April 3, 2008
Countrywide Ins. Co. v 563 Grand Med., P.C. (2008 NY Slip Op 03059)
https://www.beynensonlaw.com/case-law/countrywide-ins-co-v-563-grand-med-p-c-2008-ny-slip-op-03059/
- Decided
- April 3, 2008
- Citation
- 2008 NY Slip Op 03059 · 50 AD3d 313
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Later treatment
- Followed in 4 later decisions (see Cited by)
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 Countrywide Ins. Co. v 563 Grand Med., P.C. (2008 NY Slip Op 03059)
| Countrywide Ins. Co. v 563 Grand Med., P.C. |
| 2008 NY Slip Op 03059 [50 AD3d 313] |
| April 3, 2008 |
| Appellate Division, First Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| Countrywide Insurance Company, Appellant, v 563 Grand Medical, P.C., as Assignee of Robert Alford, Respondent. |
—[*1] Thomas Torto, New York (Jason Levine of counsel), for appellant.
Gary Tsirelman, Brooklyn, for respondent.
Judgment, Supreme Court, New York County (Helen E. Freedman, J.), entered January 30, 2007, awarding defendant the principal sum of $12,638.96, and bringing up for review an order, same court and Justice, entered May 25, 2006, which granted defendant’s motion for summary judgment on its claim for first-party no-fault insurance benefits, and an order, same court and Justice, entered May 30, 2006, which in effect granted plaintiff’s motion for reargument and, upon reargument, adhered to its prior determination, unanimously reversed, on the law, without costs, the judgment vacated, and defendant’s motion for summary judgment denied. Appeal from the order entered May 30, 2006 unanimously dismissed, without costs, as subsumed in the appeal from the judgment.
Defendant medical provider established prima facie its entitlement to judgment as a matter of law by demonstrating that the necessary billing documents were mailed to and received by plaintiff insurer and that payment of the no-fault benefits was overdue (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [a] [1]; New York & Presbyt. Hosp. v Countrywide Ins. Co., 44 AD3d 729, 730 [2007]). However, in opposition to the motion, plaintiff raised a triable issue of fact whether the claimed benefits were properly denied for lack of medical justification. Plaintiff was not required to set forth the medical rationale in the prescribed denial of claim form (see A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779 [2007]). Nor is a nurse’s review denying no-fault claims for lack of medical necessity per se invalid (see Channel Chiropractic, P.C. v Country-Wide Ins. Co., 38 AD3d 294, 295 [2007]). [*2]
Plaintiff waived its objection to defendant’s standing (see Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 320 [2007]). Concur—Saxe, J.P., Sweeny, McGuire and Acosta, JJ.
Legal questions (3)
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 the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?
This decision: Insurer's proof was enough to defeat the provider's motion but not to win
Held the insurer raised a triable issue whether the benefits were properly denied for lack of medical justification, noting a nurse's review is not per se invalid, so the provider's summary judgment was vacated.
Of the 73 decisions on this question in the First Department courts and the Court of Appeals, 7 (this one included) are in the same category. 2 decisions in other departments that cite or are cited by this one are on 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 (rules on the question, but another ground decided the case)
Held the provider established its prima facie case by showing the billing documents were mailed to and received by the insurer and payment was overdue, but summary judgment failed because the insurer raised a triable issue.
Of the 52 decisions on this question in the First Department courts and the Court of Appeals, 45 (this one included) are in the same category. 4 decisions in other departments that cite or are cited by this one are on the full map.
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 (rules on the question, but another ground decided the case)
Held in one sentence, citing Hospital for Joint Diseases, that the insurer had waived its objection to the provider-assignee's standing; the judgment was nonetheless reversed because a triable issue existed on medical necessity.
Of the 12 decisions on this question in the First Department courts and the Court of Appeals, 9 (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 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.
- A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. (2007 NY Slip Op 03636) FollowedAn insurer denying no-fault benefits for lack of medical justification need not include a medical rationale in the prescribed denial form.
- Channel Chiropractic, P.C. v Country-Wide Ins. Co. (2007 NY Slip Op 01973) FollowedA nurse's peer review denying no-fault benefits for lack of medical necessity is not per se invalid.
- Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067) FollowedAn 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.
- Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co. (2009 NY Slip Op 06984) FollowedThe insurer's medical-necessity denials raised a triable issue, and severance was proper for claims arising from 14 unrelated accidents.
- Meridan Health Acupuncture, P.C. v Auto One Ins. Co. (2010 NY Slip Op 51263(U)) FollowedAn insurer's blanket objections to a notice to admit constituted admissions establishing the provider's prima facie case at trial.
- NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U)) FollowedThe insurer failed to raise a medical necessity issue because it submitted neither the IME report supporting its denial nor other evidence.
- Tutto Anesthesia v American Country Ins. Co. (2015 NY Slip Op 50738(U)) FollowedThe insurer's own date-stamped claim forms established receipt and overdue payment of the providers' no-fault claims.
- Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2015 NY Slip Op 04787)A provider establishes entitlement to summary judgment on overdue no-fault claims with admissible proof of mailing and receipt of statutory claim forms.
- 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.
Similar decisions
- 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.
- 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.
- 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.
- NY Comprehensive Med., P.C. v Maryland Cas. Co. (2008 NY Slip Op 50521(U))The provider's summary judgment cross motion failed because conflicting medical affirmations raised a triable issue of medical necessity.
- 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.