Reported in New York Official Reports at Lenox Hill Radiology & MIA, P.C. v Great N. Ins. Co. (2015 NY Slip Op 50680(U))
| Lenox Hill Radiology & MIA, P.C. v Great N. Ins. Co. |
| 2015 NY Slip Op 50680(U) [47 Misc 3d 143(A)] |
| Decided on May 1, 2015 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on May 1, 2015
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS
PRESENT: : GARGUILO, J.P., MARANO and CONNOLLY, JJ.
2013-2049 N C
against
Great Northern Insurance Company Doing Business as CHUBB GROUP OF INSURANCE COMPANIES, Appellant.
Appeal from an order of the District Court of Nassau County, First District (Fred J. Hirsh, J.), dated July 31, 2013. The order denied defendant’s motion for summary judgment dismissing the complaint.
ORDERED that the order is affirmed, without costs.
In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the District Court which denied defendant’s motion for summary judgment dismissing the complaint.
Defendant established that the denial of claim forms, which denied the claims on the ground of lack of medical necessity, had been timely and properly mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). While the affirmed peer review report by defendant’s doctor set forth a factual basis and medical rationale for the doctor’s opinion that there was a lack of medical necessity for the services at issue, plaintiff proffered a doctor’s affirmation in opposition, which affirmation was sufficient to raise a triable issue of fact as to whether the services were medically necessary (see Zuckerman v City of New York, 49 NY2d 557 [1980]). Consequently, defendant’s motion for summary judgment dismissing the complaint was properly denied.
Accordingly, the order is affirmed.
Garguilo, J.P., Marano and Connolly, JJ., concur.
Decision Date: May 01, 2015
Reported in New York Official Reports at Geico Gen. Ins. Co. v Class 1 Transp. (2015 NY Slip Op 50679(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
Class 1 Transport and LAUREL E. STONE, Respondents.
Appeal from an order of the Civil Court of the City of New York, Queens County (James E. d’Auguste, J.), entered March 22, 2013, deemed from a judgment of the same court entered August 22, 2013 (see CPLR 5501 [c]). The judgment, entered pursuant to the March 22, 2013 order granting defendants’ motion for summary judgment, dismissed the complaint.
ORDERED that the judgment is reversed, without costs, the order entered March 22, 2013 is vacated, and defendants’ motion for summary judgment is denied.
Plaintiff Geico General Insurance Company (Geico) commenced this subrogation action against defendants Class 1 Transport and Laurel E. Stone to recover the sum of $6,330.60, representing the amount paid for property damage to, and loss of use of, the subrogors’ vehicle as a result of an accident involving that vehicle and defendants’ vehicle. The complaint alleged that the accident was due to the negligence of defendants in the ownership, operation, maintenance, management and control of their vehicle. Prior to the commencement of this action, Geico had paid first-party no-fault benefits to its insured, and had sought to recoup those benefits from Daily Underwriters of America (DUOA), defendants’ insurer, pursuant to Insurance Law § 5105, through mandatory loss-transfer arbitration conducted by Arbitration Forums, Inc. (AFI). The AFI arbitrator determined that Geico was not entitled to recover from DUOA because Geico had not demonstrated any negligence on the part of DUOA’s insureds. As Geico had not proven liability, no damages were awarded.
After issue was joined in this action, defendants moved for summary judgment dismissing the complaint on the ground that the AFI arbitrator’s decision precluded plaintiff, based on collateral estoppel, from litigating this action. Plaintiff opposed the motion, referring to section (d) (5) of AFI’s NY Personal Injury Protection Rule Revisions, which provides: “A decision of an arbitrator on the liability issue is conclusive only of the controversy in the claim submitted to the arbitrator by the same parties and has no legal effect on any other claim or suit arising out of the same accident or occurrence between different parties.” Plaintiff appeals from an order entered March 22, 2013, in which the Civil Court granted defendants’ motion, upon a finding that the AFI arbitrator’s decision on liability barred plaintiff from bringing this action. A judgment was subsequently entered, from which plaintiff’s appeal is deemed to have been taken [*2](see CPLR 5501 [c]).
“[I]n general the doctrines of claim preclusion and issue preclusion between the same parties (more familiarly referred to as res judicata or direct estoppel) apply as well to awards in arbitration as they do to adjudications in judicial proceedings” (Matter of American Ins. Co. [Messinger—Aetna Cas. & Sur. Co.], 43 NY2d 184, 189-190 [1977]). Explicit restrictions in the arbitration rules, however, may limit the carry-over effect of the arbitration ruling (see id. at 193; see also Feinberg v Boros, 17 AD3d 275, 276 [2005]; Matter of State Farm Ins. Co. v Smith, 277 AD2d 390, 390-391 [2000]). The AFI rule limiting the preclusive effect of its arbitrator’s decision was clear and unambiguous, and should be given effect (see also Government Empls. Ins. Co. v Town of Oyster Bay, 26 Misc 3d 34 [App Term, 9th & 10th Jud Dists 2009] [AFI rule then in effect operated to preclude the application of the doctrine of collateral estoppel respecting the arbitrator’s decision in a separate judicial proceeding]). Consequently, defendants’ motion for summary judgment dismissing the complaint on collateral estoppel grounds should have been denied.
Accordingly, the judgment is reversed, the order entered March 22, 2013 is vacated, and defendants’ motion for summary judgment is denied.
Pesce, P.J., Weston and Aliotta, JJ., concur.
Decision Date: May 01, 2015
Reported in New York Official Reports at South Nassau Orthopedic Surgery & Sports Medicine, P.C. v Geico Ins. Co. (2015 NY Slip Op 50674(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
GEICO Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Queens County (Barry A. Schwartz,J.), entered November 28, 2012. The order denied defendant’s motion to dismiss the complaint pursuant to CPLR 3216.
ORDERED that the order is reversed, with $30 costs, and defendant’s motion to dismiss the complaint pursuant to CPLR 3216 is granted.
In this action by a provider to recover assigned first-party no-fault benefits, defendant moved, pursuant to CPLR 3216, to dismiss the complaint based upon plaintiff’s failure to prosecute the action. Plaintiff opposed the motion, contending that it had been prosecuting the action and that only about four months had elapsed since defendant’s motion for summary judgment had been denied by the Civil Court. The Civil Court denied defendant’s motion, finding that, since only four months had passed from the time plaintiff had served defendant with a copy of the order denying defendant’s motion for summary judgment, with notice of entry, dismissal pursuant to CPLR 3216 was not warranted.
Once a 90-day demand is received by a plaintiff, in a Civil Court action, the plaintiff must either comply with the demand by filing a notice of trial within 90 days (see CPLR 3216 [c]), or move before the default date either to vacate the demand or to extend the 90-day period pursuant to CPLR 2004 (see Felix v County of Nassau, 52 AD3d 653 [2008]; Katina, Inc. v Town of Hempstead, 13 AD3d 343 [2004]; A.M. Med., P.C. v State Farm Mut. Ins. Co., 22 Misc 3d 43 [App Term, 2d & 11th Jud Dists 2008]). Since plaintiff failed to do either of these, it was required, in opposition to defendant’s motion to dismiss, to establish a justifiable excuse for its delay in properly responding to the 90-day demand, and the existence of a meritorious cause of action (see Baczkowski v Collins Constr. Co., 89 NY2d 499 [1997]; Felix, 52 AD3d 653; A.M. Med., P.C., 22 Misc 3d 43).
As plaintiff notes, in Baczkowski (89 NY2d at 503), the Court of Appeals stated that CPLR 3216 is “extremely forgiving” and, “depending on the circumstances, a plaintiff is not always required to establish both a justifiable excuse and a potentially meritorious cause of action to avoid such a dismissal” (see Davis v Goodsell, 6 AD3d 382, 383-384 [2004]). However, the Court of Appeals further stated:
“If plaintiff fails to demonstrate a justifiable excuse, the statute says the court may’ dismiss the action—it does not say must’ (see, CPLR 3216 [e])—but this presupposes that plaintiff has tendered some excuse in response to the motion in an attempt to satisfy the statutory threshold.
Although a court may possess residual discretion to deny a motion to dismiss when plaintiff tenders even an unjustifiable excuse, this discretion should be exercised sparingly to honor the balance struck by the generous statutory protections already built into CPLR 3216. Even such exceptional exercises of discretion, moreover, would be reviewable within the Appellate Division’s plenary discretionary authority. If plaintiff unjustifiably fails to comply with the 90-day requirement, knowing full well that the action can be saved simply by filing a note of issue but is subject to dismissal otherwise, the culpability for the resulting dismissal is squarely placed at the door of plaintiff or plaintiff’s counsel. Were courts routinely to deny motions to dismiss even after plaintiff has ignored the 90-day period without an adequate excuse, the procedure established by CPLR 3216 would be rendered meaningless” (Baczkowski, 89 NY2d at 504-505).
In the instant case, in opposition to defendant’s motion to dismiss the complaint, plaintiff made no attempt to demonstrate the existence of an excuse, justifiable or otherwise, for plaintiff’s failure to comply with the 90-day notice. Nor did plaintiff make any attempt to demonstrate that it possessed a meritorious cause of action.
Accordingly, the order is reversed and defendant’s motion to dismiss the complaint pursuant to CPLR 3216 is granted.
Pesce, P.J., Weston and Aliotta, JJ., concur.
Decision Date: May 01, 2015
Reported in New York Official Reports at Velocity Chiropractic, P.C. v Chubb Indem. Ins. Co. (2015 NY Slip Op 50673(U))
| Velocity Chiropractic, P.C. v Chubb Indem. Ins. Co. |
| 2015 NY Slip Op 50673(U) [47 Misc 3d 142(A)] |
| Decided on May 1, 2015 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on May 1, 2015
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., WESTON and ALIOTTA, JJ.
2012-2730 Q C
against
Chubb Indemnity Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Queens County (Richard G. Latin, J.), entered October 26, 2012. The order, insofar as appealed from, denied defendant’s motion to strike the complaint and dismiss the action pursuant to CPLR 3126.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and defendant’s motion to strike the complaint and dismiss the action pursuant to CPLR 3126 is granted.
In this action by a provider to recover assigned first-party no-fault benefits, on June 22, 2012, the parties entered into a so-ordered stipulation pursuant to which
plaintiff agreed to serve defendant with verified responses to defendant’s written discovery demands within 80 days of the date of the order or be precluded from offering such evidence. After plaintiff failed to provide the so-ordered discovery responses, defendant moved pursuant to CPLR 3126 to strike the complaint and dismiss the action, asserting that plaintiff had failed to timely provide it with the so-ordered discovery responses; that, as a consequence, plaintiff was precluded from offering any evidence; and that, therefore, plaintiff could not establish its prima facie case. In opposition, plaintiff admitted that its responses had been served late but asserted that the delay was due to law office failure and that defendant was not prejudiced by the delay. The Civil Court denied defendant’s motion, stating that it was preferable to resolve the case on the merits and holding that the accrual of interest was tolled during the time period in which plaintiff’s so-ordered discovery responses were untimely.
A conditional so-ordered stipulation becomes absolute upon a party’s failure to sufficiently and timely comply (see e.g. Panagiotou v Samaritan Vil., Inc., 66 AD3d 979 [2009]; State Farm Mut. Auto. Ins. Co. v Hertz Corp., 43 AD3d 907, 908 [2007]; Siltan v City of New York, 300 AD2d 298 [2002]; Blumenthal Chiropractic, P.C. v Praetorian Ins., 34 Misc 3d 135[A], 2011 NY Slip Op 52386[U] [App Term, 2d, 11th & 13th Jud Dists 2011]). To avoid the adverse impact of the conditional so-ordered stipulation, plaintiff was required to demonstrate a reasonable excuse for its failure to timely comply with the stipulation and the existence of a meritorious cause of action (see e.g. Panagiotou, 66 AD3d at 980; State Farm Mut. Auto. Ins. Co., 43 AD3d at 908). We find that plaintiff failed to meet this burden. Plaintiff’s opposing affirmation made no attempt to demonstrate the existence of a meritorious cause of action and failed to present sufficient facts to establish a reasonable excuse for its failure to [*2]comply with the so-ordered stipulation. Accordingly, as the order of preclusion prevents plaintiff from establishing its prima facie case, the order is reversed and defendant’s motion to strike the complaint and dismiss the action is granted.
Pesce, P.J., Weston and Aliotta, JJ., concur.
Decision Date: May 01, 2015
Reported in New York Official Reports at Compas Med., P.C. v ELRAC, Inc. (2015 NY Slip Op 50675(U))
[*1]| Compas Med., P.C. v ELRAC, Inc. |
| 2015 NY Slip Op 50675(U) [47 Misc 3d 143(A)] |
| Decided on May 1, 2015 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on May 1, 2015
PRESENT: : WESTON, J.P., SOLOMON and ELLIOT, JJ.
2013-145 K C
against
ELRAC, Inc., Appellant.
Appeal from an order of the Civil Court of the City of New York, Kings County (Robin S. Garson, J.), entered October 24, 2012, deemed from a judgment of the same court entered December 20, 2012 (see CPLR 5501 [c]). The judgment, entered pursuant to the October 24, 2012 order granting plaintiff’s motion for summary judgment and denying defendant’s cross motion for summary judgment dismissing the complaint, awarded plaintiff the principal sum of $6,318.67.
ORDERED that the judgment is reversed, without costs, so much of the order entered October 24, 2012 as granted plaintiff’s motion for summary judgment is vacated, and plaintiff’s motion is denied.
In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court entered October 24, 2012 which granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment dismissing the complaint. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).
Inasmuch as defendant raises no issue on appeal with respect to plaintiff’s prima facie case, we do not pass upon the propriety of the Civil Court’s determination with respect thereto.
The affidavit submitted by defendant established that the denial of claim forms had been mailed on the dates alleged in accordance with defendant’s standard office practices and procedures (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]).
Defendant alleges that it received the claims underlying the first and eighth causes of action on April 5, 2010 and that it denied those claims on May 13, 2010, which was more than 30 days later. While defendant demonstrated that it had mailed what it denominated as “verification/delay request(s)” on April 5, 2010 and May 7, 2010, those letters were insufficient to constitute verification requests (see Nyack Hosp. v Encompass Ins. Co., 23 AD3d 535 [2005]; Points of Health Acupuncture, P.C. v Lancer Ins. Co., 28 Misc 3d 133[A], 2010 NY Slip Op 51338[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Consequently, defendant failed to prove, as a matter of law, that it had tolled its 30-day period to pay or deny these claims (see 11 [*2]NYCRR 65-3.8 [a]), and the court properly denied the branches of defendant’s cross motion seeking summary judgment dismissing the first and eighth causes of action. However, defendant did submit a letter dated April 19, 2010 which scheduled plaintiff’s assignor for an examination under oath (EUO), as well as proof that plaintiff’s assignor had appeared for the scheduled EUO. While defendant did not submit proof that the EUO scheduling letter had been timely mailed, we find that defendant’s submissions are sufficient to raise a triable issue of fact as to whether the time to pay or deny the claims underlying the first and eighth causes had been tolled, and therefore whether the denials were timely. Furthermore, under the circumstances presented, plaintiff was also not entitled to summary judgment on the remaining causes of action, as defendant demonstrated that the claims underlying those causes of action had been timely denied. However, the branches of defendant’s cross motion seeking summary judgment dismissing the second through seventh causes of action, on the ground that the services billed for had not been rendered, were properly denied, albeit for a different reason than that advanced by the Civil Court. Contrary to the Civil Court’s finding, the certified EUO transcript relied upon by defendant was admissible (American States Ins. Co. v Huff, 119 AD3d 478 [2014]). Nevertheless, on this record, we find the existence of a triable issue of fact as to whether the services billed for were rendered.
Accordingly, the judgment is reversed, so much of the order entered October 24, 2012 as granted plaintiff’s motion for summary judgment is vacated, and plaintiff’s motion is denied.
Weston, J.P., Solomon and Elliot, JJ., concur.
Decision Date: May 01, 2015First Care Chiropractic of NJ, P.C. v Mvaic (2015 NY Slip Op 50677(U))
Reported in New York Official Reports at First Care Chiropractic of NJ, P.C. v Mvaic (2015 NY Slip Op 50677(U))
[*1]| First Care Chiropractic of NJ, P.C. v Mvaic |
| 2015 NY Slip Op 50677(U) [47 Misc 3d 143(A)] |
| Decided on May 1, 2015 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on May 1, 2015
PRESENT: : PESCE, P.J., WESTON and ALIOTTA, JJ.
2013-1400 K C
against
MVAIC, Respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Carolyn E. Wade, J.), entered April 19, 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 modified by providing that defendant’s 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, defendant Motor Vehicle Accident Indemnification Corporation (sued herein as MVAIC) moved for summary judgment dismissing the complaint on the ground that plaintiff was ineligible for reimbursement of no-fault benefits (see 11 NYCRR 65-3.16 [a] [12]) as plaintiff was incorporated in the State of New Jersey, and not in the State of New York. Plaintiff cross-moved for summary judgment. The Civil Court granted defendant’s motion and denied plaintiff’s cross motion.
Contrary to defendant’s apparent position in this litigation, a professional service corporation organized under the laws of another state (see Business Corporation Law § 1525 [d]) may practice in this state (see Business Corporation Law § 1529), so long as certain conditions and requirements are met (see e.g. Business Corporation Law §§ 1526-1530). In support of its motion, defendant failed to allege and prove that plaintiff failed to meet any of the requirements for a foreign professional service corporation operating in New York State, much less whether any violations by plaintiff rendered it ineligible to collect no-fault benefits (see State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313, 321-322 [2005]). Thus, defendant’s motion should have been denied.
However, plaintiff’s cross-moving papers failed to establish either that defendant had failed to timely deny the claim (see Viviane Etienne Med. Care, P.C. v Country- Wide Ins. Co., 114 AD3d 33 [2013]), or that defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law (see Insurance Law § 5106 [a]; Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]). Consequently, plaintiff failed to establish its entitlement to summary judgment, and, thus, its cross motion for summary judgment was properly denied, albeit on grounds other than those stated by the Civil Court.
Accordingly, the order is modified by providing that defendant’s motion for summary judgment dismissing the complaint is denied.
Pesce, P.J., Weston and Aliotta, JJ., concur.
Decision Date: May 01, 2015Meridian Acupuncture Care, P.C. v Mercury Cas. Co. (2015 NY Slip Op 50681(U))
Reported in New York Official Reports at Meridian Acupuncture Care, P.C. v Mercury Cas. Co. (2015 NY Slip Op 50681(U))
[*1]| Meridian Acupuncture Care, P.C. v Mercury Cas. Co. |
| 2015 NY Slip Op 50681(U) [47 Misc 3d 143(A)] |
| Decided on May 1, 2015 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on May 1, 2015
PRESENT: : MARA
P.J., IANNACCI and GARGUILO, JJ.
against
Mercury Casualty Company, Appellant.
Appeal from an order of the District Court of Suffolk County, Third District (C. Stephen Hackeling, J.), dated August 26, 2013. The order, insofar as appealed from as limited by the brief, denied the branch of defendant’s motion seeking summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, is modified by providing that the branch of defendant’s motion seeking summary judgment dismissing the complaint is granted except as to so much of the complaint as sought to recover for services provided on June 13 to July 9, 2008, July 11 to July 16, 2008, July 30 to August 13, 2008, October 17 to November 5, 2008, and December 31, 2008; as so modified, the order is affirmed, without costs.
In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals, as limited by its brief, from so much of an order of the District Court as denied the branch of defendant’s motion seeking summary judgment dismissing the complaint on the ground that plaintiff had raised a triable issue of fact with respect to the medical necessity of the treatment at issue.
With respect to the bills for services provided on June 13 to July 9, 2008, July 11 to July 16, 2008, July 30 to August 13, 2008, October 17 to November 5, 2008, and December 31, 2008, defendant’s moving papers failed to make a prima facie showing that the billed-for services were not medically necessary, as defendant relied upon a report of an independent medical examination that had been performed on a patient who was not plaintiff’s assignor (see generally Avicenna Med. Arts, P.L.L.C. v GEICO Ins. Co., 41 Misc 3d 140[A], 2013 NY Slip Op 52010[U] [App Term, 2d, 11th & 13th Jud Dists 2013]).
With respect to the bills for services provided on April 25 to April 30, 2008, May 2 to May 12, 2008 and May 23 to June 4, 2008, the affidavit of defendant’s claims representative established that the denial of claim forms had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Furthermore, as defendant demonstrated that it had fully paid plaintiff for the treatment at issue in accordance with the workers’ compensation fee schedule, the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon these claims should have been granted (see Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]).
Finally, with respect to the remaining six bills, for services purportedly provided from August 15 to August 27, September 5 to September 17, October 1 to October 10, November 7 to November 12, and December 3 to December 12, 2008 and January 23, 2009, the affidavit of defendant’s claims representative contained more than a mere conclusory denial of receipt of the claim forms allegedly mailed to it (cf. Top Choice Med., P.C. v GEICO Gen. Ins. Co., 33 Misc 3d 137[A], 2011 NY Slip Op 52063[U] [App Term, 2d, 11th & 13th Jud Dists 2011]) and sufficiently established that defendant had not received those claim forms. In the absence of a sworn statement by someone with personal knowledge attesting to plaintiff’s submission of the claim forms at issue, defendant was entitled to summary judgment dismissing so much of the complaint as sought to recover upon these claims (see Natural Therapy Acupuncture, P.C. v Interboro Ins. Co., 36 Misc 3d 135[A], 2012 NY Slip Op 51350[U] [App Term, 2d, 11th & 13th Jud Dists 2012]; Fiveborough Chiropractic & Acupuncture, PLLC v American Employers’ Ins. Co., Div. of Onebeacon Am. Ins. Co., 24 Misc 3d 133[A], 2009 NY Slip Op 51395[U] [App Term, 9th & 10th Jud Dists 2009]).
Accordingly, the order is modified by providing that the branch of defendant’s motion seeking summary judgment dismissing the complaint is granted except as to so much of the complaint as sought to recover for services provided on June 13 to July 9, 2008, July 11 to July 16, 2008, July 30 to August 13, 2008, October 17 to November 5, 2008, and December 31, 2008.
Marano, P.J., Iannacci and Garguilo, JJ., concur.
Decision Date: May 01, 2015Quality Psychological Servs. v Infinity Prop. & Cas. Co. (2015 NY Slip Op 50645(U))
Reported in New York Official Reports at Quality Psychological Servs. v Infinity Prop. & Cas. Co. (2015 NY Slip Op 50645(U))
[*1]| Quality Psychological Servs. v Infinity Prop. & Cas. Co. |
| 2015 NY Slip Op 50645(U) [47 Misc 3d 142(A)] |
| Decided on April 29, 2015 |
| 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. |
Decided on April 29, 2015
SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT
PRESENT: Lowe, III, P.J., Schoenfeld, Hunter, Jr., JJ.
570719/14
against
Infinity Property & Casualty Company Defendant-Appellant.
Defendant appeals from an order of the Civil Court of the City of New York, Bronx County (Lizbeth Gonzalez, J.), entered June 11, 2012, which denied its motion for summary judgment dismissing the complaint.
Per Curiam.
Order (Lizbeth Gonzalez, J.), entered June 11, 2012, affirmed, with $10 costs.
The action, seeking recovery of assigned first-party no-fault benefits, is not ripe for summary dismissal. While defendant-insurer submitted proof indicating that it properly rescinded the underlying insurance policy pursuant to Pennsylvania law based upon misrepresentations made by the insured, one Catrina Gordon, in the underlying policy application, defendant failed to demonstrate that plaintiff’s assignor, who was injured in an accident involving the Gordon vehicle, was “not an innocent third party” who should be precluded from receiving protection under the policy (Delta Diagnostic Radiology, P.C. v Infinity Group, 43 Misc 3d 130[A], 2014 NY Slip Op 50602[U] [App Term, 2nd, 11th and 13th Jud Dists 2014] [interpreting Pennsylvania law]).
Defendant’s argument that this action is barred by collateral estoppel – based upon a Pennsylvania court’s order rescinding the underlying insurance policy ab initio – is improperly raised for the first time on appeal (see Gavin v Catron, 35 AD3d 354 [2006]). In any event, since plaintiff medical services provider was not a party to the Pennsylvania action, it is not bound by that court’s determination, as it did not have a full and fair opportunity to contest the issues in that action (see Gilberg v Barbieri, 53 NY2d 285, 291 [1981]). Although plaintiff’s assignor was a party to the Pennsylvania court action, defendant failed to show that plaintiff was in privity with its assignor at the time that action was commenced (see Gramatan Home Invs. Corp. v Lopez, 46 NY2d 481, 486-487 [1979]; Ideal Med. Supply v Mercury Cas. Ins. Co., 39 Misc 3d 15 [2013]).
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concur I concur
Decision Date: April 29, 2015AR Med. Rehabilitation, P.C. v State-Wide Ins. Co. (2015 NY Slip Op 50631(U))
Reported in New York Official Reports at AR Med. Rehabilitation, P.C. v State-Wide Ins. Co. (2015 NY Slip Op 50631(U))
AR Medical
Rehabilitation, P.C. a/a/o JOHNNY TAYLOR, Plaintiff,
against State-Wide Ins. Co., Defendant. |
70806/2005
Gary Tsirelman, PC
Attorney for Plaintiff
129 Livingston
Street
Brooklyn, NY 11201
by Stefan Belinfanti, Esq.
Law Office
of Deirdre J. Tobin & Assoc.
Attorney for Defendant
P.O. Box 9330
Garden City, NY 11530
by Janine Gentile, Esq.
Reginald A. Boddie, J.
Plaintiff brought this action to recover assigned first-party no-fault benefits in the amount of $3,960.57. Trial commenced on February 13, 2015, and was continued over several days. The issues presented were whether plaintiff may establish submission and receipt of its claim through the use of defendant’s witness and whether defendant insurer asserted a valid defense in denying payment.
At trial, instead of the customary method of establishing a prima facie case by calling a witness of the provider, plaintiff called defendant’s claims examiner, Ms. Dachs. Ms. Dachs testified that defendant received plaintiff’s bills for dates of service 11/17/03-1/19/04.
She further established that, in response to the bills, the insurer sent plaintiff three delay letters, dated 1/30/04, 4/12/04, and 7/6/04, which stated, “All No Fault Benefits are pending investigation.” The delay letters were followed by a denial, also admitted into evidence.The denial, dated 7/26/04, indicated bills in the amount of $3,962.57, for dates of service 11/17/03-1/19/04, were received between 1/23/03 [sic] and 3/1/04. It also stated, “By the claimants [sic] own admission he allegedly was treated by a chiropractor and acupuncturist. [*2]However carrier received bills from an orthopedic [sic] and a physical therapist as well. Claimant stated that the receptionist at the chiropractors [sic] office gave him supplies, not an outside vendor as carrier was billed from. Carrier questions validity of claim/treatment.” Neither party presented the actual bills and defendant relied on these latter statements as the basis for the denial. Both parties rested and moved for a directed verdict. The court reserved decision and heard closing arguments.
In no-fault insurance cases, plaintiff’s prima facie burden requires establishing proof of submission to the defendant of the claim and that defendant failed to pay or deny the claim within thirty days or issued a denial that was vague, conclusory or without merit as a matter of law (see Insurance Law § 5106 [a]; Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33 [2d Dept 2013]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U], *1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]; see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2d Dept 2010]).
In Optimal Well-Being Chiropractic, P.C. v Chubb Indem. Ins. Co. (46 Misc 3d 129[A], 2014 NY Slip Op 51807[U], *1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014] [citations omitted]), the court noted, at trial, a no-fault plaintiff’s prima facie burden is to demonstrate proof of the submission of the claim forms at issue to defendant. The court indicated where the record establishes that the bills were denied and the denials admit receipt of the bills, plaintiff may prevail at trial (id. at *1-*2 [citations omitted]).The Appellate Term reached a similar result in Prestige Med. & Surgical Supply, Inc. v Clarendon Natl. Ins. Co. (13 Misc 3d 127[A], 2006 NY Slip Op 51672[U], *1 [App Term, 2d Dept, 2d & 11th Jud Dists 2006]). There, the court, albeit in the context of a motion for summary judgment, found that although a “provider [ordinarily] establishes the submission’ of the claim form by demonstrating proof of proper mailing, which gives rise to the presumption that the claim form was received by the addressee,” where plaintiff’s proof was insufficient to establish mailing, the “deficiency was cured by defendant’s acknowledgment of receipt in its denial of claim forms [citations omitted] and by the admissions of the claims’ receipt in the affidavits by defendant’s claims adjusters” (id. at *2). As such, the court found plaintiff met its prima facie burden and the burden shifted to defendant to demonstrate triable issues of fact (id. [citations omitted]).
Thus, after the provider establishes submission of the bills, defendant’s burden is to prove that it paid or denied the claims within 30 days as required by statute (see Insurance Law § 5106 [a]; Insurance Department Regulations [11 NYCRR] § 65-3.8 [c]). Defendant may extend its time to pay or deny the claims by issuing timely requests for verification (11 NYCRR 65-3.5 [b]). However, it is well-established that delay letters that do not timely request verification will not serve to toll the time to pay or deny a claim (see 11 NYCRR 65-3.5 [a] [1]; Nyack Hosp. v Encompass Ins. Co., 23 AD3d 535 [2d Dept 2005] [citations omitted]).
Here, rather than the customary method of establishing submission and receipt of the claim through introduction of a witness of the assignee or its billing company, as was articulated in Viviane Etienne (114 AD3d at 45), plaintiff proved such through the testimony of defendant’s witness and the introduction of the denial into evidence, which referenced the bills at issue. The court finds plaintiff was not constrained to prove its case through the conventional method of producing its own witness, but was permitted to prove such through admissible evidence using the documents and witnesses of the defendant insurer (Prestige Med. & Surgical Supply, Inc., 13 Misc 3d 127[A], 2006 NY Slip Op 51672[U], at * 2; Optimal Well-Being Chiropractic, P.C., [*3]46 Misc 3d 129[A], 2014 NY Slip Op 51807[U], at *1-*2; East Acupuncture, P.C. v Electric Ins. Co., 16 Misc 3d 128[A], 2007 NY Slip Op 51281[U], *1 [App Term, 2d Dept, 2d & 11th Jud Dists 2007] [holding NF-10 claim denial forms and affidavits of defendant’s claims examiner cured deficiencies in plaintiff’s proof of mailing]).
Furthermore, it is well-settled that “a medical provider is not required, as part of its prima facie case, to demonstrate the admissibility of its billing records or the truth of their content under the business records exception to the hearsay rule” (New York Hosp. Med. Ctr. of Queens v QBE Ins. Corp., 114 AD3d 648 [2d Dept 2014], citing see CPLR 4518 [a]; Viviane Etienne Med. Care P.C., 114 AD3d at 45). Where the insurer fails to timely contest the adequacy of the claims forms at the claims stage, as here, it is precluded from relying on any deficiencies in those forms or raising evidentiary challenges to the admissibility of the contents of the billing forms under the business records exception at the litigation stage (New York Hosp. Med. Ctr. of Queens, 114 AD3d at 649 [citations omitted]).
Therefore, defendant’s attack on the validity of the bills at trial here will not suffice to defeat plaintiff’s proof of a prima facie case. The testimony of Ms. Dachs and the denials were accepted into evidence and treated as admissions of receipt of the bills and the amount billed and not as a testament to the truth of their content (see Viviane Etienne Med. Care, P.C., 114 AD3d at 45). This result is consistent with the regulatory scheme for the prompt payment and processing of no-fault claims (see id.). Thus, plaintiff sufficiently met its prima facie burden by eliciting the credible testimony of defendant’s witness and admission of defendant’s denials. By establishing submission and receipt of the bills, the plaintiff shifted the burden to defendant to establish a valid defense for its failure to timely issue payment (see Viviane Etienne Med. Care, P.C., 114 AD3d at 45, 47; see Westchester Med. Ctr., 78 AD3d at 1169).
Defendant failed to meet its burden of establishing a justiciable defense because it failed to pay or deny the claims within 30 days as required by statute (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [c]). Defendant also failed to extend its time to pay or deny the claims by issuing timely requests for verification (11 NYCRR 65-3.5 [b]). As defendant is sufficiently aware, delay letters, as here, that do not timely request verification will not suffice to toll the time to pay or deny a claim (see 11 NYCRR 65-3.5 [a] [1]; Nyack Hosp. v Encompass Ins. Co., 23 AD3d 535 [2d Dept 2005]). After the fact, only a non-precluded defense will suffice to prevent payment (see 11 NYCRR 65-3.8). Further, although defendant denied these claims based on alleged fraud, no fraud was demonstrated at trial and defendant failed to produce a competent witness or other evidence from which same could be adduced.
Accordingly, based on the credible testimony of Ms. Dachs and examination of the denial and other exhibits admitted into the record, the court finds plaintiff met its prima facie burden of establishing proof of submission of the bills to defendant, receipt of the bills, and that payment is overdue (see Viviane Etienne Med. Care, P.C., 114 AD3d 33; see Westchester Med. Ctr., 78 AD3d 1168; see Ave T MPC Corp., 32 Misc 3d 128[A]). Defendant failed to establish an adequate defense to payment (see 11 NYCRR 65-3.8; see Viviane Etienne Med. Care, P.C., 114 AD3d at 45-47; see Nyack Hosp. v Encompass Ins. Co., 23 AD3d at 536). Therefore, plaintiff is entitled to a judgment.
The Clerk of the Court shall enter judgment for the plaintiff in the amount of $3,960.57 plus statutory costs, interest, and attorney’s fees. The motions for directed verdict are denied as moot. This constitutes the Decision and Order of the Court.
Dated: April 27, 2015_________________________
Hon. Reginald A. Boddie
Acting Supreme Court Justice
Reported in New York Official Reports at H & H Chiropractic Servs., P.C. v Metropolitan Prop. & Cas. Ins. Co. (2015 NY Slip Op 25132)
| H & H Chiropractic Servs., P.C. v Metropolitan Prop. & Cas. Ins. Co. |
| 2015 NY Slip Op 25132 [47 Misc 3d 1075] |
| April 24, 2015 |
| Love, J. |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| As corrected through Wednesday, July 8, 2015 |
[*1]
| H & H Chiropractic Services, P.C., as Assignee of Jesus Jimenez, Plaintiff, v Metropolitan Property and Casualty Insurance Company, Defendant. |
Civil Court of the City of New York, Queens County, April 24, 2015
APPEARANCES OF COUNSEL
Bruno, Gerbino & Soriano, LLP, Melville (Lienne Pisano of counsel), for defendant.
The Odierno Law Firm, P.C., Melville (Paul Bargellini of counsel), for plaintiff.
{**47 Misc 3d at 1076} OPINION OF THE COURT
Defendant’s motion for summary [*2]judgment is decided as follows:
This is an action to recover assigned no-fault benefits for chiropractic services allegedly rendered to plaintiff’s assignor on February 20, 2013 in the billed amount of $1,365.68. Defendant seeks an order dismissing this action based upon plaintiff’s alleged violation of Insurance Department Regulations Implementing the Comprehensive Motor Vehicle Insurance Reparations Act (11 NYCRR) § 65-3.16 [a] [12]), which states as follows:
“A provider of health care services is not eligible for reimbursement under section 5102(a)(1) of the Insurance Law if the provider fails to meet any applicable New York State or local licensing requirement necessary to perform such service in New York or meet any applicable licensing requirement necessary to perform such service in any other state in which such service is performed.”
On July 8, 2013, as established by Lori Mann, a claims representative employed by defendant, a timely denial of plaintiff’s bill was issued, based, inter alia, upon plaintiff’s alleged illegal fee-splitting. On February 10, 2014, defendant served a notice to admit, pursuant to CPLR 3123, upon the plaintiff, seeking to admit a copy of a contract purportedly entered into between plaintiff and its billing company, Systems Management Group, Inc. (SMG). The purported contract states that “[t]he Practice will pay SMG 6% of all fees charged & ultimately collected by SMG.” The court notes that the purported contract is not in admissible form as defendant has failed to lay a sufficient foundation for its admission (see Bajaj v General Assur., 18 Misc 3d 25 [App Term, 2d Dept, 2d & 11th Jud Dists 2007]). Defendant also submits the deposition transcript of Dr. Lucas Bottcher, DC, a member of the plaintiff’s practice. Therein, Dr. Bottcher admitted that plaintiff employs SMG and they are paid a fixed fee of five percent of collections. Defendant argues that since plaintiff allegedly pays six (or five) percent of its fees to its billing company, that its billing company owns six percent of plaintiff’s practice.
In opposition, plaintiff correctly argues that no court has found improper fee-splitting to be fraud nor a licensing requirement. Furthermore, defendant failed to present any case law{**47 Misc 3d at 1077} that improper fee-splitting is a defense in a no-fault action. Finally, plaintiff contends there is no support for the assertion that payment of six percent of receivables constitutes any form of ownership or control over the plaintiff. As such the parties have presented a case of first impression.
In State Farm Mut. Auto. Ins. Co. v Mallela (4 NY3d 313 [2005]), the Court of Appeals upheld the Insurance Department’s regulation and held that a medical corporation that was fraudulently incorporated under Business Corporation Law §§ 1507 and 1508, and Education Law § 6507 (4) (c) is not entitled to be reimbursed by insurers, under Insurance Law § 5101 et seq. Business Corporation Law §§ 1507 and 1508, as applied to this action, prohibit non-chiropractors from owning any shares of or serving on the board of a professional corporation authorized to provide chiropractic services. Mallela and its progeny (Metroscan Imaging, P.C. v GEICO Ins. Co., 13 Misc 3d 35 [App Term, 2d Dept, 2d & 11th Jud Dists 2006]; Andrew Carothers, M.D., P.C. v Progressive Ins. Co., 42 Misc 3d 30 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]) have consistently held that ownership of a professional corporation by non-professionals renders that corporation ineligible to [*3]recover no-fault benefits and that a carrier may conduct an investigation and look beyond the licensing documents in order to identify improper ownership and control of a professional corporation.
Defendant alleges that plaintiff has violated a licensing requirement by engaging in impermissible fee-splitting, in violation of the Rules of the Board of Regents (8 NYCRR) § 29.1 (b) (4) and Education Law §§ 6509-a and 6530 (19), with its billing company, Systems Management Group, Inc. Pursuant to 8 NYCRR 29.1 (b) (4) and Education Law § 6530 (19), unprofessional conduct shall include:
“permitting any person to share in the fees for professional services, other than: a partner, employee, associate in a professional firm or corporation, professional subcontractor or consultant authorized to practice [the same profession], or a legally authorized trainee practicing under the supervision of a licensed practitioner. This prohibition shall include any arrangement or agreement whereby the amount received in payment for furnishing space, facilities, equipment or personnel services used by a professional licensee constitutes{**47 Misc 3d at 1078} a percentage of, or is otherwise dependent upon, the income or receipts of the licensee from such practice.”
In Necula v Glass (231 AD2d 457 [1st Dept 1996]), the Appellate Division found that the Department of Social Services had properly found that petitioner had engaged in illegal fee-splitting pursuant to 8 NYCRR 29.1 (b) (4) where petitioner had entered into contracts with management companies under which the management companies were to provide facilities, supplies, equipment and staff necessary to operate his professional practice and petitioner was to pay the companies a percentage of his receipts. In Sachs v Saloshin (138 AD2d 586, 587 [2d Dept 1988]), the Appellate Division found that “by tendering a percentage of his patient fees to the plaintiffs, [defendant] violated the public policy of this State as reflected in Education Law § 6509-a [and] the rules for professional conduct established by the Board of Regents (8 NYCRR 29.1 [b] [4]).” A common thread throughout all of the cases cited by defendant is that while courts will refuse to enforce a contract which violates 8 NYCRR 29.1 (b) (4) and the Education Law, any punishment for unprofessional misconduct as defined by those sections is imposed by the State Board for Professional Medical Conduct. In cases where the State Board has imposed punishments, the role of the courts has been to review those punishments in the context of a CPLR article 78 proceeding.
In Mallela (4 NY3d at 322), the Court found that in the licensing context, carriers will be unable to show “good cause” unless they can demonstrate behavior tantamount to fraud and that technical violations will not do. In every case where 11 NYCRR 65-3.16 (a) (12) has been successfully used as a complete and non-precludible defense in a no-fault action, the provider has been found to have committed violations of Business Corporation Law §§ 1507 and 1508 and Education Law § 6507 (4) (c) and appears to have never been based upon impermissible fee-splitting alone. The issue in this case is the definition of the term “licensing requirement.” The Court in Mallela (at 321) highlighted that the medical service corporation in that case “exists to receive payment only because of its willfully and materially false filings with state regulators.” Furthermore, the Court noted in footnote 2 that the Superintendent of Insurance promulgated 11 NYCRR 65-3.16 (a) (12) “to combat rapidly growing incidences of fraud in the no-fault regime, fraud that he has identified as correlative with the corporate practice of medicine by nonphysicians” (Mallela at 320 n 2).
{**47 Misc 3d at 1079}In this case, plaintiff has not been shown to have filed any fraudulent documents with the State and has not allowed non-physicians to control any aspect of their practice. As such, it is the conclusion of this court that impermissible fee-splitting, standing alone, is not a violation of a licensing requirement, does not constitute an available defense to a no-fault action and, as such, any action is solely within the purview of the appropriate state licensing board.
For the foregoing reasons, defendant’s motion is hereby denied in its entirety.