Decided on March 17, 2016

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

Appeal from an order of the Civil Court of the City of New York, Kings County (Pamela L. Fisher, J.), entered February 22, 2013. The order granted defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, with $30 costs, and defendant’s motion for summary judgment dismissing the complaint is denied.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint.

Plaintiff correctly argues on appeal that defendant’s moving papers failed to establish as a matter of law that the letters scheduling the independent medical examinations (IMEs) of plaintiff’s assignor had been timely and properly mailed to the assignor (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Consequently, defendant failed to demonstrate that the IMEs had been properly scheduled and, thus, that it is entitled to summary judgment dismissing the complaint on the ground that plaintiff’s assignor had failed to comply with a condition precedent to an insurer’s liability on a policy (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Although defendant attempted, in its reply papers, to cure the defect, the affirmation of defendant’s counsel was insufficient to do so since counsel lacked personal knowledge. In any event, defendant could not establish its entitlement to judgment by submitting, as part of its reply papers, sufficient evidence in admissible form to cure defects in its moving papers (see North Acupuncture, P.C. v State Farm Ins. Co., 14 Misc 3d 130[A], 2006 NY Slip Op 52523[U] [App Term, 2d Dept, 2d & 11th Jud Dists 2006]).

Accordingly, the order is reversed and defendant’s motion for summary judgment dismissing the complaint is denied.

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

Decided on March 17, 2016

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

Appeal from an order of the Civil Court of the City of New York, Queens County (Jodi Orlow, J.), entered May 21, 2013. The order granted defendant’s motion for summary judgment dismissing the complaint and denied plaintiff’s cross motion for summary judgment.

ORDERED that the order is affirmed, with $25 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 granted defendant’s motion for summary judgment dismissing the complaint and denied plaintiff’s cross motion for summary judgment.

In support of its motion, defendant sufficiently established the timely mailing (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]) of the denial of claim form at issue, which denied the claim on the ground of lack of medical necessity. Defendant further submitted an affirmed peer review which set forth a factual basis and medical rationale for the peer reviewer’s determination that there was a lack of medical necessity for the services at issue. In opposition to the motion, plaintiff submitted an affidavit from a doctor which failed to meaningfully refer to, let alone sufficiently rebut, the conclusions set forth in the peer review report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2nd Dept, 2d, 11th & 13th Jud Dists 2009]). Consequently, defendant established its entitlement to summary judgment dismissing the complaint.

Accordingly, the order is affirmed.

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

Decided on March 17, 2016

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

Appeal from an order of the Civil Court of the City of New York, Queens County (Jodi Orlow, J.), entered May 21, 2013. 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 as premature because plaintiff had failed to provide requested verification.

In support of its cross motion, defendant established that it had timely mailed its verification request and follow-up verification request (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Defendant also demonstrated prima facie that it had not received the requested verification and, thus, that plaintiff’s action is premature (see 11 NYCRR 65-3.8 [a]; Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 [2005]). However, in opposition to the cross motion, plaintiff submitted an affidavit from plaintiff’s employee, which affidavit was sufficient to give rise to a presumption that the requested verification had been mailed to, and received by, defendant (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]). In light of the foregoing, there is a triable issue of fact as to whether this action is premature (see Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co., 44 Misc 3d 59 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]).

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

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

Decided on March 17, 2016

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

Appeal from an order of the Civil Court of the City of New York, Kings County (Carol Ruth Feinman, J.), entered March 12, 2013. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, with $30 costs, and defendant’s motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court which denied defendant’s motion for summary judgment dismissing the complaint.

In support of its motion, defendant submitted an affidavit by the president of Media Referral, Inc., a company that had been retained by defendant to schedule independent medical examinations (IMEs), which affidavit sufficiently established that the IME requests had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Defendant also submitted an affidavit from the medical provider who was to perform the IMEs, which sufficiently established that plaintiff’s assignor had failed to appear for those duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). In addition, an affidavit executed by defendant’s claims examiner demonstrated that the denial of claim forms, which, insofar as is relevant to this appeal, denied the claims based on plaintiff’s assignor’s nonappearance at the IMEs, had been timely mailed (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123). Consequently, defendant demonstrated that plaintiff’s assignor had failed to comply with a condition precedent to coverage (see 11 NYCRR 65-1.1; Stephen Fogel Psychological, P.C., 35 AD3d at 722). As plaintiff failed to raise a triable issue of fact in opposition to the motion, the Civil Court should have granted defendant’s motion for summary judgment.

Accordingly, the order is reversed and defendant’s motion for summary judgment dismissing the complaint is granted.

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

Decided on March 17, 2016

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

Appeal from an order of the Civil Court of the City of New York, Queens County (William A. Viscovich, J.), entered April 30, 2013. 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 the branch of plaintiff’s motion seeking summary judgment upon the first cause of action is granted and the branch of defendant’s cross motion seeking summary judgment dismissing that cause of action is denied; as so modified, the order is affirmed, without costs, and the matter is remitted to the Civil Court for the calculation of statutory interest and an assessment of attorney’s fees upon the first cause of action.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The Civil Court denied plaintiff’s motion and granted defendant’s cross motion.

Contrary to plaintiff’s contention, defendant established that the independent medical examination (IME) scheduling letters had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), that plaintiff’s assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]), and that defendant had timely denied (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123) the claim underlying the second cause of action on that ground. Since defendant demonstrated that plaintiff’s assignor had failed to comply with a condition precedent to coverage (Stephen Fogel Psychological, P.C., 35 AD3d at 722) and plaintiff failed to raise a triable issue of fact in opposition to this branch of defendant’s cross motion, defendant was entitled to summary judgment dismissing the second cause of action.

However, with respect to the first cause of action, plaintiff established submission of the claim form, and the affidavit of defendant’s no-fault claims adjuster states that the claim at issue was not denied within 30 days of its receipt (see 11 NYCRR 65-3.8 [a] [1]). As a result, the record establishes plaintiff’s prima facie case upon its first cause of action (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498, 506 [2015]). Since defendant did not demonstrate that the 30-day claim determination period (see 11 NYCRR 65-3.8) had been tolled for this claim, defendant is precluded from asserting, with respect to this claim, its proffered defense that plaintiff’s assignor had failed to appear for the duly scheduled IMEs (see Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045 [2009]). Consequently, plaintiff is entitled to summary judgment upon its first cause of action.

Accordingly, the order is modified by providing that the branch of plaintiff’s motion seeking summary judgment upon the first cause of action is granted and the branch of defendant’s cross motion seeking summary judgment dismissing that cause of action is denied, and the matter is remitted to the Civil Court for the calculation of statutory interest and an assessment of [*2]attorney’s fees upon the first cause of action, pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

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

Decided on March 17, 2016

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

Appeal from an order of the Civil Court of the City of New York, Queens County (Barry A. Schwartz, J.), entered May 6, 2013. The order granted defendant’s motion for summary judgment dismissing the complaint.

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

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground that it had timely and properly denied the claims based on plaintiff’s assignor’s failure to appear for independent medical examinations. The Civil Court granted defendant’s motion.

Contrary to plaintiff’s sole contention on appeal, the affidavit submitted by defendant in support of its motion established the timely and proper mailing of the denial of claim form (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Accordingly, the order is affirmed.

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

Decided on March 17, 2016

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

Appeal from an order of the Civil Court of the City of New York, Kings County (Dawn Jimenez Salta, J.), entered July 31, 2012. The order, insofar as appealed from, denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground that it had timely and properly denied all of the claims at issue based upon plaintiff’s assignor’s failure to appear for duly scheduled independent medical examinations (IMEs). Defendant also sought to dismiss the first through third and fifth through seventh causes of action on the additional ground that the fees sought exceeded the amounts permitted by the workers’ compensation fee schedule. Plaintiff cross-moved for summary judgment. In an order entered July 31, 2012, insofar as appealed from, the Civil Court denied defendant’s motion.

While defendant submitted properly sworn statements by the chiropractor and doctor who were scheduled to perform the IMEs, neither health care professional demonstrated personal knowledge of the nonappearance of plaintiff’s assignor for the Fexaminations, and, therefore, defendant failed to establish its entitlement to judgment as a matter of law dismissing any causes of action on this ground (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]; Bright Med. Supply Co. v IDS Prop. & Cas. Ins. Co., 40 Misc 3d 130[A], 2013 NY Slip Op 51123[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]; Quality Health Prods. v Hertz Claim Mgt. Corp., 36 Misc 3d 154[A], 2012 NY Slip Op 51722[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]).

The affidavit of defendant’s litigation examiner was sufficient to demonstrate prima facie that defendant had also properly reduced the amount of plaintiff’s claims underlying the first through third and fifth through seventh causes of action pursuant to the workers’ compensation fee schedule. However, in opposition to defendant’s motion, plaintiff raised a triable issue of fact with respect to whether these reductions were proper. As a result, defendant was not entitled to summary judgment upon these causes of action based on fee schedule grounds.

Accordingly, the order, insofar as appealed from, is affirmed.

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

[*1]

Law Office of George T. Lewis, Jr., Syosset (George T. Lewis, Jr. Of counsel), for appellant.

Bruno, Gerbino & Soriano LLP, Melville (Mitchell L. Kaufman of counsel), for respondent.

Order and judgment (one paper), Supreme Court, New York County (Eileen A. Rakower, J.), entered August 25, 2014, vacating the master arbitration decision of Frank G. Godson dated December 17, 2013, and reinstating the award of arbitrator Laura Yantsos dated September 25, 2013, unanimously affirmed.

It is undisputed that petitioner’s second follow-up request for an examination under oath was sent 11 days after respondent failed to appear on the date set in the first request and that the 10th day fell on a Sunday (see 11 NYCRR 65-3.6 [b]). Plaintiff was entitled to an extension of time to the next business day to send its second follow-up request (see General Construction Law § 25-a). Concur—Friedman, J.P., Andrias, Saxe and Kapnick, JJ.

[*1]

Bruno, Gerbino & Soriano, LLP, Melville (Matthew Lavoie of counsel), for appellant.

Law Office of George T. Lewis, Jr., P.C., Syosset (George T. Lewis, Jr. of counsel), for respondent.

Order, Supreme Court, New York County (Joan M. Kenney, J.), entered on or about September 17, 2014, which denied plaintiff’s motion for a de novo review of a master arbitrator’s findings dated December 17, 2013, and for summary judgment declaring in its favor, and sua sponte dismissed the complaint, unanimously modified, on the law, to reinstate the complaint and grant the part of the motion seeking a de novo review of the arbitrator’s findings, and otherwise affirmed, without costs.

Plaintiff satisfied the requirements for a de novo adjudication of this dispute pursuant to Insurance Law § 5106 (c).

Plaintiff’s second follow-up request for an examination under oath was sent 11 days after defendant failed to appear on the date set in the first request; the 10th day fell on a Sunday (see 11 NYCRR 65-3.6 [b]). Plaintiff correctly argues that it was entitled to an extension of time to the next business day to send its second follow-up request (see General Construction Law § 25-a). Concur—Friedman, J.P., Andrias, Saxe and Kapnick, JJ.