October 20, 2005
Corona Med. Imaging, P.C. v State Farm Ins. Cos. (2005 NY Slip Op 51685(U))
https://www.beynensonlaw.com/case-law/corona-med-imaging-p-c-v-state-farm-ins-cos-2005-ny-slip-op-51685u/
- Decided
- October 20, 2005
- Citation
- 2005 NY Slip Op 51685(U) · 9 Misc 3d 135(A)
- Posture
- Summary judgment
- Outcome
- Split result
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 Corona Med. Imaging, P.C. v State Farm Ins. Cos. (2005 NY Slip Op 51685(U))
| Corona Med. Imaging, P.C. v State Farm Ins. Cos. |
| 2005 NY Slip Op 51685(U) [9 Misc 3d 135(A)] |
| Decided on October 20, 2005 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports.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., ANGIOLILLO and McCABE, JJ.
2004-1770 N C
against
STATE FARM INSURANCE COMPANIES, Appellant.
Appeal from an order of the District Court of Nassau County, First District (Francis D. Ricigliano, J.), entered October 1, 2004. The order, insofar as appealed from, granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment.
Order unanimously modified by denying plaintiff’s motion for summary judgment; as so modified, affirmed with $10 costs.
In this action to recover first-party no-fault benefits for medical services rendered to its assignor, plaintiff health care provider established its prima facie entitlement to summary judgment by proof that it submitted a claim, setting forth the fact and the
amount of the loss 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]; 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]). Inasmuch as defendant herein failed to pay or deny the claim within the 30-day prescribed period (11 NYCRR 65-3.8 [c]), it was precluded from raising most defenses (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]). Defendant was not, however, precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, despite the untimely denial of the claim (see Matter of Metro Med. Diagnostics v Eagle Ins. Co., 293 AD2d 751 [2002]). Contrary to the finding of the [*2]court below, the affidavit of defendant’s special investigator, which, inter alia, revealed numerous discrepancies in the examinations under oath of plaintiff’s assignor and defendant’s insured as to the circumstances surrounding the accident, was sufficient to demonstrate that said defense was based upon a “founded belief that the alleged injur[ies] do[] not arise out of an insured incident” (Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]). Accordingly, since defendant raised a triable issue of fact as to whether there was a lack of coverage (see Zuckerman v City of New York, 49 NY2d 557 [1980]), the court below erred in granting plaintiff’s motion for summary judgment.
Decision Date: October 20, 2005
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.
Did the insurer show the claimed injuries did not arise from a covered accident (staged, intentional, or unrelated)?
This decision: Founded belief shown; the question must be tried
Held the special investigator's affidavit revealing numerous discrepancies in the assignor's and insured's EUO accounts of the accident sufficient to show a founded belief of a fraudulent collision, raising a triable issue that defeated the provider's motion.
Of the 233 decisions on this question in the Second Department courts and the Court of Appeals, 102 (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 provider established its prima facie entitlement by proof that it submitted a claim stating the fact and amount of loss and that payment was overdue.
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.
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.
- 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.
Similar decisions
- Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2005 NYSlipOp 50535(U))The insurer's fraud evidence raised a coverage issue but did not establish lack of coverage as a matter of law.
- Ocean Diagnostic Imaging, P.C. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51624(U))An insurer's untimely denial does not preclude a defense that the collision furthered an insurance fraud scheme.
- GPM Chiropractic, P.C. v State Farm Mut. Ins. Co (2005 NYSlipOp 50861(U))The insurer's investigator affidavit raised a triable staged-collision coverage issue despite an untimely denial.
- A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51432(U))The insurer's investigator raised a triable coverage issue based on a founded belief that the collision furthered an insurance fraud scheme.
- New Century Chiropractic, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 52236(U))The insurer's investigator established a founded belief that the injuries did not arise from an insured incident, raising a coverage issue.