February 14, 2006
PDG Psychological P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50246(U))
https://www.beynensonlaw.com/case-law/pdg-psychological-p-c-v-utica-mut-ins-co-2006-ny-slip-op-50246u/
- Decided
- February 14, 2006
- Citation
- 2006 NY Slip Op 50246(U) · 11 Misc 3d 128(A)
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Later treatment
- Followed in 3 later decisions (see Cited by)
- 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 PDG Psychological P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50246(U))
| PDG Psychological P.C. v Utica Mut. Ins. Co. |
| 2006 NY Slip Op 50246(U) [11 Misc 3d 128(A)] |
| Decided on February 14, 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| This opinion is uncorrected and will not be published in the printed Official Reports.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: 2nd and 11th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., WESTON PATTERSON and BELEN, JJ
2005-508 K C.
against
Utica Mutual Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Kings County (Peter Paul Sweeney, J.), entered February 2, 2005. The order, insofar as appealed from, as limited by the brief, granted plaintiff’s cross motion for summary judgment.
Order, insofar as appealed from, affirmed without costs.
In this action to recover first-party no-fault benefits for health care services rendered to its assignor, defendant moved for summary judgment dismissing the complaint and plaintiff cross-moved for summary judgment. Plaintiff established a prima facie entitlement to summary judgment by proof that it submitted 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]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). Contrary to defendant’s contention, plaintiff was entitled to rely upon defendant’s denial of claim forms which were annexed to defendant’s motion papers to establish the dates of defendant’s receipt of the claim forms (see A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co., 7 Misc 3d 14 [App Term, 2d & 11th Jud Dists 2005]; A.B. Med. Servs. v New York Cent. Mut. Fire Ins. Co., 3 Misc 3d 136[A], 2004 NY Slip Op 50507[U] [App Term, 2d & 11th Jud Dists]). Since defendant failed to establish that it mailed the denial of claim forms to plaintiff within the [*2]prescribed 30-day claim determination period (Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [c]; see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Careplus Med. Supply Inc. v Travelers Home & Mar. Ins. Co., 7 Misc 3d 133[A], 2005 NY Slip Op 50648[U] [App Term, 2d & 11th Jud Dists]; Amaze Med. Supply v Allstate Ins. Co., 3 Misc 3d 133[A], 2004 NY Slip Op 50447[U] [App Term, 2d & 11th Jud Dists]), it is precluded from raising its defenses with
exceptions not herein relevant (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]). As a result, the court properly granted plaintiff’s cross motion for summary judgment.
Pesce, P.J., Weston Patterson and Belen, JJ., concur.
Decision Date: February 14, 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
Rejected the insurer's challenge, holding the provider made its prima facie case because it could rely on the insurer's own denial forms to establish the dates of receipt of the claims.
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 insurer's proof did not establish mailing of its denial, verification request or IME/EUO notice
Held the insurer failed to establish it mailed its denials within the 30-day period, so it was precluded from its defenses.
Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 260 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- 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.
- Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U))A provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
- A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2005 NY Slip Op 25032) FollowedAn insurer may assert a lack-of-coverage defense despite an untimely denial of no-fault claims.
- A.B. Med. Servs. v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50507(U)) FollowedAn insurer opposing summary judgment on medical necessity must submit admissible proof even if unaffirmed reports supported a timely denial.
- Careplus Med. Supply Inc. v Travelers Home & Mar. Ins. Co. (2005 NYSlipOp 50648(U)) FollowedThe insurer failed to establish verification tolling because requests were untimely or unproved and its policy's EUO endorsement was not shown.
- Amaze Med. Supply Inc. v Allstate Ins. Co. (2004 NY Slip Op 50447(U)) FollowedThe provider's signed postal ledger and president's affidavit established mailing, and the insurer failed to raise a triable issue of timely denial.
Cited by
A label shows how the later decision treated this one.
- Prestige Med. & Surgical Supply, Inc. v Clarendon Natl. Ins. Co. (2006 NY Slip Op 51672(U)) FollowedThe insurer's adjuster affidavits failed to establish timely mailing of denials, precluding its defenses.
- Starrett Med. L.C.P.C. v GEICO Cas. Ins. Co. (2006 NY Slip Op 52493(U)) FollowedThe insurer was precluded from asserting medical necessity because its denials lacked factual grounds and timely delivery of peer reviews was unproved.
- Magnezit Med. Care, P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 52515(U)) FollowedThe provider failed to prove claim submission because its mailing evidence and the insurer's claim acknowledgments were insufficient.
- Oleg Barshay, D.C., P.C. v State Farm Ins. Co. (2006 NY Slip Op 26496)A provider's deficient proof of claim submission may be cured by an insurer's denial form submitted in opposition to summary judgment.
- Bath Med. Supply, Inc. v Allstate Indem. Co. (2006 NY Slip Op 52273(U))The insurer's mailing affidavit was inadmissible under CPLR 2309 (c), precluding its medical-necessity defense for lack of timely denial proof.
- New York Craniofacial Care, P.C. v Allstate Ins. Co. (2006 NY Slip Op 50500(U))A provider seeking summary judgment on overdue claims must address whether those claims were timely and validly denied.
- Mid Atl. Med. P.C. v GEICO (2007 NY Slip Op 50014(U))The insurer established a timely verification request and denial, preserving a medical-necessity defense that raised a triable issue.
- Boai Zhong Yi Acupuncture Servs. P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 26485)A medical-necessity denial must state its factual basis and medical rationale; merely referring to a peer review or IME report is insufficient.
- Delta Diagnostic Radiology, P.C. v Allstate Ins. Co. (2006 NY Slip Op 52034(U))The insurer failed to prove timely mailing of its denial and was precluded from asserting lack of medical necessity.
Similar decisions
- Five Boro Psychological Servs., P.C. v Utica Mut. Ins. Co. (2011 NY Slip Op 51119(U))The insurer established that one claim was premature for unanswered verification and two others lacked medical necessity.
- PDG Psychological, P.C. v Lumbermans Mut. Cas. Co. (2007 NY Slip Op 51343(U))The insurer failed to prove timely mailing of its denial and was precluded from asserting lack of medical necessity.
- Five Boro Psychological Servs., P.C. v Progressive Northeastern Ins. Co. (2011 NY Slip Op 51528(U))A denial form offered to show that a claim was denied, rather than to prove its contents, needs no CPLR 4518 business-record foundation.
- PDG Psychological, P.C. v State Farm Mut. Ins. Co. (2007 NY Slip Op 51757(U))The insurer's unrefuted need for discovery on licensing defeated the provider's summary judgment motion.
- PDG Psychological P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 51432(U))The provider obtained summary judgment on one claim because the insurer failed to prove timely denial; two claims lacked submission proof.