Medical Imaging of Bronx, P.C., Inc. v MVAIC (2026 NY Slip Op 26160)

Reported in New York Official Reports at Medical Imaging of Bronx, P.C., Inc. v MVAIC (2026 NY Slip Op 26160)

Medical Imaging of Bronx, P.C., Inc. v MVAIC

2026 NY Slip Op 26160

Decided on October 1, 2026

Appellate Term, First Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This decision is uncorrected and subject to revision before publication in the Official Reports.

Supreme Court, Appellate Term, First Department

Decided on October 1, 2026

570613/26

Present: James, P.J., Brigantti, Alpert, JJ.

Defendant appeals from a judgment of the Civil Court of the City of New York, Bronx County (Brenda Rivera, J.), entered on or about August 11, 2025, after a nonjury trial, in favor of plaintiff and awarding it damages in the principal amount of $967.70.

[*1]

Per Curiam.

Judgment (Brenda Rivera, J.), entered on or about August 11, 2025, reversed, with $30 costs, and judgment directed in favor of defendant dismissing the complaint.

In this action by a provider to recover assigned first-party no-fault benefits, the parties stipulated that: (1) plaintiff provided medical services to its assignor in May and June of 2021; (2) the claims were timely submitted to American Transit Insurance Company [ATIT], but were denied in July and August of 2021 on the ground that the underlying policy expired; (3) plaintiff then submitted the claims to MVAIC, with a copy of the ATIT denial and cover letter; and (4) MVAIC received the claims on December 15, 2021 and timely denied the claim based upon the 45-day rule. The parties’ stipulation further limited the issues to be tried to whether plaintiff had a “reasonable justification” for the delay in submitting the claims to MVAIC (see 11 NYCRR 65-3.3 [e]).

At trial, plaintiff’s witness testified that upon receiving the ATIT denial, he reached out to the referring physician to determine if another carrier should be billed. However, the witness had no independent knowledge or records of when this contact was made. He only indicated that the physician responded on November 15, 2021, indicating that MVAIC was the new insurance.

Following the trial, the court determined that “plaintiff has proffered a reasonable excuse for the delay” in submitting the claim to MVAIC. This determination was not based upon the evidence, but upon what the court characterized as “strong policy considerations,” including the size of the population, the “overburdened” medical service providers, and the “reasonableness” of the time to submit claims.

We reverse. The court had no authority to disregard the strict time frames and criteria on the filing of no-fault claims, which were intended to combat an escalating fraud problem, were consistent with the policy underlying the No—Fault Law to provide prompt compensation to legitimate claimants (see Raffellini v State Farm Mut. Auto. Ins. Co., 9 NY3d 196, 201 [2007]). [*2]Indeed, no party requested that the court consider public policy considerations in making its determination.

Based upon our authority to render judgment warranted by the facts (see Northern Westchester Professional Park Assoc. v Town of Bedford, 60 NY2d 492, 499 [1983]), we direct judgment in favor of defendant dismissing the complaint. Plaintiff failed to establish a reasonable justification for the delay in submitting the claims to MVAIC. Even assuming that plaintiff’s submission of the claims to ATIT justified the initial delay, the evidence was insufficient to establish a “reasonable justification” for the additional four-month delay between the July/August denial of claims by ATIT and the submission of the claims to MVAIC in or about December 2021 (see Bronx Expert Radiology, P.C. v Motor Veh. Acc. Indem. Corp., 23 Misc 3d 129[A], 2009 NY Slip Op 50621[U] [App Term, 1st Dept 2009]; Bronx Expert Radiology, P.C. v Motor Veh. Acc. Indem. Corp., 20 Misc 3d 140[A], 2008 NY Slip Op 51612[U] [App Term, 1st Dept 2008]; NY Arthroscopy & Sports Medicine PLLC v Motor Veh. Acc. Indem. Corp., 15 Misc 3d 89 [App Term, 1st Dept 2007]). Plaintiff’s evidence, including the testimony of its witness, was insufficient. Although the witness testified that plaintiff reached out to the referring physician to determine whether plaintiff should bill another carrier, the witness was unable to recall or otherwise determine when plaintiff contacted the physician.

Furthermore, MVAIC’s denials informed plaintiff that the delay could be excused if plaintiff provided reasonable justification. However, plaintiff did not respond to the denials, and, instead chose to rely upon the cover letters submitted with its claims stating that the claims had previously been submitted to another carrier. However, this was insufficient because the cover letters did not explain the several months delay between ATIT’s denial and the submission to MVAIC (see Carniol v MVAIC, 62 Misc 3d 148[A], 2019 NY Slip Op 50232[U] [App Term, 1st Dept 2019]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.

I concur I concur I concur

Decision Date: October 1, 2026

Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. PIP/BI Claims (2026 NY Slip Op 26164)

Reported in New York Official Reports at Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. PIP/BI Claims (2026 NY Slip Op 26164)

Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. PIP/BI Claims

2026 NY Slip Op 26164

Decided on September 24, 2026

Civil Court of the City of New York, Kings County

Sandra Elena Roper, J.

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This decision is uncorrected and subject to revision before publication in the Official Reports.

Civil Court of the City of New York, Kings County

Decided on September 24, 2026

Index No. CV-733610

Sandra Elena Roper, J.

[*1]

Recitation, as required by CPLR §2219(a) of the papers considered in review of this Motion:

Papers

Notice of Motion and Affidavits 1-2

Answering Affidavits 3

Reply Affirmations

Upon the foregoing cited papers and after oral argument, Defendant’s Motion for Summary Judgment, Plaintiff’s Cross-Motion for Summary Judgment, and Plaintiff’s Amended Cross-Motion are determined as follows:

Defendant’s Motion is GRANTED and Plaintiff’s Cross-Motion is DENIED as moot. Plaintiff’s Amended Cross-Moton was served 18 months after Defendant served its Opposition and Reply, therefore, is not being considered. Arguendo, even where Plaintiff’s Amended Cross-Motion and amended affidavits were to be considered, they would be found insufficient to raise a triable issue of fact to defeat Defendant’s Motion for Summary Judgment. This Court finds that Defendant demonstrated Plaintiff failed to comply with the timely verification requests issued pursuant to 11 NYCRR 65-3.5 (o) within 120 days, thus satisfying its prima facie burden for judgment as a matter of law in the first instance. Upon the shifting of the burden to rebut to Plaintiff, it failed to demonstrate that it provided the requested verification or set forth a reasonable justification for the failure to respond to Defendant’s verification requests, as required pursuant to 11 NYCRR 65-3.5 (o). Thus, Plaintiff failed to meet its burden to rebut Defendants prima facie judgment as a matter of law.

Defendant submitted admissible evidence that it had not received the requested [*2]documentary verification from Plaintiff. In Plaintiff’s affidavit in opposition submitted, document number 34 on NYSCEF, the affidavit of Plaintiff’s owner merely states he mailed the requested verification to the address designated by Defendant on the verification requests “to the extent such response was proper and, in [his] possession,” and without appending documentary proof of responsive compliance with the verification requests the affidavit is insufficient to meet Plaintiff’s shifted burden to rebut (see NY St Cts Elec Filing [NYSCEF] Doc No. 34, plaintiff’s owner aff at 2, 3). This affidavit is insufficient to raise a triable issue of fact as it failed to demonstrate that it had provided the requested verification nor did it set forth a reasonable justification for the failure to comply with Defendant’s verification requests (see Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co., 75 Misc 3d 143[A], 2022 NY Slip Op 50623[U] [App Term 2022]). Further, Plaintiff’s owner affidavit contradictorily states that he mailed the requested verification “to the address designated by the defendant on the verification requests” then in paragraph 7 states “to Defendant, State Farm Claims, at P.O. Box 52257, Phoenix, AZ 85072-2257” (NYSCEF Doc No. 34, ¶ 5 & 7). Whereas Defendant’s verification letters state that all requested documentation should be sent to “claims specialist, Doug Babin at State Farm Insurance 1 State Farm Drive Concordville, PA 19339-9300,” such internal factual inconsistency within Plaintiff’s affidavit without unimpeachable corroborating documentary proof of mailing vitiates its probative value to establish a finding of a triable issue of fact (see Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co., 85 Misc 3d 132[A], 2025 NY Slip Op 50306[U] [App Term 2025] [Second Department decision on this exact address issue was decided]). In further internal contradictions, Plaintiff also proffered 197 pages of correspondence submitted to Defendant objecting to the verification requested information and unilaterally on its own volition deeming Defendant’s verification request a nullity to the very same verification requests it contradictorily simultaneously contends were indeed responded to in its affidavit (see NY St Cts Elec Filing [NYSCEF] Doc No. 52). Further, it has been held, “[c]ontrary to plaintiff’s further contention, it was not improper for defendant to seek, during the claim verification stage, information – such as management agreements, W-2 forms, business-related bank records and lease agreements — for the purpose of determining whether plaintiff was ineligible to collect no-fault benefits due to a failure to meet licensing requirements” (Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co., 85 Misc 3d 130[A], 2025 NY Slip Op 50195[U] [App Term 2025], citing 11 NYCRR § 65-3.16 [2] [12]; see also State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313 [2005]). Moreover, the Court further held, “[a]s plaintiff objected to the verification requests claiming they were nullities, the record establishes that plaintiff did not “provide within 120 calendar days from the date of the initial request either all such verification under [plaintiff’s] control or possession or written proof providing reasonable justification for the failure to comply’ (11 NYCRR 65-3.5 [o]). Consequently, the arguments raised on appeal lack merit” (id. at [*3] [*4]).Plaintiff errs in its reliance on the recent Court of Appeals case in Government Employees Ins. Co. v Mayzenberg (45 NY3d 397 [2025]). This case clearly does not apply during the discovery/investigatory phase in the seeking of verification requests pursuant to 11 NYCRR 65-3.5 (o). In Mayzenberg, the Court of Appeals specifically answered the Second Circuit’s certified question: “If an insurer determines a healthcare provider has improperly paid others for patient referrals, in violation of [Education Law § 6350 (18)] and [8 NYCRR 29.1 (b) (3)], can the insurer deny payment for no-fault benefits on the ground that the provider ‘fail[ed] to meet’ a ‘necessary’ State or local licensing requirement under [11 NYCRR 65-3.16 (a) (12)]?” (id.). The Court of Appeals answered in the negative, holding that an insurer may not deny a [*3]provider’s claim for reimbursement based on alleged professional misconduct that falls short of ceding control of a professional services corporation to an unlicensed party (id.). However, The Court of Appeals reaffirmed that DFS regulation does authorize an insurer to deny no-fault benefit claims when a provider fails to fulfill a foundational licensing requirement necessary to perform healthcare services in any instance, and when they are effectively abdicating or ceding control to an unlicensed party (State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313 [2005]; see Andrew Carothers, M.D., P.C. v Progressive Ins. Co., 33 NY3d 389, 406 [2019]). Whereas “the Education Law vests the Board of Regents with ‘final authority’ concerning matters of professional discipline (Mayzenberg at 405, citing David v Biondo, 92 NY2d 318 [1998]). “The Court further explained that when a professional services corporation violates a foundational statutory requirement for licensure, that violation voids the corporation’s license regardless of when the violation is discovered or committed. By contrast, Mayzenberg’s alleged professional misconduct would not affect his license until State regulators choose, in their discretion, to impose such a penalty” (Mayzenberg at 407). Such delay is antithetical to the No-Fault law’s legislative intent of “prompt payment for basic economic loss to injured persons regardless of fault, in exchange for a limitation on litigation to cases involving serious injury” (id.).

Mayzenberg is triggered upon an insurer’s conclusive determination of a provider’s professional misconduct, which cannot be had until the conclusion of the investigatory phase. Insurer’s verification requests are part of the investigatory phase. Where provider fails to respond to the insurer’s verification requests, as herein, it cuts off the processing of the claim at the investigatory phase depriving insurer from ever reaching any substantive conclusive determination on the merits of alleged professional misconduct. Rather, insurer’s denial is premised upon procedural grounds of provider failing to respond to verification request within 120 days, as herein.

Investigatory verification requests determine whether there is determination of professional misconduct:

1st- Plaintiff provider failed to meet a necessary New York State or local licensing requirement;

2nd-Plaintiff provider’s offending licensing failure of professional misconduct ceded, abdicated or surrendered its control of its licensed professional services corporation to an unlicensed party or entity; Thus, where:

3rd- Defendant insurer’s finding to the second prong is in the affirmative at the conclusion of the investigatory phase of Defendant insurer’s verification requests and Plaintiff provider’s responses thereto prove professional misconduct that rises to the level of ceding, abdicating, or surrendering Plaintiff provider’s control of its licensed professional healthcare services corporation to an unlicensed party or entity, then the Defendant insurer maintains its authority to deny the claimed services as reaffirmed by The Court of Appeals in Mayzenberg (Mayzenberg at 403, citing State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313 [2005]; see Andrew Carothers, M.D., P.C. v Progressive Ins. Co., 33 NY3d 389, 406 [2019]).

4th- Where the finding to the second prong is in the negative at the conclusion of the investigatory phase of Defendant insurer’s verification requests and Plaintiff provider’s responses thereto prove alleged professional misconduct of some kind, i.e. unethical referral agreements or kickbacks in violation of Education Law § 6530 (18) and attendant regulation, 8 NYCRR 29.1 (b) (3) which does not rise to the level of ceding, [*4]abdicating, or surrendering Plaintiff provider’s control of its licensed professional healthcare services corporation to an unlicensed party or entity, then the Defendant insurer cannot deny the claimed services and shall pay Plaintiff provider for those claimed services billed accordingly.^FN1 The Court of Appeals definitively vests that authority solely with the Board of Regents and divests such authority from No-Fault insurers to deny on that faction or branch of professional misconduct.^FN2

It is reiterated; there must be a final conclusive determination of the investigatory phase in compliance with Defendant insurer’s verification requests upon Plaintiff provider’s responses thereto. Plaintiff errs in its argument that Mayzenberg’s holding is to be applied to the underlying materiality of the verification requests as circumscribed by the SIU’s investigatory reports. The SIU reports are of no moment to trigger Mayzenberg at the investigatory phase. Mayzenberg is not triggered until Defendant insurer conclusively makes a finding of professional misconduct upon which will be the basis of the denial. There can only be such a finding upon the conclusion of the investigatory phase. Even upon such a finding, the inquiry doesn’t end there. There must be further inquiry into what type or faction of professional misconduct. Whether it rises to Mallella/Caruthers‘ professional misconduct which maintains authority vested in Defendant insurer to deny Plaintiff’s claims. Or, whether some other professional misconduct such as “[d]irectly or indirectly offering [and] giving . . . any fee . . . to . . . a third party for the referral of a patient or in connection with the performance of professional services” or paying kickbacks pursuant to Education Law § 6530 (18) and attendant regulation, 8 NYCRR 29.1 (b) (3), which divests authority from Defendant insurer (id.). Nevertheless, this instant matter has failed to reach the trigger point for the application of Mayzenberg. There has been no conclusive finding or determination of any professional misconduct by Defendant insurer for which Plaintiff’s claims may be denied pursuant to the Eligibility Regulation 11 NYCRR 65-3.16 (a) (12), since Plaintiff failed to respond to the verification requests which essentially cut off the investigatory phase, upon which the denial is premised. The instant claim was not denied pursuant to professional misconduct of which Mayzenberg would be controlling. Rather, the instant claim is denied for Plaintiff’s failure to respond to verification requests within 120 days pursuant to 11 NYCRR 65-3.5 (o).

In this instant case, there has been nor could there have been any conclusive finding or determination of any professional misconduct since Plaintiff failed to respond to verification requests within 120 days thereby thwarting the investigatory phase to its detriment, depriving it of a potential Mayzenberg challenge.

Therefore, Plaintiff’s Complaint is hereby DISMISSED with PREJUDICE.

This constitutes the Decision and Order of This Court.

Date: September 24, 2026

Brooklyn, New York

Judge Sandra Elena Roper, JCC

Matter of Hartford Fire Ins. Co. v Villanueva (2026 NY Slip Op 05393)

Reported in New York Official Reports at Matter of Hartford Fire Ins. Co. v Villanueva (2026 NY Slip Op 05393)

Matter of Hartford Fire Ins. Co. v Villanueva

2026 NY Slip Op 05393

Decided on September 23, 2026

Appellate Division, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This decision is uncorrected and subject to revision before publication in the Official Reports.

Supreme Court of the State of New York, Appellate Division, Second Judicial Department

Decided on September 23, 2026

2024-09821, (Index No. 503370/23)

Colleen D. Duffy, J.P.

Barry E. Warhit

Lourdes M. Ventura

Lisa S. Ottley, JJ.

[*1]

DECISION & ORDER

In a proceeding pursuant to CPLR article 75, inter alia, to permanently stay arbitration of a claim for uninsured motorist benefits, Devorah Villanueva appeals from an order of the Supreme Court, Kings County (Anne J. Swern, J.), dated June 20, 2024. The order, insofar as appealed from, denied that branch of the motion of Devorah Villanueva which was pursuant to CPLR 5015(a)(1) to vacate an order of the same court (Robin S. Garson, J.) dated June 22, 2023, which upon Villanueva’s default, in effect, in opposing the petition, granted that branch of the petition which was to permanently stay arbitration.

ORDERED that the order dated June 20, 2024, is affirmed insofar as appealed from, with costs.

The petitioner, Hartford Fire Insurance Company (hereinafter Hartford), commenced this proceeding pursuant to CPLR article 75, inter alia, to permanently stay arbitration of a claim by Devorah Villanueva for uninsured motorist benefits arising out of an alleged hit-and-run collision in February 2022 involving Villanueva, who was riding a motorized scooter, and an unidentified motorcyclist. In an order dated June 1, 2023, the Supreme Court directed Villanueva to serve written opposition to the petition by June 15, 2023, and adjourned the petition to June 22, 2023. Villanueva failed to submit written opposition to the petition. Thereafter, in an order dated June 22, 2023 (hereinafter the June 2023 order), the court granted that branch of the petition which was to permanently stay arbitration upon Villanueva’s default, in effect, in opposing the petition.

In August 2023, Villanueva moved, among other things, pursuant to CPLR 5015(a)(1) to vacate the June 2023 order. Hartford opposed the motion. In an order dated June 20, 2024, the Supreme Court, inter alia, denied that branch of Villanueva’s motion. Villanueva appeals.

To obtain relief pursuant to CPLR 5015(a)(1), Villanueva was required to show both a reasonable excuse for the default and a potentially meritorious defense to the petition (see Matter of Maya Assur. Co. v Long Sheng Zheng, 207 AD3d 632, 632; Matter of Liberty Mut. Ins. Co. v Fiduciary Ins. Co. of Am., 111 AD3d 731, 732). “The determination of whether an excuse is reasonable lies within the sound discretion of the trial court” (126 Henry St., Inc. v Cater, 197 AD3d 598, 600; see Beach 28 RE, LLC v Somra, 216 AD3d 610, 611). Here, Villanueva failed to proffer [*2]a reasonable excuse for the default. Villanueva’s conclusory and unsubstantiated assertions that she was hampered in opposing the petition by the lack of production of certain medical records and a purported police report did not constitute a reasonable excuse, as she provided no explanation as to efforts made to obtain those documents. Since Villanueva failed to demonstrate a reasonable excuse for the default, it is unnecessary to consider whether she demonstrated a potentially meritorious defense to the petition (see Matter of Maya Assur. Co. v Long Sheng Zheng, 207 AD3d at 633; Matter of Government Empls. Ins. Co. v Dae-Hee Lee, 78 AD3d 944, 945).

The parties’ remaining contentions either are without merit, need not be reached in light of our determination, or are improperly raised for the first time on appeal.

DUFFY, J.P., WARHIT, VENTURA and OTTLEY, JJ., concur.

ENTER:

Darrell M. Joseph

Clerk of the Court

Matter of Nostrand Drugs Rx, Inc. v Church Mut. Ins. Co. (2026 NY Slip Op 05400)

Reported in New York Official Reports at Matter of Nostrand Drugs Rx, Inc. v Church Mut. Ins. Co. (2026 NY Slip Op 05400)

Matter of Nostrand Drugs Rx, Inc. v Church Mut. Ins. Co.

2026 NY Slip Op 05400

Decided on September 23, 2026

Appellate Division, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

This decision is uncorrected and subject to revision before publication in the Official Reports.

Supreme Court of the State of New York, Appellate Division, Second Judicial Department

Decided on September 23, 2026

2025-00470, (Index No. 511903/23)

Francesca E. Connolly, J.P.

Linda Christopher

Barry E. Warhit

Donna-Marie E. Golia, JJ.

[*1]

DECISION & ORDER

In a proceeding pursuant to CPLR article 75 to vacate an award of a master arbitrator dated February 24, 2023, which confirmed an award of an arbitrator dated December 11, 2022, the petitioner appeals from an order of the Supreme Court, Kings County (Carolyn E. Wade, J.), dated December 4, 2024. The order denied the petition to vacate the master arbitrator’s award.

ORDERED that the order is affirmed, with costs.

In September 2020, Ahsan Ali was involved in a motor vehicle accident. Ali received prescription medications from the petitioner Nostrand Drugs Rx, Inc. (hereinafter Nostrand), for injuries he sustained in the accident. Nostrand submitted an insurance claim to Church Mutual Ins. Co. (hereinafter Church Mutual) for reimbursement of the cost of the medication dispensed, in the total sum of $2,343.20. Nostrand never received payment. Thereafter, Nostrand submitted the insurance claim to arbitration. In an award dated December 11, 2022, after a hearing, an arbitrator denied Nostrand’s claim. Nostrand then requested that the matter be reviewed by a master arbitrator. In an award of a master arbitrator dated February 24, 2023, the master arbitrator confirmed the arbitration award dated December 11, 2022, in its entirety.

In April 2023, Nostrand commenced this proceeding pursuant to CPLR article 75 to vacate the master arbtirator’s award. In an order dated December 4, 2024, the Supreme Court denied the petition to vacate the master arbitrator’s award. Nostrand appeals.

“‘Consistent with the public policy in favor of arbitration, the grounds specified in CPLR 7511 for vacating or modifying a no-fault arbitration award are few in number and narrowly applied'” (Matter of Allstate Ins. Co. v Westchester Med. Group, M.D., 125 AD3d 649, 650, quoting Matter of Mercury Cas. Co. v Healthmakers Med. Group, P.C., 67 AD3d 1017, 1017). “Arbitrators exceed their power only when they issue an award that ‘violates a strong public policy, is irrational or clearly exceeds a specifically enumerated limitation on the arbitrator’s power'” (Matter of County of Nassau v Nassau County Investigators Police Benevolent Assn., Inc., 203 AD3d 824, 826, quoting American Intl. Specialty Lines Ins. Co. v Allied Capital Corp., 35 NY3d 64, 70). “The master arbitrator’s determination of the law need not be correct: mere errors of law are insufficient to set aside the award of a master arbitrator” (Acuhealth Acupuncture, P.C. v Country-Wide Ins. Co., 170 [*2]AD3d 1168, 1168, quoting Matter of Liberty Mut. Ins. Co. v Spine Americare Med., 294 AD2d 574, 577).

Here, Nostrand failed to demonstrate the existence of any statutory grounds for vacating the master arbitrator’s award (see Matter of American Tr. Ins. Co. v Big Apple Pain Mgt., PLLC, 242 AD3d 1198, 1199; Matter of V.S. Care Acupuncture, P.C. v Country-Wide Ins. Co., 176 AD3d 832, 833-834).

Nostrand’s remaining contentions either are improperly raised for the first time on appeal or need not be reached in light of our determination.

Accordingly, the Supreme Court properly denied Nostrand’s petition to vacate the master arbitrator’s award.

CONNOLLY, J.P., CHRISTOPHER, WARHIT and GOLIA, JJ., concur.

ENTER:

Darrell M. Joseph

Clerk of the Court

RVA Leasing Corp. v Nationwide Mut. Ins. Co. (2026 NY Slip Op 51527(U))

Reported in New York Official Reports at RVA Leasing Corp. v Nationwide Mut. Ins. Co. (2026 NY Slip Op 51527(U))

RVA Leasing Corp. v Nationwide Mut. Ins. Co.

2026 NY Slip Op 51527(U)

Decided on September 22, 2026

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.

Supreme Court, Appellate Term, First Department

Decided on September 22, 2026

571015/26

Present: James, P.J., Brigantti, Alpert, JJ.

Defendant, as limited by its brief, appeals from so much of an order of the Civil Court of the City of New York, New York County (Wendy C. Li, J.), entered August 15, 2024, which denied its motion for summary judgment dismissing the complaint.

[*1]

Per Curiam.

Order (Wendy C. Li, J.), entered August 15, 2024, insofar as appealed from, reversed, with $10 costs, and defendant’s motion for summary judgment dismissing the complaint is granted. The Clerk is directed to enter judgment accordingly.

Defendant-insurer’s motion for summary judgment dismissing this action for first-party, no-fault benefits should have been granted. Defendant made a prima facie showing that it timely and properly mailed the notices for examinations under oath [EUO] to plaintiff and that plaintiff failed to appear at the initial and follow-up EUOs (see Kemper Independence Ins. Co. v Cornerstone Chiropractic, P.C., 185 AD3d 468, 469 [2020]; Mapfre Ins. Co. of NY v Manoo, 140 AD3d 468, 470 [2016]; Town RX Inc. v Nationwide Mut. Ins. Co., 87 Misc 3d 132[A], 2025 NY Slip Op 51853[U] [App Term, 1st Dept 2025]). The affidavit of defendant’s attorney sufficiently described the standard practices and procedures of his office for mailing EUO scheduling letters (see Nationwide Affinity Ins. Co. of Am. v George, 183 AD3d 755, 757 [2020]; Liberty Mut. Ins. Co. v Five Boro Med. Equip., Inc.,130 AD3d 465, 465-466 [2015]), and counsel further represented, under penalty of perjury, that he had personal knowledge that the described practices and procedures were followed (130 AD3d at 466). This represented adequate proof that the EUO letters were mailed to plaintiff.

In opposition, plaintiff failed to raise any issue of fact. Contrary to plaintiff’s contention, defendant provided a specific objective justification for conducting EUOs (see 11 NYCRR 65—3.5 [e]; Liberty Mut. Ins. Co. v Mercado, 235AD3d 410, 410-411 [2025]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.

I concur I concur concur

Decision Date: September 22, 2026

RVA Leasing Corp. v Nationwide Mut. Ins. Co. (2026 NY Slip Op 51528(U))

Reported in New York Official Reports at RVA Leasing Corp. v Nationwide Mut. Ins. Co. (2026 NY Slip Op 51528(U))

RVA Leasing Corp. v Nationwide Mut. Ins. Co.

2026 NY Slip Op 51528(U)

Decided on September 22, 2026

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.

Supreme Court, Appellate Term, First Department

Decided on September 22, 2026

571016/26

Present: James, P.J., Brigantti, Alpert, JJ.

Defendant appeals from an order of the Civil Court of the City of New York, Bronx County (Edit Shkreli, J.), dated July 28, 2025, which denied defendant’s motion for summary judgment dismissing the complaint.

[*1]

Per Curiam.

Order (Edit Shkreli, J.), dated July 28, 2025, reversed, with $10 costs, and defendant’s motion for summary judgment dismissing the complaint is granted. The Clerk is directed to enter judgment accordingly.

Defendant-insurer’s unopposed motion for summary judgment dismissing this action for first-party, no-fault benefits should have been granted. Defendant made a prima facie showing that it timely and properly mailed the notices for examinations under oath [EUO] to plaintiff and that plaintiff failed to appear at the initial and follow-up EUOs (see Kemper Independence Ins. Co. v Cornerstone Chiropractic, P.C., 185 AD3d 468, 469 [2020]; Mapfre Ins. Co. of NY v Manoo, 140 AD3d 468, 470 [2016]; Town RX Inc. v Nationwide Mut. Ins. Co., 87 Misc 3d 132(A) [App Term, 1st Dept 2025]). Plaintiff’s failure to attend the EUOs is a violation of a condition precedent to coverage (see Hertz Corp. v Active Care Med. Supply Corp., 124 AD3d 411, 411 [2015]).

Plaintiff’s argument that defendant failed to establish that the EUO requests were reasonable is improperly raised for the first time on appeal and therefore is unpreserved for our review (see Massaro v Manfredi Auto Cent., LLC, 248 AD3d 514, 514 [2026]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.

I concur I concur I concur

Decision Date: September 22, 2026

NR Motion PT, P.C. v Allstate Ins. (2026 NY Slip Op 51460(U))

Reported in New York Official Reports at NR Motion PT, P.C. v Allstate Ins. (2026 NY Slip Op 51460(U))

NR Motion PT, P.C. v Allstate Ins.

2026 NY Slip Op 51460(U)

Decided on September 3, 2026

Civil Court of the City of New York, Kings County

Sandra Elena Roper, J.

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.

Civil Court of the City of New York, Kings County

Decided on September 3, 2026

Index No. CV-034409-15/KI

Sandra Elena Roper, J.

[*1]

Papers

Notice of Motion and Affidavits Annexed NYSCEF

Exhibits NYSCEF

Upon the foregoing cited papers, the Decision/Order on Defendant’s Motion for Summary Judgment is as follows:

Defendant’s motion for summary judgment is DENIED in its entirety. An insurer seeking summary judgment based upon the statutory intoxication exclusion bears the burden of establishing, through competent and admissible evidence, both: (1) that the eligible injured person was intoxicated or impaired; and (2) that the person’s injuries resulted from operating a motor vehicle while in that condition (see Westchester Med. Ctr. v Government Empls. Ins. Co., 77 AD3d 737 [2d Dept 2010]). Defendant has failed to satisfy its burden. The insurer in Westchester Medical Center, upon which Defendant relies, supported its motion with unimpeachable certified hospital records with confirming toxicology report of intoxication. Here, Defendant relies upon uncertified and unauthenticated medical records and a police accident report that were not submitted in admissible form. Defendant failed to provide an affidavit or other admissible competent evidentiary foundation establishing the admissibility of those documents under CPLR § 4518 or any other applicable evidentiary rule. Consequently, those materials are insufficient to establish Defendant’s entitlement to judgment as a matter of law, obviating the shifting of the burden to rebut by Plaintiff.

Moreover, the assignor’s examination-under-oath testimony expressly disputes that she was intoxicated or impaired at the time of the accident. Defendant failed to submit competent [*2]evidence conclusively establishing either the assignor’s intoxication or the requisite causal connection between any alleged intoxication and the accident or resulting injuries. Speculation, suspicion, and unauthenticated documentary evidence cannot satisfy Defendant’s prima facie burden.

Upon Defendant’s failure to establish its prima facie entitlement to summary judgment, its motion must be denied regardless of the sufficiency of Plaintiff’s opposing papers. Defendant also failed to establish its fee-schedule defense as a matter of law. Defendant did not submit competent and admissible evidence demonstrating that Plaintiff’s charges exceeded the applicable fee schedule or otherwise identifying a legally sufficient basis for reducing or denying the subject claims.

Accordingly, it is hereby:

ORDERED, that Defendant’s Motion for Summary Judgment is DENIED in its entirety and that no finding is made that the assignor was intoxicated or impaired or that any alleged intoxication or impairment caused or contributed to the accident or resulting injuries. To the extent Defendant continues to pursue intoxication defense at trial, Defendant shall bear the burden of proving, through competent and admissible evidence, both the alleged intoxication or impairment and the required causal connection between that condition and the accident and resulting injuries. Defendant shall likewise bear the burden of establishing any fee-schedule defense through competent and admissible evidence at trial. LH

This constitutes the decision and order of the Court.

Date: September 3, 2026

Brooklyn, New York

Honorable Sandra Elena Roper

Judge of the Civil Court, Kings County

Citimed Surgery Ctr. LLC v Allstate Ins. Co. (2026 NY Slip Op 51435(U))

Reported in New York Official Reports at Citimed Surgery Ctr. LLC v Allstate Ins. Co. (2026 NY Slip Op 51435(U))

Citimed Surgery Ctr. LLC v Allstate Ins. Co.

2026 NY Slip Op 51435(U)

Decided on August 24, 2026

Civil Court of the City of New York, New York County

Wendy Changyong Li, J.

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.

Civil Court of the City of New York, New York County

Decided on August 24, 2026

Index No. CV-706493-24/NY

Wendy Changyong Li, J.

[*1]

I. Recitation, as required by CPLR §2219(a), of the papers considered in review of this Motion:

The following papers read herein: Numbered

Notice of Motion, Affirmation and Exhibits 1

Affirmation in Opposition 2

Affirmation in Reply and Exhibits 3

II. Background

The matter at hand concerns a no-fault benefits reimbursement for medical expenses incurred by Plaintiff, a healthcare provider, from Defendant, arising from an automobile accident that occurred on September 26, 2023, where Plaintiff’s assignor, I. Enninful (“Assignor“) allegedly sustained injuries.

On August 29, 2024, Plaintiff commenced the instant action against Defendant by filing of a summons and complaint seeking to recover monetary damages in the amount of $1,988.70 plus statutory interest, statutory attorney’s fees, costs and disbursements. Defendant joined the action by interposing an answer.

Thereafter, on March 17, 2025, Defendant moved by motion seeking to dismiss the action for lack of jurisdiction pursuant to CPLR 3211, or in the alternative, seeking summary judgment to dismiss the complaint on the ground that there was lack of coverage pursuant to CPLR 3212 (“Motion Seq. #1“). Defendant alleged that the insurance policy at issue was not issued by Defendant but by Allstate New Jersey Property and Casualty Insurance Company, a separate and distinct company that does not do business or maintain an office in the City of New York (see affirmation of M. Zeleznock, Esq.). Defendant alleged that Plaintiff improperly served Defendant, the incorrect party, and that as such, jurisdiction over Allstate New Jersey Property and Casualty Insurance Company was not properly obtained (id.). Plaintiff opposed and Defendant replied.

Motion Seq. #1 was submitted on May 18, 2026 and subsequently assigned to this Court for determination on June 15, 2026.

III. Discussion

To prevail on a motion for summary judgment, the movant must show that “there are no material issues of fact in dispute, and that it is entitled to judgment as a matter of law” (see Dallas-Stephenson v Waisman, 39 AD3d 303, 306 [1st Dept 2007] quoting Winegrad v New York Univ Med Center, 64 NY2d 851, 853 [1985]; Ostrov v Rozbruch, 91 AD3d 147, 152 [1st Dept 2012]). The movant has the initial burden of coming forward with admissible evidence, such as affidavits by persons having knowledge of the facts, reciting the material facts and showing that there is no defense to the cause of action or that the cause of action or defense has no merit (CPLR 3212[b]; see Zuckerman v City of New York, 49 NY2d 557, 562 [1980]; GTF Mktg. v Colonial Aluminum Sales, 66 NY2d 965, 967 [1985]; see also Kershaw v Hospital for Special Surgery, 114 AD3d 75, 81-82 [1st Dept 2013]). “[M]ere conclusions, expressions of hope or unsubstantiated allegations or assertions are insufficient” (Zuckerman, 49 NY2d 557, 562 [1980]).

Only when the movant meets this burden, does the burden shift to the opposing party to [*2]submit proof in admissible form that establishes a triable issue of fact (CPLR 3212[b]; see Zuckerman, 49 NY2d 557, 562 [1980]; Kosson v Algaze, 84 NY2d 1019 [1995]; Gonzalez v 98 Mag Leasing Corp., 95 NY2d 124, 128-129 [2000]).

Summary judgment is a drastic remedy and should not be granted where there are material and triable issues of fact present (see Stillman v Twentieth Century Fox F. Corp., 3 NY2d 395 [1957]; F. Garofalo Elec Co v NY Univ, 300 AD2d 186 [1st Dept 2002]). The evidence must be viewed in the light most favorable to the party opposing the motion, including resolving all reasonable inferences in that party’s favor (see Jacobsen v New York City Health and Hosps. Corp., 22 NY3d 824, 833 [2014]). Where different conclusions may reasonably be drawn from the evidence, the motion must be denied (see Sommer v Federal Signal Corp., 79 NY2d 540 [1992]; Jaffe v Davis, 214 AD2d 330 [1st Dept 1995]).

In support of the instant motion, Defendant proffered the following: affirmation of M. Zeleznock, Esq.; affirmation of M. Thompson-McKenna (hereinafter, “Thompson-McKenna”), Senior Product and Risk Management Litigation Consultant of Defendant; affirmation of R. Ferreira (hereinafter, “Ferreira“), claims service leader for Allstate New Jersey Insurance Company and Allstate New Jersey Property and Casualty Insurance Company and a copy of the relevant insurance policy in question; summons and complaint; Defendant’s answer; Certificate of Compliance; and a list of prior decisions.

Based upon her search of Defendant’s file and records, Thompson-McKenna, Senior Product and Risk Management Litigation Consultant of Defendant, stated that she was unable to locate a policy of insurance covering I. Enninful, the Assignor in this action, on the date of loss, September 26, 2023 (see affirmation of Thompson-McKenna, ¶¶ 3-4). A search for the claim number 0730518826 provided by Plaintiff in the summons and complaint similarly did not render any result identifying a policy covering the Assignor (id. ¶ 5).

The affirmation of Ferreira, claims service leader for Allstate New Jersey Insurance Company and Allstate New Jersey Property and Casualty Insurance Company, averred that Allstate New Jersey Property and Casualty Insurance Company assigned the forementioned claim number and issued the policy of insurance in question with a policy number of 989 109 129 (see affirmation of Ferreira, ¶ 5). Ferreira further stated that Allstate New Jersey Property and Casualty Insurance Company only issues insurance policies in the State of New Jersey and Illinois (id., ¶ 18) and that Allstate New Jersey Property and Casualty Insurance Company is not authorized to issue insurance policies in the State of New York (id., ¶ 23).

Based on the submissions, the Court finds that Defendant established its prima facie case that (1) Defendant did not issue a policy of insurance for the Assignor; (2) that it was Allstate New Jersey Property and Casualty Insurance Company that issued the policy in question; and (3) that Defendant was not a proper party to this action.

The burden is then shifted to Plaintiff to submit proof in admissible form sufficient to raise a triable issue of fact. Plaintiff failed to raise a triable issue of fact as to whether Defendant issued the policy of insurance at issue, as it merely alleged in a conclusory fashion that an issue [*3]of fact existed as to the identity of the policy issuer and the relationship between Defendant and Allstate New Jersey Property and Casualty Insurance Company. In light of the foregoing, Plaintiff’s contention that Defendant failed to disclose whether it had received the bills at issue for the services rendered to the Assignor and whether it had issued a denial on the ground of lack of coverage is immaterial to the jurisdictional issue presented.

Therefore, Defendant’s motion for summary judgment to dismiss Plaintiff’s complaint is granted.

IV. Order

Accordingly, it is hereby:

ORDERED that Defendant’s Motion for summary judgment to dismiss Plaintiff’s complaint is GRANTED; and it is further

ORDERED that Plaintiff’s complaint is dismissed; and it is further

ORDERED that Defendant shall serve a copy of this Decision and Order upon Plaintiff with notice of entry within thirty (30) days thereof.

This constitutes the DECISION and ORDER of the Court.

DATE August 24, 2026

HON. WENDY CHANGYONG LI, J.C.C.

Medical Supply Depot Group Corp v State Farm Mut. Auto. Ins. Co. PI/BI Claims (2026 NY Slip Op 51339(U))

Reported in New York Official Reports at Medical Supply Depot Group Corp v State Farm Mut. Auto. Ins. Co. PI/BI Claims (2026 NY Slip Op 51339(U))

Medical Supply Depot Group Corp v State Farm Mut. Auto. Ins. Co. PI/BI Claims

2026 NY Slip Op 51339(U) [89 Misc 3d 1250(A)]

Decided on August 20, 2026

Civil Court of the City of New York, Kings County

Sandra E. Roper, J.

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.

Civil Court of the City of New York, Kings County

Decided on August 20, 2026

Index No. CV- 764166-19/KI

Sandra E. Roper, J.

[*1]

Recitation, as required by CPLR §2219(a) of the papers considered in review of this Motion:

Papers

Notice of Motion and Affidavits Annexed 1-2

Cross Motion and Affidavit Annexed 3-4

Plaintiff’s Opp/Reply 5

Defendant’s Opp/Reply 6

Upon the foregoing cited papers, pursuant to CPLR §3212, and after oral argument on August 11, 2026, the Decision and Order on Defendant’s Motion for Summary Judgment and Plaintiff’s Cross Motion for Summary Judgment are as follows:

Defendant’s motion for Summary Judgment is granted in its entirety and Plaintiff’s Cross-Motion is denied. The subject bill was received on September 13, 2019. Defendant scheduled an examination under oath (“EUO”) by letter dated September 23, 2019. Plaintiff appeared for the EUO on October 21, 2019. Defendant submits that due to Plaintiff’s insufficient testimony, it requested additional written verification on October 29, 2019. Thereafter, Defendant denied the claim on March 4, 2020, as Plaintiff failed to issue any response within the statutory timeframe of 120 days. Following issuance of the denial, Plaintiff responded on April 17, 2020, and while it did not provide written verification, Plaintiff advised that it intended to provide written verification in the future.

Although Plaintiff is indeed correct in its argument that post-EUO verification is not addressed in the No-Fault Statute, nevertheless, case law has established that post-EUO verification request is permissible as consistent with legislative intent. Where EUO was held but [*2]failed to provide verification responses insurer requires to verify the claim for services, post-EUO requests have been upheld not merely in the written form of verification responses. “If the insurer is unable to garner the information that it needs from the [EUO] of a person submitted by the assignee corporation or partnership, the insurer may request additional examinations of the assignee until a person is submitted for examination by the assignee who can provide the ‘items necessary to verify the claim’?” (Nationwide Affinity Ins. Co. of Am. v Gepp, 234 AD3d 1320, 1322 [4th Dept 2025], citing 11 NYCRR .§65-3.5 [c]). The Nationwide Court acknowledged that the time to pay or deny a claim can be tolled by a verification request. An insurer is entitled to receive all items necessary to verify the claim. The Court opined that where the verification is the EUO, verification is deemed complete as of the date of the EUO. However, if verification cannot be deemed complete as all the necessary verification could not be garnered from the EUO, then pursuant to case law, an insurer is permitted to request additional verification through additional EUOs pursuant to Nationwide, or seek post-EUO written verification requests, which Defendant pursued in the case at bar. Thereafter, where verification sought is not provided within 120 days, an insurer is permitted to deny the claim at issue, as done here.

In the instant case, Defendant’s initial request for the EUO tolled its time to pay or deny the claim. Defendant submitted a copy of the transcript and the SIU affidavit in order to demonstrate that it did not obtain all the necessary information from the EUO and was entitled to seek written verification following the EUO. Thereafter, Defendant demonstrated that Plaintiff did not respond until after 120 days from Defendant’s first request and demonstrated that Plaintiff failed to provide written verification responses to Defendant’s requests. Plaintiff’s purported response to eventually respond to the specific verification requests in the future is not a response. As a result, Defendant was entitled to deny the claim at issue.

Plaintiff errs in its argument that the EUO being held stops the tolling notwithstanding that post-EUO verification requests were made. Rather, the post-EUO verification requests continue the tolling. Most notably, post-EUO verification requests are the consequence of Plaintiff deponent’s failure to provide verification responses in the first instance at the EUO. Thus, requiring Defendant to serve post-EUO verification requests to address non-responsiveness of the EUO held. Similarly to Nationwide, although there is no specific agreement between the parties, in this instant matter, Plaintiff acknowledges the validity of the post-EUO verification requests, where Plaintiff, although untimely, responded with an intent to respond eventually, not a response, after the expiration of the 120-day period. Further, Plaintiff’s argument in its reliance on Burke Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co., 83 Misc 3d 41 (App Term 2024) that Defendant’s post-EUO verification request on October 29, 2019, was untimely and that verification regarding the subject claim was received on the date of the EUO (i.e. October 21, 2019) is misplaced and rejected pursuant to Nationwide. Accordingly, Defendant’s Motion is granted in its entirety and Plaintiff’s Cross-Motion is denied.

This constitutes the Decision and Order of the Court.

DATE August 20, 2026

HON. SANDRA E. ROPER

Baldwin Med. Servs., P.C. v Maya Assur. Co (2026 NY Slip Op 51329(U))

Reported in New York Official Reports at Baldwin Med. Servs., P.C. v Maya Assur. Co (2026 NY Slip Op 51329(U))

Baldwin Med. Servs., P.C. v Maya Assur. Co

2026 NY Slip Op 51329(U) [89 Misc 3d 1248(A)]

Decided on August 19, 2026

Civil Court of the City of New York, Bronx County

Eric J. Wursthorn, J.

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.

Civil Court of the City of New York, Bronx County

Decided on August 19, 2026

Index No. CV-721510-22/BX

Eric J. Wursthorn, J.

[*1]

Plaintiff Baldwin Medical Services, P.C. (“Baldwin”), as assignee of Ana Lopez, seeks reimbursement from defendant Maya Assurance Co. (“Maya”) for medical services provided by it in accordance with New York State No-Fault Law. Maya now moves for summary judgment, arguing that Baldwin’s failure to respond to additional verification requests warrants dismissal (CPLR 3212). Baldwin opposes the motion. Issue has been joined and the motion was timely brought after notice of trial was filed. For the reasons that follow, Maya’s motion for summary judgment is denied.

Relevant facts

On 3/2/22, Ana Lopez was allegedly injured in an automobile accident. On 5/17/22, Baldwin allegedly provided medical services to Ms. Lopez and now seeks reimbursement for those services from Maya, Ms. Lopez’s insurer. Specifically, Baldwin billed $408.16 for bilateral paravertebral facet joint injections to the cervical and thoracic spine with image guidance, and arthrocentesis to the left shoulder rendered on 5/17/22.

By letter dated 6/15/22, Sanders Grossman Aranova, PLLC (“SGA PLLC”) advised Maya that the firm had been retained by Baldwin and submitted the subject claim for reimbursement. The 6/15/22 letter further provides that “[p]ursuant to New York State Insurance Law, all requests for additional verification, denials and explanations of benefits must be mailed both to the above-referenced provider and this office” (emphasis in original). The claim form submitted by SGA PLLC lacked Ms. Lopez’s signature in the portions authorizing release of information, requesting payment of benefits, and assigning benefits to the provider. Instead, the form stated that her signature was ‘on file.’

Maya claims that it then sent an additional verification request on 7/7/22 and a second additional verification request on 8/5/22 seeking an NF-3 completed and signed by the provider and a completed and signed Assignment of Benefits. Copies of verification requests addressed to Baldwin care of SGA PLLC at SGA PLLC’s mailing address have been provided to the Court.

Meanwhile, while the additional verification was still pending, Baldwin commenced this action on 8/23/22. Baldwin alleges in its complaint that it did not receive requests for additional verification from defendant (see Summons and Complaint, ¶ 21 [NYSCEF Doc. No. 1]). Defendant does not argue in this motion that this action was prematurely commenced, although defendant has preserved this defense in its answer (fourth and seventh affirmative defenses).

On 1/25/23, Maya sent Baldwin an NF-10 Denial of Claim Form which denied payment for the subject claim on the grounds that Maya requested, but never received, additional information which it needed to verify Baldwin’s claim or reasonable justification for the failure to comply with the verification request. The Explanation of Benefits attached to the Denial of Claim Form specifically states: “Our 1st verification letter was mailed out on 07/08/22 which 120 days have passed.”

Parties’ arguments

Defendant seeks summary judgment on the grounds that it properly denied plaintiff’s bill based on plaintiff’s failure to provide additional verification requested. Maya contends that after receiving the claim, it mailed the initial request for additional verification on 7/7/22 and a second additional verification request on 8/5/22, and that Baldwin did not respond to either. Maya further argues that because no verification or reasonable justification was provided within 120 days of the initial verification request, it properly issued an NF-10 denial on 1/25/23 pursuant to 11 NYCRR 65-3.5 (o).

Plaintiff does not dispute verifications were not answered. Rather, plaintiff argues in opposition that defendant failed to establish the verification requests were timely and properly mailed, or at least a triable issue of fact remains as to such. Plaintiff further argues that defendant failed to establish that it complied with applicable No-Fault regulations by mailing its [*2]verification requests to both plaintiff and plaintiff’s attorney and that defendant has failed to demonstrate a “good reason” for delaying plaintiff’s claim.

Discussion

On a motion for summary judgment, the proponent bears the initial burden of setting forth evidentiary facts to prove a prima facie case that would entitle it to judgment in its favor, without the need for a trial (CPLR 3212; Winegrad v New York Univ. Med. Ctr., 64 NY2d 851 [1985]; Zuckerman v City of New York, 49 NY2d 557, 562 [1980]). If the proponent fails to make out its prima facie case for summary judgment, however, then its motion must be denied, regardless of the sufficiency of the opposing papers (Alvarez v Prospect Hosp., 68 NY2d 320 [1986]; Ayotte v Gervasio, 81 NY2d 1062 [1993]).

Granting a motion for summary judgment is the functional equivalent of a trial, therefore it is a drastic remedy that should not be granted where there is any doubt as to the existence of a triable issue (Rotuba Extruders v Ceppos, 46 NY2d 223 [1978]). The court’s function on these motions is limited to “issue finding,” not “issue determination” (Sillman v Twentieth Century-Fox Film Corp., 3 NY2d 395 [1957]).

Pursuant to the No-Fault regulations, generally, an insurer must pay or deny a claim for medical services within 30 calendar days after proof of the claim is received (11 NYCRR 65-3.8 [a] [1]). However, an insurer may toll the 30-day period to pay or deny a claim by requesting additional verification to establish proof of the claim within 15 business days of receipt of the claim (11 NYCRR 65-3.5 [b]). If the insurer has not received the requested verification within 30 days of the initial request, then it “shall, within 10 calendar days, follow up with the party from whom the verification was requested, either by telephone call or by mail. At the same time the insurer shall inform the applicant and such person’s attorney of the reason(s) why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested.” (11 NYCRR 65-3.6 [b]).

An insurer shall not issue a denial of claim form prior to its receipt of verification of all relevant information requested by the insurer (11 NYCRR 65-3.8 [b] [3]; see Omega Diagnostic Imaging, P.C. v MVAIC, 32 Misc 3d 128(A) [App Term, 1st Dept 2011]). However, pursuant to 11 NYCRR 65-3.5(o), an insurer may deny the claim after 120 calendar days if the party from whom verification is requested does not provide all the requested verification under its control or possession, or written proof providing reasonable justification for its failure to comply.

The information sought in a verification request “must have some rational relationship to the specific claims” (see Medical Supply of NY Direct Servs. Corp. v State Farm Ins. Co., 88 Misc 3d 1252(A) [Civ Ct, Richmond County 2026]; Doshi Diagnostic Imaging Servs. v State Farm Ins. Co., 16 Misc 3d 42 [App Term, 9th & 10th Jud Dists 2007]). At the outset, the Court rejects Baldwin’s argument that Maya lacked a good reason for seeking the requested information. An NF-3 signed by the provider and proof of assignment from Ms. Lopez are plainly rationally related to the claim and facially reasonable given the claim form submitted by SGA PLLC lacked the relevant information.

However, for an insurer to succeed on a motion for summary judgment based upon the failure to respond to verification requests, there must be evidence the requests were sent and that the party failed to provide the information and failed to provide any reasonable justification for noncompliance (Burke Physical Therapy P.C. v State Farm Mut. Auto. Ins. Co., 75 Misc 3d 143(A) [App Term, 2d Dept, 9th & 10th Jud Dists 2022]). Proof that a letter was properly mailed creates a rebuttable presumption that the letter was received by the addressee (Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]). One way such proof can be established is through proof of office practices and procedures that ensure items are properly addressed and mailed (New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2d Dept 2006]).

Defendant submitted the affidavit of Ryan Donnelly, a claims adjuster employed by Maya as proof of its mailing practices. Mr. Donnelly states that he has been employed by Maya since February 8, 2021, and that it is his duty to ensure compliance with the procedures described in his affidavit (see Affidavit of Ryan Donnelly, ¶ 16).

The Court finds that no presumption of mailing is created for the 7/7/22 verification request. Mr. Donnelly’s affidavit does not describe the office’s mailing practices and procedures applicable to the initial request. While Mr. Donnelly is the person who prepared both verification requests and his affidavit details Maya’s office mailing practices and procedures for the second additional verification request dated 8/5/22 (see Affidavit of Ryan Donnelly, ¶ 10 [NYSCEF Doc. No. 10]), Mr. Donnelly does not state that the same procedures were followed with respect to mailing of the initial request, describe what standard mailing practices were in place on the relevant date nor does Mr. Donnelly state that Maya followed uniform mailing practices during the relevant period.

Regarding the initial request, Mr. Donnelly states only that he “placed the window envelope containing the duplicate verification request letter in the ‘out’ box for the support department to process,” without detailing the steps taken by the support department to process the letter to ensure proper mailing and receipt (emphasis added). Moreover, the use of the word duplicate in relation to the first verification request is unexplained by Mr. Donnelly or defense counsel. Thus, Mr. Donnelly’s affidavit is insufficient to establish the presumption of mailing with respect to defendant’s initial verification request.

Further, even if Donnelly’s affidavit were sufficient, the NF-10 states that the first verification request was sent on 7/8/22, not 7/7/22 as Maya contends. This inconsistency itself raises a triable issue of fact as to when the first verification request was mailed.

Therefore, the Court finds that Maya failed to meet its burden of establishing its prima facie defense that it timely and properly mailed its requests for additional verification, thereby tolling the 30-day period in which to pay or deny plaintiff’s claim.

Baldwin’s remaining arguments

Having determined that Maya has not proven its timely and proper mailing of the [*3]verification requests, the Court will address Baldwin’s remaining argument that the additional verification was not properly sent to both Baldwin and its attorney. Plaintiff cites 11 NYCRR 65-3.6 (b), which requires the insurer to follow up with the party from whom the verification was requested, either by telephone call or by mail, and “[a]t the same time inform the ‘applicant’ and such person’s attorney of the reason(s) why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested” (see e.g. Doshi Diagnostic Imaging Services v State Farm Ins. Co., 16 Misc 3d 42 [App Term, 2d Dept, 9th and 10th Jud. Dists. 2007]). As the Court explained in Doshi, “[w]here verification is sought from a party other than the applicant, the applicant is entitled to be timely informed of the nature of the verification sought and from whom it is requested when, after an initial verification request remains unsatisfied, a follow-up request is necessary.”

Plaintiff’s counsel misconstrues 11 NYCRR 65-3.6 (b), which does not stand for the proposition that Maya’s verification requests were not properly sent because they were not separately sent to both Baldwin and SGA PLLC. This No-Fault regulation only requires notice to the applicant (the party seeking payment on a claim) and its attorney where the verification request is sent to a third party, not where the verification request is sent to the applicant itself (GNK Medical Supply, Inc. v Tri-State Consumer Ins. Co., 37 Misc 3d 138(A) [App Term, 1st Dept 2012]). Here, the verification request was directed to Baldwin, through its attorney, who had filed the claim. Nor does section 65-3.6 (b) require Maya to send two separate verification requests to both Baldwin and its attorney when Baldwin’s claim was filed by its attorney who clearly stated in the 6/15/22 letter that it was retained by Baldwin in connection with the underlying claim. This Court is unaware of any other court that has reached such a holding, and such a requirement would be manifestly unfair where it is not only undisputed that Baldwin did not respond to Maya’s verification requests, but Baldwin does not claim any prejudice resulting from Maya sending its verification requests to Baldwin’s attorney.

Baldwin’s attorney clearly put Maya on notice that it was the agent for Baldwin with respect to the claim submitted and thus “sending the verification request to the attorneys was the same as sending the request to the principal,” regardless of whatever directions Baldwin’s attorney puts in their pro forma letters (Lenox Hill Radiology v Global Liberty Ins. Co. of NY, 20 Misc 3d 434 [Civ Ct, NY County 2008] quoting Bauer v CS-Graces, LLC, 48 AD3d 922 [3d Dept 2008] [“The law is well settled that, unless obtained confidentially, ‘knowledge acquired by an agent acting within the scope of [their] agency is imputed to [their] principal and the latter is bound by such knowledge'”]).

Moreover, “[a]ny confusion on the part of the plaintiff as to what was being sought should have been addressed by further communication, not inaction” (Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553 [2d Dept 1999]; see also Advantage Radiology, P.C. v Nationwide Mut. Ins. Co., 55 Misc 3d 91 [App Term, 2d Dept, 9th & 10th Jud Dists 2017]). Therefore, plaintiff’s argument that Maya’s denial was improper because copies of Maya’s verification requests were not sent to both Baldwin and Baldwin’s attorney is rejected. Thus, it remains for trial to determine whether Maya timely and properly mailed its verification requests. If that defense is proven, then this action was prematurely commenced since Maya’s verification requests were still outstanding at the time Baldwin filed its summons and complaint.

[*4]Conclusion

In accordance herewith, it is hereby

ORDERED that defendant’s motion for summary judgment is denied.

This action is ready for trial and remains on the Court’s calendar for a virtual appearance on September 9, 2026 at 11:00AM.

Any requested relief not expressly addressed herein has nonetheless been considered and is hereby denied.

This constitutes the decision and order of the Court.

Date: 08/19/2026

Hon. Eric J. Wursthorn

Civil Court Judge (NYC)