Decided on July 14, 2017

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

[*1]

Supreme Court, Appellate Term, Second Department, 2d, 11th and 13th Judicial Districts, July 14, 2017

APPEARANCES OF COUNSEL

Law Office of Jason Tenenbaum, P.C. (Jason Tenenbaum of counsel) for appellant.

Korsunskiy Legal Group, P.C. (Henry R. Guindi of counsel) for respondent.

Ordered that the order is affirmed, with $25 costs.

In July 2012, plaintiff (the provider) commenced this action to recover assigned first-party no-fault benefits for medical services rendered to its assignor, who had allegedly been injured in a motor vehicle accident that had occurred on August 8, 2011. Defendant (the insurer) failed to timely answer or appear in this action, and instead commenced a declaratory judgment action in the Supreme Court, New York County, against the provider, among others, seeking a declaration that the defendants in that action were not entitled to recover no-fault benefits arising out of the August 8, 2011 motor vehicle accident.

After the insurer defaulted in the instant action, the provider moved for leave to enter a default judgment against the insurer. The Civil Court granted the motion, and a default judgment in the principal sum of $475 was entered against the insurer on March 6, 2013.^[FN*] In July 2013, the insurer moved to vacate the default judgment and to compel the provider to accept its late{**57 Misc 3d at 19} answer. The provider opposed the motion and cross-moved for “summary judgment.” The insurer did not oppose the cross motion. By order entered July 16, 2014, the Civil Court (Devin P. Cohen, J.) denied the insurer’s motion and granted, on default, the provider’s cross motion, stating that “the judgment stands.”

On July 28, 2014, the insurer moved for “summary judgment” dismissing the complaint, contending that the amount due and owing pursuant to the Civil Court judgment had been satisfied, as an order and judgment in the Supreme Court declaratory action had been entered in [*2]the insurer’s favor on July 14, 2014, declaring that the provider, among others, was not entitled to recover no-fault benefits with respect to the motor vehicle accident at issue. The order and judgment further provided that the insurer recover from the various named defendants therein, including the provider, “costs and disbursements as taxed by the Clerk in the sum of $1,125.” The insurer alleged, in its motion papers, that the judgment in this action had been fully satisfied by virtue of a “partial satisfaction,” resulting from the judgment entered in the Supreme Court declaratory judgment action. Annexed to the motion papers was a document entitled “Partial Satisfaction of Judgment” which had been executed by the insurer’s counsel on July 28, 2014, and which bore the caption of the Supreme Court action. In the alternative, the insurer’s motion sought a “satisfaction of any entered judgment” in the Civil Court, pursuant to CPLR 5020 (c). The provider opposed the insurer’s motion. By order entered April 23, 2015, from which the insurer appeals, the Civil Court denied the insurer’s motion. We affirm.

[1] We initially note that the branch of the insurer’s motion seeking “summary judgment” was inappropriate because a judgment had already been entered against the insurer. However, the insurer also sought, in the alternative, a “satisfaction of any entered judgment” in the Civil Court, based on the judgment in favor of the insurer in the Supreme Court declaratory judgment action. Although reference was made to CPLR 5020 (c) in support of this branch of the insurer’s motion, this provision has no applicability to the circumstances herein. If the insurer was actually seeking the entry of a satisfaction of judgment, the proper way to seek such relief would be by way of a motion pursuant to CPLR 5021 (a) (2). However, in support of its motion, the insurer did not demonstrate that it had filed a partial satisfaction of judgment in the Supreme Court action, in accordance with CPLR 5020 (a). Consequently,{**57 Misc 3d at 20} insofar as the insurer’s motion sought the entry of a satisfaction of judgment in the Civil Court action, such relief was properly denied by the Civil Court.

[2] Notwithstanding the foregoing, it was apparently the insurer’s objective to have a portion of the judgment in the Supreme Court declaratory judgment action fully offset the judgment obtained against it in the Civil Court action. While a court may exercise its “inherent authority to set one judgment off against another” (see Joseph Kali Corp. v A. Goldner, Inc., 49 AD3d 397, 398 [2008]; see also Scianna v Scianna, 205 AD2d 750 [1994]), the granting of such relief rests in the discretion of the court (see Beecher v Vogt Mfg. Co., 227 NY 468, 473 [1920]; Kretsch v Denofrio, 137 App Div 617, 619 [1910]). Assuming, without deciding, that the Civil Court possessed the jurisdiction to entertain such an application (cf. Stilwell v Carpenter, 62 NY 639 [1875]), the Civil Court’s determination not to set off the judgments was not an improvident exercise of discretion.

Accordingly, the order is affirmed.

Pesce, P.J., Weston and Aliotta, JJ., concur.

Footnotes

Footnote *:The record indicates that an amended judgment in the principal sum of $475 (and in the aggregate sum of $939.90) was entered on August 15, 2014.

SMCV 0083-16
James F. Matthews, J.

Upon the following papers numbered 1 to 10 read on this motion for an order of summary judgment dismissing the complaint ; by Notice of Motion /Order to Show Cause and supporting papers 1,2,6 ; Notice of Cross Motion and supporting papers ; Answering Affidavits and supporting papers 7,9 ; Replying Affidavits and supporting papers 10 ; Filed papers; Other exhibits: 3-5,8, ;(and after hearing counsel in support of and opposed to the motion),

it is,

ORDERED that the motion by defendant for summary judgment dismissing the complaint, pursuant to CPLR 3212, is denied.

Defendant moves by summary judgment for dismissal of plaintiff’s complaint, which seeks recovery of first-party no-fault benefits in the sum of $6,651.66 for medical services rendered to plaintiff’s assignor on 09/21/15 through 10/26/15 as the result of an automobile accident which occurred on 09/03/15.

The ground for dismissal is defendant’s contention that the claims totaling $6,651.66 are not overdue, as the time to pay or deny has not commenced, due to the plaintiff’s failure to provide the information requested in its verification requests and follow-up verification requests, for each of the collective claims. Defendant claims an “exhaustive” search of its computer and paper file revealed that the sought verification information was never received by defendant.^[FN1]

In opposition to the motion, plaintiff asserts defendant has failed to demonstrate by admissible evidence, that the verification requests were timely and properly mailed to plaintiff. Also, plaintiff contends the affidavits submitted in support of defendant’s motion, have not provided a foundation for admission of its business records, a necessary part of demonstrating plaintiff’s office practice and procedures.

Plaintiff further asserts defendant has not shown “good reasons” for demanding the verifications which tolled the time from which defendant had to pay or deny the claims. Finally, plaintiff contends it responded to the verification requests of defendant by providing all the documents within its control, which it claims were already in defendant’s possession, thereby making defendant’s verification requests defective and precluding defendant from raising non-coverage defenses to plaintiff’s claims.

No-fault regulations mandate that a claim for health services expenses be submitted by written proof of claim to the insurer, no later than 45 days after the date that health services were rendered (see 11 NYCRR §65-2.4[c]). After receipt of the written proof of claim, a no-fault claim is overdue if not paid or denied by the insurer within 30 calendar days (see Insurance Law §5106[a]; 11 NYCRR §65-3.8[a][1],[c]).

The thirty days may be extended where an insurer requests additional verification within 15 days of receipt of the claim (see 11 NYCRR 65-3.5[b]). If the insurer has not received a verification from the plaintiff within 30 days of the initial request, an insurer must send a follow-up verification request by phone call or mail within 10 days to the requested party (see 11 NYCRR §65-3.6[b]). This tolls the insurer’s obligation to pay or deny the claim until it receives the additional information requested (see 11 NYCRR 65-3.8[a][1]; Hospital For Joint Diseases v Traveler’s Property Casualty Ins. Co., 9 NY3d 312 [2007]).

Where a requested verification is not provided an insurer is not required to pay or deny the claim (see 11 NYCRR §65-3.8[3]; NY & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [2nd Dept 2004]). However, an insurer may deny the claim after 120 calendar days if plaintiff does not provide all of the requested verification under its control or possession, or written proof providing reasonable justification for its failure to comply (see 11 NYCRR §65-3.5[o], for all claims submitted after 4/1/13). Also, an insurer’s “non-substantive, technical or immaterial defect or omission, as well as an insurer’s failure to comply with a prescribed time frame” shall not “negate an applicant’s obligation to comply with the request or notice” (see 11 NYCRR §65-3.5[p], for all claims submitted after 4/1/13).

Though an insurer is entitled to request and receive information necessary to the processing and verifying of the provider’s claim (see 11 NYCRR §65-3.5[c]), the scope of the requested materials are not unlimited (see generally 11 NYCRR 65-3.6[b]). Insurance regulations require the existence of “good reasons” to demand verification (see 11 NYCRR 65-3.2[c]; Doshi Diagnostic Imaging Servs. v State Farm Ins. Co., 16 Misc 3d 42 [2nd Dept 2007).

A proponent of a motion for summary judgment must make a prima facie showing of entitlement to judgment as a matter of law with proof in admissible form sufficient to establish the lack of any material issues of fact (see Alvarez v Prospect Hospital, 68 NY2d 320, 324 [1986]; Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]; Zuckerman v City of New York, 49 NY2d 557, 562 [1980]); see also Manhattan Medical v State Farm Mut. Ins. Co., 20 Misc 3d 1144[A][Civ. Ct. Richmond Cty. 2008]).

A summary judgment motion must be supported by an affidavit of a person having knowledge of the facts and the affidavit shall recite all the material facts and show there is no [*2]defense to the cause of action or that the cause of action or defense has no merit (see CPLR 3212[b]). A conclusory affidavit or an affidavit by an individual who lacks personal knowledge of the facts does not satisfy the proponent’s prima facie burden (see JMD Holding Corp. v Congress Financial Corp., 4 NY3d 373 [2005]).

Here, the Court determines that defendant has failed to demonstrate a prima facie entitlement to summary judgment for dismissal with proof in admissible form sufficient to establish there are no material issues of fact (see Alvarez v Prospect Hospital, supra; Stephen Fogel Psychological, P.C. v Progressive Ins. Co., 35 AD3d 720, 721 [2nd Dept 2006]; Prime Psychological Services P.C. v Nationwide Prop. & Cas. Ins. Co.,24 Misc 3d 230, 232 [Civ Ct. Richmond Cty. 2009]).

The Court notes that the affidavit of Regina Abbatiello, No-Fault Claims Adjuster, demonstrates she was personally familiar with the standard office policy and operating procedures for the processing of no-fault claims in litigation or arbitration, including payments and denials of benefits. She states her affidavit was given after a detailed review “of all document/ correspondence and computer records maintained by Global in accordance with its standard operating procedures that are recorded/document and maintained under claim no. NF15930301.”

She further states she generated the verification requests, and follow-up additional verification requests with carbon copies, to the plaintiff assignor at the address shown on the NF-3 claim forms, seeking information, including MRI films, and the referring doctor’s report on the need for multiple MRI studies. Defendant’s records show that a verification request was sent out on 11/18/15 for each claim which had been received on 11/09/15.

Upon not receiving a response, a second verification request was sent out on 12/18/15. No response with the requested information was provided.

The Court finds the stated procedure in the instant matter is conclusory and lacking in relevant specifics to set forth the standard office practice or procedure used to ensure that items were properly addressed and mailed (see Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App.Term 2nd Dept 2007]). The proof establishes that verification requests are placed by the adjusters in the outgoing mail bin. However, the proof fails to sufficiently demonstrate what happens to the verification requests after placement in the mail bin. It appears that mixed mail for defendant’s office is placed in the mail bin, not just mail being sent for verification requests. Since the mail is submitted in a sealed envelope, the procedure described fails to show the contents of each envelope which is being processed (see Presbyterian Hosp. v Maryland Casualty Ins. Co., 226 AD2d 613 [2nd Dept 1996]; see also S & M Supply Inc. v GEICO Ins. Co., 2003 NY Slip Op 51192[U][App Term, 2nd & 11th Jud Dists 2003]).Consequently, it does not demonstrate that the verification requests to plaintiff were inside the envelopes taken by the defendant’s mailing clerk to the U.S. Post Office in the afternoon. In addition, there is no affidavit from an employee mail clerk attesting to the actual mailing of the verification requests. The Court also notes the lack of any certificates of mailing signed and stamped by an employee of the U.S. Postal Service to confirm the mailing of the defendant’s requests for verification, which would give rise to a rebuttable presumption of mailing by defendant (see A.B. Med. Servs. PLLC. v USAA Cas. Ins. Co., 6 Misc 3d 126[A][App. Term, 2nd & 11th Jud. Dists. 2004]; Residential Holding Corp. v Scottsdale Ins. Co., 286 Ad2d 679 [2nd Dept 2001]).

Moreover, a copy of defendant’s actual letters of requests for further verification are [*3]attached as an exhibit to the moving papers. However, there is no admissible statement from any person having knowledge of the facts which would sufficiently link the standard office practices and procedures for the generating and mailing of these verifications. Nor is there any sworn statement from a person with knowledge, for admitting these letters as business records (see CPLR 4518[a]). The only connecting statement is made by the affirmations of defendant’s counsel, which have no evidentiary value, as an attorney’s affirmation not based upon personal knowledge is without probative value or evidentiary significance (see Warrington v Ryder Truck Rental, Inc., 35 AD3d 455, 456 [2nd Dept 2006]; see also Wesh v Laidlaw, 59 AD3d 534 [2nd Dept 2009]). Also, defendant’s attorneys have not provided a proper foundation for an opinion (see People v Goldstein, 6 NY3d 119 [2005]). In addition, an attorney’s opinion which is not based upon personal knowledge “is without evidentiary value and thus unavailing” (see Zuckerman v City of New York, supra at 563).

The Court further finds that defendant has failed to establish an objective, reasonable basis for the contents of the verification demands alleged to have been mailed to plaintiff (see 11 NYCRR 65-3.2[c]; Doshi Diagnostic Imaging Servs. v State Farm Ins. Co., 16 Misc 3d 42 [2nd Dept 2007).

The evidence shows that verification requests were responded to by plaintiff’s attorneys, by 7 cover letters each dated 12/18/15, for the respective claim amounts of: $878.67, $878.67, $878.67, $878.67, $912.00, $959.61 and $879.73. In each letter, plaintiff’s attorneys stated:

“Enclosed please find a further response to your verification request”(emphasis added) concerning the above-referenced claim. These documents constitute all available documentation provided by the above-referenced provider. Accordingly, kindly remit payment. Failure to do so may result in litigation being commenced”

Attached to each letter was a copy of a pertinent medical report showing the results of an: MRI left wrist without contrast, MRI left hip without contrast, MRI left foot without contrast, MRI left shoulder without contrast, MRI lumbar spine without contrast, MRI thoracic spine without contrast, and MRI cervical spine without contrast.

Plaintiff has demonstrated it satisfied its duty to timely communicate with defendant, providing a statement of reasonable justification why it could not provide what further verification sought, as it had provided all of the available documents (see 11 NYCRR §65-3.5[o]; see also Dilon Med. Supply Corp. v Travelers Ins. Co.,7 Misc 3d 927, 931-932 [NY City Civ. Ct. 2005]), and it would be unable to fully satisfy the insurer’s request (see Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 Ad2d 553 [2nd Dept 1999]). A defendant also has a duty to act, by payment or denial of the claim or request for further verification, upon receipt of plaintiff’s response to defendant’s verification request, so long as plaintiff’s documentation is arguably responsive to defendant’s verification request (see All Health Med. Care v Government Employees Ins. Co., 2 Misc 3d 907 [NY City Civ Ct. 2004]).

Here, defendant remained silent in the face of plaintiff’s verification responses, and failed to demonstrate “good reason” to support its continued verification requests, as required by 11 NYCRR 65-3.2[c]).

Moreover, there is no sworn statement from anyone with knowledge, which provides a reasonable basis for the verification demands. The affidavit of Regina Abbatiello (No-Fault Examiner) states that upon receipt of the claim with billing, “the following represent the bills that [*4]were delayed pending the receipt of additional verification.” She further states: “the additional verification requests and follow-up additional verification requests were sent to Plaintiff Assignee with appropriate carbon copies in accordance with the regulations.”

She then relates what was sought: “The information that was sought included: copies of mri films; referring doctors report on the need for multiple mri studies.” However, the foregoing statements are conclusory, and no reason is stated for the verification requests. Nor is any recognition or credit acknowledged in her affidavit for the 7 letters of 12/18/15 with MRI medical reports supplied by plaintiff in response to the verification demands.

For the foregoing reasons, the Court determines defendant has failed to establish a prima facie showing of entitlement to summary judgment dismissing the complaint as a matter of law.

Accordingly, the motion for summary judgment by defendant dismissing plaintiff’s complaint pursuant to CPLR 3212, is denied.

The foregoing constitutes the decision and order of this Court.

Dated: July 6, 2017

Footnotes

Footnote 1: The affidavit of the No-Fault Claims Adjuster fails to state who conducted the “exhaustive” search of its computer and paper file to determine that the verification information sought was never received by the defendant.

Decided on June 23, 2017

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

Decided on June 23, 2017

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

Kopelevich & Feldsherova, P.C. (Galina Feldsherova, Esq.), for appellant. The Law Office of Printz & Goldstein (Lawrence J. Chanice, Esq.), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Pamela L. Fisher, J.), entered June 10, 2014. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order is modified by providing that defendant’s cross motion for summary judgment dismissing the complaint is denied; as so modified, the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint. The court found that defendant had demonstrated that the limits of the applicable insurance policy had been exhausted.

Since the insurance policy at issue contains a provision that “[t]he policy and any amendment(s) and endorsement(s) are to be interpreted pursuant to the laws of Georgia,” the substantive law of Georgia applies (see St. Chiropractic, P.C. v Geico Gen. Ins. Co., 53 Misc 3d 59, 61 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]; Natural Therapy Acupuncture, [*2]P.C. v . Geico Ins. Co., 50 Misc 3d 107 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]; Bay Med., P.C. v. GEICO Ins. Co., 41 Misc 3d 145[A], 2013 NY Slip Op 52084[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]). However, New York’s procedural laws control (see St. Chiropractic, P.C. v Geico Gen. Ins. Co., 53 Misc 3d at 61).

The affidavit of defendant’s underwriter which was submitted in support of defendant’s cross motion was sufficient to provide a foundation for the consideration of the annexed copies of the insurance policy and declaration page, which indicated that the policy had a $10,000 medical payment limit. However, that affidavit and an affidavit by defendant’s claims division employee failed to establish defendant’s prima facie entitlement to summary judgment dismissing the complaint, since the assertions contained therein failed to provide a foundation for the consideration of the annexed printouts—which purportedly show that the $10,000 policy limit had been exhausted—inasmuch as neither affidavit specifically addressed the printouts. Moreover, it is noted that Section 1 of the insurance policy, entitled “Out of State Insurance,” provides that when “the policy applies to the operation of a motor vehicle outside your state, we agree to increase your coverages to the extent required of out-of-state motorists by local law” (emphasis in the original). It is uncontroverted that the accident took place in South Carolina, and defendant provided no information regarding the minimum financial responsibility required by the State of South Carolina. Consequently, defendant’s cross motion for summary judgment dismissing the complaint should have been denied.

Although the affidavit plaintiff submitted in support of its motion was sufficient to establish that the claim had been timely and properly mailed to defendant, the conclusory statements contained in the affidavit failed to establish that the claim had not been timely denied (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]), or that defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law (see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]). Consequently, plaintiff failed to establish its prima facie entitlement to summary judgment.

Accordingly, the order is modified by providing that defendant’s cross motion for summary judgment dismissing the complaint is denied.

ELLIOT, J.P., PESCE and SOLOMON, JJ., concur.

[*1]

Supreme Court, Appellate Term, Second Department, 2d, 11th and 13th Judicial Districts, June 23, 2017

APPEARANCES OF COUNSEL

Law Offices of Melissa Betancourt, P.C. (Melissa Betancourt of counsel) for appellant.

Law Office of Jason Tenenbaum, P.C. (Jason Tenenbaum of counsel) for respondent.

Ordered that, on the court’s own motion, defendant’s notice of appeal is treated as an application for leave to appeal from so much of the Civil Court’s order as, in effect, sua sponte searched the record and granted defendant partial summary judgment dismissing so much of the complaint as was asserted by plaintiff Fresh Acupuncture, P.C., and leave to appeal from that portion of the order is granted (see CCA 1702 [c]); and it is further ordered that the order, insofar as appealed from, is reversed, with $30 costs, and so much of the order as, in effect, sua sponte searched the record and granted defendant partial summary judgment dismissing so much of the complaint as was asserted by plaintiff Fresh Acupuncture, P.C. is vacated.

In this action, commenced on April 12, 2013, by three providers to recover assigned first-party no-fault benefits, defendant interposed an answer, which asserted, among other things, that the action is barred by the doctrine of res judicata. Thereafter, defendant moved for partial summary judgment dismissing so much of the complaint as was asserted by plaintiffs Advanced Wellness Chiropractic, P.C. and Maximum Care Physical Therapy, P.C. upon grounds not at issue here. Plaintiffs opposed the motion and cross-moved for summary judgment in favor of all three plaintiffs. In opposition to plaintiffs’ cross motion and in further support of defendant’s motion, defendant’s attorney submitted an affirmation in which he argued that, on the basis of an order in a declaratory judgment action in the Civil Court, New York County, entered October 6, 2014, upon the default of plaintiff Fresh Acupuncture, P.C., Fresh Acupuncture is not entitled to receive no-fault benefits for the accident at issue on the ground of the failure{**56 Misc 3d at 100} by Fresh Acupuncture to appear for scheduled examinations under oath. Fresh Acupuncture appeals from so much of an order of the Civil Court as, upon plaintiffs’ cross motion for summary judgment, in effect, sua sponte searched the record and granted defendant partial summary judgment dismissing so much of the complaint as was asserted by Fresh Acupuncture.

Insofar as is relevant here, CCA 212-a provides:

“The [Civil Court] shall have the jurisdiction defined in section 3001 of the CPLR to make a declaratory judgment with respect to:

“(a) any controversy involving the obligation of an insurer to indemnify or defend a defendant in an action in which the amount sought to be recovered does not exceed $25,000.”

The Civil Court, New York County, declaratory judgment action was an action by an insurer against a provider and did not involve a “controversy involving the obligation of an insurer to indemnify or defend a defendant in an action in which the amount sought to be recovered does not exceed $25,000.” Thus, the Civil Court, New York County, lacked subject matter jurisdiction to entertain the declaratory judgment action (see CPLR 3001; see generally 133 Plus 24 Sanford Ave. Realty Corp. v Xiu Lan Ni, 47 Misc 3d 55, 58 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]). To the extent that this court’s decision in Five Boro Psychological Servs., P.C. v AutoOne Ins. Co. (27 Misc 3d 89 [2010]) may have held to the contrary, it should not be followed.

Accordingly, the order, insofar as appealed from, is reversed, and so much of the order as, in effect, sua sponte searched the record and granted defendant partial summary judgment dismissing so much of the complaint as was asserted by plaintiff Fresh Acupuncture, P.C., is vacated.

Elliot, J.P., Pesce and Solomon, JJ., concur.

601499/2017

For Plaintiff: Jason Tenenbaum, Esq.
For Defendant: Rachel Drachman, Esq.

The following papers read on this motion:

Karen V. Murphy, J.

Defendant moves this Court for an Order dismissing the complaint on the ground that this matter has already been adjudicated in arbitration, and that the pleading fails to state a cause of action. Defendant also seeks to consolidate this matter with a Bronx County matter identified by Supreme Court Index No. 25976/2016E (Motion Sequence 001).

Plaintiff opposes Motion Sequence 001 and cross-moves for an Order granting plaintiff summary judgment adjudging and declaring that defendant is not entitled to no-fault coverage for the motor vehicle accident that occurred on December 17, 2014 (Motion Sequence 002). Motion Sequence 002 is unopposed.

With regard to Motion Sequence 001, that branch seeking to consolidate this action with a Bronx County action entitled Global Liberty Insurance Co. v. FJ Orthopedics and Pain Management, PLLC, a/a/o Mary King is denied. The Bronx County action was disposed on May 1, 2017 by judgment granting Global Liberty Insurance Company of New York a default judgment declaring that defendant FJ Orthopedics and Pain Management, PLLC is not entitled to reimbursement for services performed on defendant’s assignor (Mary King) for alleged injuries sustained in a motor vehicle accident that occurred on December 17, 2014.

The action pending before this Court involves the same assignor, Mary King, and results [*2]from the same motor vehicle accident.

That branch of defendant’s motion seeking dismissal of this action on the ground that arbitration has already been held is also denied. Defendant contends that “the matter was submitted for Arbitration. In light of the fact that the claims herein have already had an opportunity to be adjudicated, and both parties had a fair hearing, it would be a waste of the parties’ time and resources . . . and a waste of this Courts (sic) time and resources and against the interests of judicial economy, for the parties to reset litigation of the subject claims and begin the process anew in the supreme courts.”^[FN1]

Contrary to defendant’s contention, Insurance Law § 5106 (c) and 11 NYCRR 4.10 (h)(1) (ii) expressly provide that either party to a matter submitted to arbitration has the right to a de novo determination of the dispute in the event that the master arbitrator’s award equals or exceeds $5,000, exclusive of interest and attorneys’ fees (Matter of Greenberg, 70 NY2d 573 [1987]; AutoOne Insurance Company v. Eastern Island Medical Care, P.C., 141 AD3d 499 [2d Dept 2016]; Allstate Insurance Company v. Nalbandian, 89 AD3d 648 [2d Dept 2011]; Progressive Insurance Company v. Strough, 55 AD3d 1402 [4th Dept 2008]).

Moreover, there is no evidence presented that the policy in question contained a binding arbitration clause, nor has defendant ever moved for confirmation of the arbitration award, which, if confirmed, would be accorded res judicata effect (see Aetna Casualty & Surety Company v. Mantovani, 240 AD2d 566 [2d Dept 1997]).

That branch of defendant’s motion seeking dismissal of the complaint for failure to plead with particularity in accordance with CPLR § 3013 is also denied. This Court has reviewed the complaint filed in this action and finds that it sets forth the facts underlying the cause of action seeking declaratory judgment with sufficient particularity to give notice of plaintiff’s claim. The series of transactions and occurrences intended to be proved, including the billing and verification demands that were sent and not complied with, are adequately set forth (Di Mauro v. Metropolitan Suburban Bus Authority, 105 AD2d 236, 239 [2d Dept 1984]).

Although defendant does not specifically refer to CPLR §3211 (a)(7) in claiming that plaintiff fails to state a cause of action, the Court will address defendant’s claim as one made pursuant to the statute.Defendant has answered; however, this branch of its motion is not time-barred by CPLR § 3211 (e).

When deciding a motion to dismiss pursuant to CPLR § 3211(a)(7), the court must afford the complaint a liberal construction, accepting all facts as alleged in the complaint to be true, and according the plaintiffs the benefit of every favorable inference (see Marcantonio v Picozzi III, 70 AD3d 655 [2d Dept 2010]). The sole criterion on a motion to dismiss is “whether the pleading states a cause of action, and if from its four corners factual allegations are discerned which taken together manifest any cognizable action at law a motion for dismissal will fail” (Guggenheimer v Ginzburg, 43 NY2d 268, 275 [1977]; see also Miglino v. Bally Total Fitness of Greater New York, Inc., 20 NY3d, 342, 351 [2013]; Leon v Martinez, 84 NY2d 83, 87-88, [1994]; Sokol v Leader, 74 AD3d 1180, 1180-1181 [2d Dept 2010]; Gershon v Goldberg, 30 AD3d 372, 373 [2d Dept 2006]). “Whether a plaintiff can ultimately establish its allegations is not part of the calculus in determining a motion to dismiss” (EBC I, Inc. v Goldman, Sachs & [*3]Co., 5 NY3d 11, 19 [2005]).

“A court is, of course, permitted to consider evidentiary material submitted by a defendant in support of a motion to dismiss pursuant to CPLR 3211 (a)(7) [citation omitted]” (Sokol, supra at 1181). “When evidentiary material is considered, the criterion is whether the proponent of the pleading has a cause of action, not whether he has stated one, and, unless it has been shown that a material fact as claimed by the pleader to be one is not a fact at all and unless it can be said that no significant dispute exists regarding it… dismissal should not eventuate” (Guggenheimer, supra at 275; see also Vertical Progression, Inc. v. Canyon Johnson Urban Funds, 126 AD3d 784 [2d Dept 2015]; YDRA, LLC v. Mitchell, 123 AD3d 1113 [2d Dept 2014]; Korsinsky v. Rose, 120 AD3d 1307 [2d Dept 2014]).

“Whether or not issue has been joined, the court, after adequate notice to the parties, may treat the motion as a motion for summary judgment” (CPLR § 3211 [c]). Without proper notice, a “court’s sua sponte treatment of the motion as one for summary judgment [would] deprive[ ] plaintiff of the ‘opportunity to make an appropriate record’ and thus thwart[ ] the very purpose of CPLR 3211 (c)” (Mihlovan v. Grozavu, 72 NY2d 506, 508 [1988], quoting Rovello v. Orofino Realty Co., 40 NY2d 633, 635 [1976]).

“There are nevertheless three circumstances under which a court’s failure to provide CPLR 3211 (c) notice may be overlooked. One circumstance is when CPLR 3211 (c) treatment is specifically requested not by one party, but by all of the parties, or is at least requested by the same party that is aggrieved by the summary judgment determination. A second circumstance is when a dispute involves no questions of fact, but only issues of law argued by all parties, such as in the context of declaratory judgment actions involving an issue of statutory construction or the application of an unambiguous contractual provision. The third circumstance is when the respective submissions of both parties demonstrate that they are laying bare their proof and deliberately charting a summary judgment course [citations omitted]” (Hendrickson v. Philbor Motors, Inc., 102 AD3d 251, 258-259 [2d Dept 2012]).

In this case, defendant claims that it complied with plaintiff’s verification request, and submits an affidavit from an individual employed as a Billing Manager for MD Capital Advisors, the third-party billing company that handles all no-fault billing for FJ Orthopedics PLLC, purporting to establish that the surgery center that hosted the surgical procedure performed on Mary King responded to Global Liberty’s verification requests. Defendant also attaches a copy of three small photographs that are claimed to be the surgical photographs requested by plaintiff Global Liberty.

Accordingly, defendant lays bare its proof, arguing that this action should be dismissed because it complied with plaintiff’s verification requests; as established in arbitration, the surgical photos were provided to plaintiff by the surgery center where the procedure was performed; “[w]hether they received the photos from FJ Orthopedics, from Doshi Diagnostic or from Excel Surgery Center should be of no importance as long as they have the photos in their possession.”

In response to defendant’s motion, plaintiff cross-moves for summary judgment (Motion Sequence 002). Plaintiff’s motion was e-filed and served on April 6, 2017; defendant’s motion was e-filed on March 15, 2017. Both Motion Sequences 001 and 002 bore return dates of April 7, 2017. On April 7, 2017, both sequences were adjourned to April 17, 2017, on which date they were marked submitted for the Court’s consideration. Defendant does not oppose plaintiff’s summary judgment motion. Thus, it would not thwart the purpose of CPLR § 3211 (c) to [*4]convert defendant’s motion to one for summary judgment. Plaintiff, having responded to defendant’s motion with its own motion for summary judgment, has not been deprived of an opportunity to make an appropriate record (cf. Mihlovan, supra). Moreover, defendant has not been deprived of an opportunity to supplement its proof by responding to plaintiff’s summary judgment motion; plaintiff’s summary judgment motion was adjourned to April 17, 2017, but defendant apparently chose not to oppose it. Accordingly, the Court will now consider plaintiff’s summary judgment motion.

It is well recognized that summary judgment is a drastic remedy and as such should only be granted in the limited circumstances where there are no triable issues of fact (Andre v. Pomeroy, 35 NY2d 361[l974]). Summary judgment should only be granted where the court finds as a matter of law that there is no genuine issue as to any material fact (Cauthers v. Brite Ideas, LLC, 41 AD3d 755 [2d Dept 2007]). The Court’s analysis of the evidence must be viewed in the light most favorable to the non-moving party, herein the defendant (Makaj v. Metropolitan Transportation Authority, 18 AD3d 625 [2d Dept 2005]).

A party moving for summary judgment must make a prima facie showing of entitlement as a matter of law, offering sufficient evidence to demonstrate the absence of any material issues of fact. (Winegrad v New York Univ. Med. Center, 64 NY2d 851 [1985]; Zuckerman v City of New York, 49 NY2d 557 [1980]).

“A no-fault claim is overdue if it is not paid or denied within thirty [30] days of receipt (see Insurance Law § 5106 [a]; 11 N.Y.C.R.R. 65-3.8 [a][1] & [c]) unless, within fifteen [15] business days of receipt of the claim, the insurer requests additional verification (see 11 N.Y.C.R.R. 65-3.8 [b][3])” (Westchester Medical Center a/a/o Salvatore Dipietro v GEICO, 2011 NY Slip Op 30862 [Sup Ct, Nassau County 2011]; A.B. Medical Services PLLC a/a/o David Ruiz v. GEICO General Insurance Company, 22 Misc 3d 1116A, 880 NYS2d 222 [Dist Ct, Nassau County 2008]).

Plaintiff contends that “[i]t is uncontroverted that the MRI films were never received” pursuant to plaintiff’s written verification requests; therefore, the no-fault billing is not overdue, and it should be declared that plaintiff does not owe defendant no-fault benefits.

In support of its motion, plaintiff submits, inter alia, the summons, complaint, and answer, the written verification requests made to defendant Lewin and to Doshi Diagnostic Imaging Services for the MRI films, and the affidavit of plaintiff’s no-fault claims adjuster.

Based upon the affidavit of Regina Abbatiello, plaintiff’s no-fault claims adjuster, plaintiff establishes that the surgery was performed on March 24, 2015, and the bill from defendant was received on April 9, 2015. The bill was delayed pending receipt of operative photographs and MRI films. By written request dated March 20, 2015, plaintiff requested, inter alia, “a copy of the R/Shoulder MRI films” from Doshi Diagnostic Imaging Services. Apparently, plaintiff did not receive the MRI films, and it sent a second written verification request to Doshi dated April 20, 2015.

Not having received the MRI films, plaintiff, by written requests dated April 28, 2015 and May 28, 2015, notified defendant and requested a copy of the right shoulder MRI films from defendant. The letters are addressed to Jonathan Lewin MD PC, and they state in relevant part, “[a]lso awaiting a copy of the R/Shoulder MRI films from Doshi Diagnostic MRI which were requested from the MRI facility and the doctor’s office. Once received the claim will be reviewed and processed.” Ms. Abbatiello’s affidavit avers that the MRI films were never received from either Doshi or from defendant Lewin.

Based upon the foregoing, plaintiff has established its prima facie entitlement to summary judgment as a matter of law that the claim is not overdue, since the additional verification remains outstanding, and that defendant is not entitled to reimbursement for no-fault benefits a/a/o Mary King related to the motor vehicle accident that occurred on December 17, 2014 (St. Vincent’s Hospital of Richmond v. American Transit Insurance Company, 299 AD2d 338 [2d Dept 2002]; 11 NYCRR 65.15 [g][1][i], [2][iii]).

Defendant does not oppose the instant cross-motion; therefore, defendant fails to raise a triable issue of fact as to the failure to respond to the request for the right shoulder MRI films.

Even considering defendant’s submissions upon Motion Sequence 001 as opposition to the instant summary judgment motion, defendant still fails to raise a triable issue of fact sufficient to defeat plaintiff’s motion.

The affidavit of Mike Manzo, billing manager for MD Capital Advisors, states that MD Capital Advisors is the third party billing company for FJ Orthopedics PLLC, which is not a party to this action. In fact, the affidavit appears to have been submitted in connection with the prior arbitration entitled FJ Orthopedics PLLC / Mary King, Applicant and Global Liberty Insurance Company of New York. Thus, it is unknown to the Court how Mr. Manzo’s affidavit is germane to defendant Lewin named in this action. Assuming, however, that his affidavit is relevant, because it relates to the assignor in this matter (Mary King), Mr. Manzo speaks to the issue of the surgical photographs, which is not the subject of the summary judgment motion. Moreover, his affidavit is vague as to “the verification response” and “requested documents” allegedly submitted to plaintiff on June 2, 2015; however, the response was likely the letter on FJ Orthopedics letter head, signed by Mike Manzo, dated May 21, 2015, which is annexed to Manzo’s affidavit. That letter states that, “your request for MRI films and color photos of surgey (sic) for the above mention (sic) claim is overly burdensome as neither our client FJ Orthopedics nor the patient Mary King does not (sic) have access to the actual films. . . The films are in Doshi Diagnostic’s possession . . . therefore, we enjoin you to obtain the actual films . . . with the attached medical authorizations signed by Mary King.”

Defendant’s submissions do nothing to raise a triable issue of fact as to the failure to provide the MRI films, nor do the submissions controvert the established fact that plaintiff attempted to get the films directly from Doshi first, by sending a first request and then a follow-up request, and when it received no films, plaintiff notified defendant of the request. Plaintiff sent the verification requests directly to Doshi, and plaintiff also timely informed the applicant, the defendant in this action, of the nature of the verification sought, and from whom it was sought, after the initial requests went unsatisfied (Doshi Diagnostic Imaging Servs. v. State Farm Insurance Co., 16 Misc 3d 42 [App Term 2d Dept 2007]; see also Advantage Radiology, P.C. v. Nationwide Mutual Insurance Company, 55 Misc 3d 91 [App Term 2d Dept 2017]).

The fact that FJ Orthopedics, albeit not a party to this action, may have provided plaintiff with a HIPPA authorization for the films does not constitute a response to the request for verification. Plaintiff did not need a HIPPA authorization to obtain the films (Eagle Surgical Supply, Inc. v. GEICO Insurance Co., 41 Misc 3d 134[A][App Term 1st Dept 2013]), and in any event, FJ Orthopedics’ statement made in its May 21, 2015 letter that the request “is overly burdensome” is evidence of its lack of motivation to satisfy plaintiff’s verification request.

Defendant has failed to raise a material, triable issue of fact; therefore, plaintiff’s summary judgment motion is granted.

Submit a judgment on notice.

The foregoing constitutes the Order of this Court.

Dated: June 22, 2017

Mineola, NY

Karen V. Murphy

Footnotes

Footnote 1:Defendant has submitted a master arbitration award in another matter, but plaintiff has submitted the correct master arbitration award pertaining to the parties in this action.

CV-011318-14

Law Offices of Joseph B. Strassman, attorneys for Plaintiff, 11 Clinton Avenue, Rockville Centre, New York 11570, (516) 766-7007; Richard T. Lau & Associates, attorneys for Defendant, P.O. Box 9040, 300 Jericho Quadrangle, Suite 260, Jericho, New York 11753-9040, (914) 229-6000.

The following named papers numbered 1 to 4

submitted on this Motion on April 24, 2017

papers numbered

No-Fault Notice of Motion for Summary Judgment1Attorney’s Affirmation2

Reply Affirmation3

Memorandum of Law4

The plaintiff commenced this action seeking reimbursement from the defendant for chiropractic treatment she received as a result of a motor vehicle accident which occurred on May 8, 2008. The defendant moves for summary judgment, pursuant to CPLR 3212, on the ground that the plaintiff executed an Assignment of Benefits to the treating doctor, and as such, lacks standing to maintain this action.

It is uncontroverted that the plaintiff was injured in an automobile accident and received chiropractic treatment from a Christopher Skurka, D.C. It is also uncontroverted that the plaintiff executed an Assignment of Benefits to Dr. Skurka, of her no-fault benefits. As such, the defendant moves for summary judgment.

Summary judgment is drastic relief – – it denies one party the opportunity to go to trial. Thus, summary judgment should only be granted where there are no triable issues of fact (see Andre v Pomeroy, 35 NY2d 361 [1974]). The focus for the court is on issue finding, not issue determining (see Hantz v Fishman, 155 AD2d 415 [2d Dept 1989]).

The proponent of a summary judgment motion must make a prima facie showing of entitlement to judgment as a matter of law, tendering evidence in admissible form to demonstrate the absence of any material issues of fact. Failure to make such a prima facie showing requires denial of the motion, regardless of the sufficiency of the opposing papers (see Alvarez v Prospect Hosp., 68 NY2d 320 [1986]; Winegrad v NY Univ. Med. Ctr., 64 NY2d 851 [1985]). Once the movant has demonstrated a prima facie showing, the burden shifts to the non-moving party, to produce evidentiary proof in admissible form sufficient to establish the existence of material issues of fact, which require a trial of the action (see Zuckerman v New York, 49 NY2d 557 [1980]).

In support of the instant motion, the defendant submits, inter alia, the affirmation of Jeremey R. Maline, Esq., an attorney of the law office of Richard T. Lau & Associates; the affidavit of Beverly A. Croteau, a Claim Representative for State Farm Mutual Automobile Company; and a copy of an Assignment of Benefits signed by the plaintiff and Dr. Shurka D.C., dated May 29, 2008, establishing that the plaintiff assigned to Dr. Skurka D.C., all of her “rights privileges and remedies to payment for health care services” to which she would otherwise be entitled to (see Plaintiff’s Memorandum of Law, Exhibit A). The defendant contends that as a result of the Assignment to Dr. Shurka, D.C., the plaintiff’s action must be dismissed.

In reliance thereon, the defendant cites Lopes v Liberty Mutual Insurance Company, 24 Misc 3d 127(A) (App Term, 2nd, 11th, and 13th Jud Dists 2009). In Lopes, the plaintiff sought reimbursement from her insurance company after making payments directly to several medical providers. The court granted the defendant’s motion in part, finding that the executed assignment of benefits deprived the plaintiff of standing. In doing so, the court stated that for an assignment to be valid, it must assign “all rights, privileges and remedies to the assignee.” The court further held:

“The no-fault regulations contemplate payment directly to an EIP or her legal representative, unless said individual has executed an assignment, in which case payment shall be made directly to providers of health care services (Insurance Department Regulations [11 NYCRR]§65-3.11[a])… An insurer [*2]seeking dismissal pursuant to CPLR 3211(a)(7), on the ground that the claim has been assigned by the plaintiff EIP to a provider, bears the burden of demonstrating that the claim submitted by the health care provider was submitted on such provider’s own behalf by demonstrating that there was an assignment…. Defendant submitted documents that clearly assign plaintiff’s claims for services rendered… . As a result, plaintiff’s causes of action seeking reimbursement for said services were properly dismissed under CPLR 3211(a)(7), because defendant demonstrated that the providers submitted the claims on their own behalf and the causes of action are being asserted by an individual without standing.”

In the case at bar, the New York Motor Vehicle No-Fault Insurance Law Assignment of Benefits Form signed by the plaintiff on May 29, 2008, provides:

“I, Carla Santorello, (“Assignor”) assigns to Dr. Shurka (“Assignee”) all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the No-Fault statute) of Insurance Law.

The assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained due to the motor vehicle accident which occurred on 5/8/08, notwithstanding any prior written agreement to the contrary.

This agreement may be revoked by the assignee when benefits are not payable based upon the assignor’s lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor.”

Here, the subject Assignment clearly and unambiguously transferred the plaintiff’s rights for the reimbursement of no-fault benefits to Dr. Skurka, D.C. As such, the plaintiff’s cause of action seeking reimbursement of those medical expenses cannot be sustained, given her lack of standing (see also Hernandez v Kalpakis, 2014 WL 12680588 [Supreme Ct, Nassau County]). The defendant having met its burden, the burden shifts to the plaintiff to establish a triable issue of fact.

However, in opposition, counsel for the plaintiff wholly fails to address the issue of the plaintiff’s lack of standing to sue based upon the assignment. Moreover, no affidavit is submitted from the plaintiff herself. The attorney’s affirmation alone is insufficient to raise an issue of fact warranting a trial (see Barbieri v D’Angelo, 128 AD2d 661[2d Dept 1987]). Accordingly, the defendant’s motion for summary judgment is granted, and the action is dismissed.

This constitutes the decision and order of the court.

Hon. Scott Fairgrieve

DISTRICT COURT JUDGE

Dated:June 21, 2017

HUCV 1227-16
James F. Matthews, J.

Upon the following papers numbered 1 to 15 read on this motion by defendant for an order granting summary judgment of dismissal ; by Notice of Motion /Order to Show Cause and supporting papers 1,2,9 ; Notice of Cross Motion and supporting papers ; Answering Affidavits and supporting papers 10,12 ; Replying Affidavits and supporting papers 13,15; Filed papers; Other exhibits: 3-8,11,14 ; (and after hearing counsel in support of and opposed to the motion), it is,

ORDERED that the motion by defendant for summary judgment dismissing plaintiff’s complaint pursuant to CPLR 3212, is denied.

Defendant moves by summary judgment for dismissal of plaintiff’s complaint which seeks to recover first-party no-fault benefits for medical services rendered to plaintiff’s assignor on 02/24/15 in the total amount of $878.67 as the result of an automobile accident of 12/05/14.

The grounds for dismissal are the failure of plaintiff to fully comply with defendant’s 3rd request for additional verification dated 05/07/15, by providing “a copy of the decision-making report from the referring doctor demonstrating the medical necessity and/or need for the MRI(s).” In addition, defendant asserts plaintiff failed to provide “documentation identifying the relationship between each individual involved in the rendering of services and the professional corporation, including the manner in which the person is compensated [ie: W-2, 1099).” Also, plaintiff failed to provide verification of documents “that establishes the licensure, certification or credentials for each individual involved in the rendering of the services for which payment is sought”; the name and model number of the MRI machine used on the above date[s] of service”; [*2]and “the completed NF-3 Form with original signature[non-stamped]”).^[FN1] Defendant contends that the above stated verification requests remain outstanding to date, though defendant acknowledges receipt on 04/20/15 of a “partial response” containing certain items previously requested.

In support of the motion, defendant asserts the first verification request was sent on 03/18/15 within 15 business days of receipt of plaintiff’s claim on 03/04/15. Upon non-compliance, a second verification request was sent on 04/20/15. After 120 days elapsed without receipt of the requested verification, defendant denied the claim by mailing a NF-10 Denial of Claim form dated 09/17/15 with an Explanation of Review (“EOR”) stating inter alia “that your claim has been denied as you have failed to submit the requested verification of additional relevant information under your control of possession, or written proof providing reasonable justification for the failure to comply, within 120 calendar days of the initial request.”

In opposition to the motion, plaintiff asserts defendant failed to demonstrate by admissible evidence, that the verification requests were timely and properly mailed to plaintiff. Plaintiff contends the affidavits submitted in support of defendant’s motion, have not provided a foundation for admission of its business records, a necessary part of demonstrating defendant’s office practice and procedures. Plaintiff further asserts defendant has not shown “good reasons” for demanding the verifications which would toll the time from which defendant had to pay or deny the claims.

No-fault regulations mandate that a written proof of claim for health service expenses are overdue if not paid or denied by the insurer within 30 calendar days (see Insurance Law §5106[a]; 11 NYCRR §65-3.8[a][1]). An insurer may toll the 30 day period by requesting additional verification of the claim within 15 business days from its receipt of the claim (see 11 NYCRR 65-3.5[b]). If the insurer has not received verification from the plaintiff within 30 days of the initial request, the insurer may send a follow-up verification request by phone or mail within 10 calendar days (see 11 NYCRR 65-3.6[b]). An insurer may not issue a denial of claim form (NF-10) prior to its receipt of verification of all relevant information requested by the insurer (see Insurance Law §5106[a]; 11 NYCRR §65-3.5[c]). However, an insurer may deny the claim after 120 calendar days if plaintiff does not provide all of the requested verification under its control or possession, or written proof providing reasonable justification for its failure to comply (see 11 NYCRR §65-3.5[o], for all claims submitted after 4/1/13). Also, an insurer’s “non-substantive, technical or immaterial defect or omission, as well as an insurer’s failure to comply with a prescribed time frame” shall not “negate an applicant’s obligation to comply with the request or notice” (see 11 NYCRR §65-3.5[p], for all claims submitted after 4/1/13).

Here, the Court determines that defendant has failed to make a prima facie showing of entitlement to judgment as a matter of law with proof in admissible form sufficient to establish the lack of any material issues of fact (see Alvarez v Prospect Hospital, 68 NY2d 320, 324 [1986]; Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]; Zuckerman v City of New York, 49 NY2d 557, 562 [1980]); see also Manhattan Medical v State Farm Mut. Ins. Co., 20 Misc 3d 1144[A][Civ. Ct. Richmond Cty. 2008]).

Defendant’s sole Affidavit of its No-Fault Litigation Supervisor, is insufficient to establish the timeliness and propriety of the mailing of its verification request, follow-up [*3]verification requests, and the NF-10 denial of claim. The affidavit’s statements are conclusory and based upon hearsay, and fail to sufficiently demonstrate defendant’s standard office practice and procedures used to ensure the proper mailing of its verification requests and denials (see St. Vincent’s Hosp. of Richmond v Government Employees Ins. Co., 50 AD3d 1123 [2nd Dept 2008]; Ortho-Med Surgical Supply, Inc. v MVAIC, 28 Misc 3d 139[A][App Term 2nd, 11th & 13th Jud Dists 2010]; Delta Diagnostic Radiology, P.C. v Chubb Group of Insurance, 17 Misc 3d 16, 18 [App Term 2nd & 11th Jud Dists 2007]). The Court notes the lack of an affidavit from a claims representative and/or a mailroom employee, who would be familiar with defendant’s office practice and procedures for mailing verification requests and denials, especially as it applied in the instant matter.

As a result, defendant has failed to create a presumption of timely and proper mailing (see S & M Supply Inc. v GEICO, 2003 NY Slip Op. 51192[U][App Term, 2nd & 11th Jud. Dists. 2003]; Harbor Medical & Diagnostics P.C. v Allstate Ins. Co., 11 Misc 3d 1063[A][Civ Ct, New York City 2006]).

Moreover, defendant claims “a copy of the decision-making report from the referring doctor demonstrating the medical necessity and/or need for the MRI(s)” has not been provided to date. However, defendant’s own evidence demonstrates that plaintiff provided a Physician’s Letter of Medical Necessity dated 02/16/15 to defendant with its letter dated 04/15/15 (see defendant’s Exhibit “C” and plaintiff’s Exhibit “1”). As a result, defendant has failed to demonstrate a prima facie case.

In addition, defendant has failed to demonstrate that it informed “the applicant AND its attorney of the reason why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested.” Defendant’s prima facie proof fails to show defendant informed the applicant and his attorney, in compliance with 11 NYCRR §65-3.6(b).

Accordingly, the motion by defendant for summary judgment dismissing plaintiff’s action against it pursuant to CPLR 3212, is denied.

It is not necessary for the Court to reach any remaining contentions.

The foregoing constitutes the decision and order of this Court.

Dated: June 14, 2017

Hon. James F. Matthews
J.D.C.

Footnotes

Footnote 1: The language for the additional verification requests is taken from defendant’s Explanation of Benefits, attached as exhibit B).