by supporting a founded belief that the assignor's alleged injuries did not arise from an insured incident.