October 5, 2006
Delta Diagnostic Radiology, P.C. v Allstate Ins. Co. (2006 NY Slip Op 52034(U))
https://www.beynensonlaw.com/case-law/delta-diagnostic-radiology-p-c-v-allstate-ins-co-2006-ny-slip-op-52034u/
- Decided
- October 5, 2006
- Citation
- 2006 NY Slip Op 52034(U) · 13 Misc 3d 135(A)
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Legal questions
- Claimant's prima facie case on motions · Proof of mailing (see the maps)
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 Delta Diagnostic Radiology, P.C. v Allstate Ins. Co. (2006 NY Slip Op 52034(U))
| Delta Diagnostic Radiology, P.C. v Allstate Ins. Co. |
| 2006 NY Slip Op 52034(U) [13 Misc 3d 135(A)] |
| Decided on October 5, 2006 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS
PRESENT: : RUDOLPH, P.J., McCABE and LIPPMAN, JJ
2005-1831 N C.
against
Allstate Insurance Co., Respondent.
Appeal from an order of the District Court of Nassau County, Third District (Sondra K. Pardes, J.), dated August 30, 2005. The order denied plaintiff’s motion for summary judgment.
Order reversed without costs, plaintiff’s motion for summary judgment granted and matter remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees.
In this action to recover first-party no-fault benefits for medical services rendered to its assignor, plaintiff established a prima facie entitlement to summary judgment by
proof that it submitted the claims, setting forth the fact and the amounts of the losses sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86 [App Term, 2d & 11th Jud Dists 2004]; Damadian MRI in Elmhurst v Liberty Mut. Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51700[U] [App Term, 9th & 10th Jud Dists]). Annexed to plaintiff’s moving papers was defendant’s explanation of benefits form which indicated the date on which the claim was received, thereby adequately establishing that plaintiff sent, and that defendant received, the claim (see Ultra Diagnostics Imaging v Liberty Mut. Ins. Co., 9 Misc 3d 97 [App Term, 9th & 10th Jud Dists 2005]; Capio [*2]Med., P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 129[A], 2005 NY Slip Op 50526[U] [App Term, 2d & 11th Jud Dists]). Thus, the burden shifted to defendant to raise a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]; Modern Psychiatric Servs. P.C. v Progressive Ins. Co., 10 Misc 3d 145[A], 2006 NY Slip Op 50143[U] [App Term, 9th & 10th Jud Dists]).
Because defendant failed to establish that it mailed a timely denial of claim form to plaintiff (see 11 NYCRR 65-3.8 [c]), it is precluded from raising the proffered defense of lack of medical necessity (see PDG Psychological P.C. v Utica Mut. Ins. Co., 11 Misc 3d 128[A], 2006 NY Slip Op 50246[U] [App Term, 2d & 11th Jud Dists]; Modern Psychiatric Servs. P.C. v Progressive Ins. Co., 10 Misc 3d 145[A], 2006 NY Slip Op 50143[U], supra). As a result, plaintiff’s motion for summary judgment should have been granted. Accordingly, the matter is remanded to the court below for a calculation of the statutory interest and an assessment of attorney’s fees pursuant to Insurance Law § 5106 and the regulations promulgated thereunder.
Rudolph, P.J., McCabe and Lippman, JJ., concur.
Decision Date: October 5, 2006
Legal questions (2)
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.
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 established its prima facie case because the insurer's explanation of benefits form, giving the date the claim was received, showed submission and receipt.
Of the 1,063 decisions on this question in the Second Department courts and the Court of Appeals, 511 (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: Different mailing results for different documents or claims in one decision
Held the insurer's explanation of benefits, stating the date of receipt, established that the provider sent the claim, while the insurer failed to establish that it mailed a timely denial, so it was precluded.
Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 55 (this one included) are in the same category.
Cited in this decision
- Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359)The hospitals established entitlement to summary judgment by proving that statutory billing forms were mailed and received and payment was overdue.
- A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co. (2004 NY Slip Op 24194)An insurer's timely medical-necessity denial does not replace admissible proof opposing a provider's summary judgment motion.
- Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U))A provider need not submit additional medical-necessity evidence to obtain summary judgment when the insurer is precluded from that defense.
- Ultra Diagnostics Imaging v Liberty Mut. Ins. Co. (2005 NY Slip Op 25402)The insurer's wage-verification fraud allegations failed to establish a lack-of-coverage defense exempt from untimely-denial preclusion.
- Capio Med., P.C. v Progressive Cas. Ins. Co. (2005 NYSlipOp 50526(U))The insurer's EUO requests did not toll the denial period because it failed to prove an authorizing endorsement or timely requests.
- Modern Psychiatric Servs. P.C. v Progressive Ins. Co. (2006 NY Slip Op 50143(U))The insurer failed to prove timely mailing of verification requests and therefore failed to establish a toll of the claim determination period.
- PDG Psychological P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50246(U))A provider may rely on denial forms annexed to an insurer's motion to establish the insurer's receipt of the claims.
Similar decisions
- Delta Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51557(U))The insurer's timely denials and reasoned peer reviews raised triable issues of medical necessity.
- Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 50293(U))The insurer failed to establish timely denials because it mailed them more than 30 days after receiving the claims without proving tolling.
- Delta Diagnostic Radiology, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 51345(U))The insurer's investigator affidavit raised a coverage issue concerning an alleged fraud scheme, but neither side was entitled to summary judgment.
- Delta Diagnostic Radiology, P.C. v Republic W. Ins. Co. (2007 NY Slip Op 27088)The insurer failed to prove timely mailing of its denials and was precluded from asserting lack of medical necessity on three claims.
- Delta Diagnostic Radiology, P.C. v American Mfrs. Mut. Ins. Co. (2006 NY Slip Op 51439(U))The insurer raised a triable issue of medical necessity through detailed peer reviews and timely denials following verification.