Reported in New York Official Reports at Lotus Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51315(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
State Farm Mutual Automobile Ins. Co., Respondent.
Appeal from an order of the Civil Court of the City of New York, Queens County (Joseph E. Capella, J.), entered August 3, 2012, deemed from a judgment of the same court entered September 28, 2012 (see CPLR 5501 [c]). The judgment, entered pursuant to the August 3, 2012 order granting defendant’s motion for summary judgment dismissing the complaint and denying plaintiff’s cross motion to, among other things, disqualify defendant’s law firm from representing defendant in this action, dismissed the complaint.
ORDERED that the judgment is affirmed, with $25 costs.
In this action by a provider to recover assigned first-party no-fault benefits, insofar as is relevant to this appeal, defendant moved for summary judgment dismissing the complaint on the ground that plaintiff had failed to appear for duly scheduled examinations under oath (EUOs). The motion was supported by, among other things, an affirmation from a partner in the law firm representing defendant, attesting to plaintiff’s failure to appear. Plaintiff cross-moved to, among other things, disqualify the law firm representing defendant, pursuant to rule 3.7 of the Rules of Professional Conduct (22 NYCRR 1200.0), on the ground that a member of the firm was a necessary witness in this case. Plaintiff appeals from an order of the Civil Court entered August 3, 2012 granting defendant’s motion and denying plaintiff’s cross motion. A judgment was subsequently entered dismissing the complaint, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).
As to defendant’s motion for summary judgment, we find that, contrary to plaintiff’s arguments on appeal, defendant submitted sufficient proof to show that the EUO scheduling letters and the denial of claim form had been timely mailed (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]), and that plaintiff had failed to appear at either of the duly scheduled EUOs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). An appearance at an EUO is a condition precedent to an insurer’s liability on a policy (see Insurance Department Regulations [11 NYCRR] § 65-1.1; Stephen Fogel Psychological, P.C., 35 AD3d 720). Therefore, and as plaintiff’s remaining contentions with respect to this motion lack merit, we find that the Civil Court properly granted defendant’s motion for summary judgment dismissing the complaint.
In light of the foregoing, plaintiff’s request that defendant’s law firm be disqualified based [*2]on the attorney/witness rule is “moot since, summary judgment having been granted, there will be no trial of this matter” (Quiros v Mount St. Michael Academy, 303 AD2d 185, 186 [2003]; see also Lombino v Town Bd. of Town of Rye, 206 AD2d 462 [1994]). In any event, plaintiff failed to establish that disqualification of defendant’s law firm was warranted (see S & S Hotel Ventures Ltd. Partnership v 777 S. H. Corp., 69 NY2d 437 [1987]; see also e.g. Magnus v Sklover, 95 AD3d 837 [2012]; Matter of Advent Assoc., LLC v Vogt Family Inv. Partners, L.P., 56 AD3d 1023 [2008]; Hudson Val. Mar., Inc. v Town of Cortlandt, 54 AD3d 999 [2008]; Daniel Gale Assoc., Inc. v George, 8 AD3d 608 [2004]; Broadwhite Assoc. v Truong, 237 AD2d 162 [1997]; Matter of Cowen & Co. v Tecnoconsult Holdings, 234 AD2d 86 [1996]; Talvy v American Red Cross in Greater NY, 205 AD2d 143 [1994], affd 87 NY2d 826 [1995]; Kaplan v Maytex Mills, 187 AD2d 565 [1992]).
Accordingly, the judgment is affirmed.
Pesce, P.J., Solomon and Elliot, JJ., concur.
Decision Date: August 20, 2014
Reported in New York Official Reports at Natural Therapy Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51310(U))
| Natural Therapy Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. |
| 2014 NY Slip Op 51310(U) [44 Misc 3d 141(A)] |
| Decided on August 20, 2014 |
| 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 August 20, 2014
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., WESTON and ALIOTTA, JJ.
2012-947 K C
against
State Farm Mutual Automobile Ins. Co., Respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Carolyn E. Wade, J.), entered March 14, 2012. 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, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint. The Civil Court found that defendant had timely and properly denied the claims at issue on the ground that plaintiff had failed to comply with a condition precedent to coverage, in that plaintiff had failed to appear for duly scheduled examinations under oath (EUOs). On appeal, plaintiff argues that defendant failed to prove that it had mailed its EUO scheduling letters and denial of claim forms or that plaintiff had failed to appear for the EUOs; that defendant lacked justification for its EUO requests; and that defendant’s motion should have been denied pursuant to CPLR 3212 (f), as plaintiff had not received discovery regarding the reasonableness of defendant’s EUO requests.
Contrary to plaintiff’s argument, the affidavits submitted by defendant established that the EUO scheduling letters and the denial of claim forms had been timely mailed 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]), and the affirmation submitted by defendant’s attorney, who was present in his office to conduct plaintiff’s EUO on the scheduled dates, was sufficient to establish that plaintiff had failed to appear. Furthermore, since plaintiff does not claim to have responded in any way to the EUO requests, its objections regarding the EUO requests will not now be heard (see Viviane Etienne Med. Care, P.C. v State Farm Mut. Auto. Ins. Co., 35 Misc 3d 127[A], 2012 NY Slip Op 50579[U] [App Term, 2d, 11th & 13th Jud Dists 2012]; Crescent Radiology, PLLC v American Tr. Ins. Co., 31 Misc 3d 134[A], 2011 NY Slip Op 50622[U] [App Term, 9th & 10th Jud Dists 2011]). Consequently, discovery relevant to the reasonableness of the EUO requests was not necessary for plaintiff to oppose defendant’s motion (see CPLR 3212 [f]).
Accordingly, the order is affirmed.
Pesce, P.J., Weston and Aliotta, JJ., concur.
Decision Date: August 20, 2014
Reported in New York Official Reports at SS Med. Care, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51305(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
Eveready Ins. Co., Appellant.
Appeal from an order of the Civil Court of the City of New York, Kings County (Katherine A. Levine, J.), entered July 26, 2011. The order, insofar as appealed from, upon denying plaintiff’s motion for summary judgment, made CPLR 3212 (g) findings in plaintiff’s favor, and denied defendant’s cross motion for summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, the CPLR 3212 (g) findings in plaintiff’s favor are vacated, and defendant’s cross motion for summary judgment dismissing the complaint is granted.
In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for, among other things, summary judgment, and defendant cross-moved for summary judgment dismissing the complaint on the ground that the action is premature due to plaintiff’s failure to provide requested verification. Insofar as is relevant to this appeal, the Civil Court, upon denying plaintiff’s motion, made CPLR 3212 (g) findings in plaintiff’s favor, denied defendant’s cross motion, and limited the issues for trial.
In support of its cross motion for summary judgment dismissing the complaint, defendant submitted an affidavit by its claims examiner which established that defendant had timely mailed its verification requests and follow-up verification requests (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 demonstrated that it had not received the requested verification. Plaintiff did not oppose defendant’s cross motion. Contrary to the Civil Court’s statement, there is nothing in the record which would require defendant to prove that the copies of the verification letters annexed to defendant’s cross motion had not been tampered with or altered (see Schozer v William Penn Life Ins. Co. of NY, 84 NY2d 639, 643 [1994]; People v Dicks, 100 AD3d 528 [2012]; Rotanelli v Longo, 210 AD2d 392 [1994]). As the 30-day period within which defendant was required to pay or deny the claims did not begin to run (see Insurance Department Regulations [11 NYCRR] § 65-3.8 [a]; Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 [2005]; Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533 [2004]; D & R Med. Supply v American Tr. Ins. Co., 32 Misc 3d 144[A], 2011 NY Slip Op 51727[U] [App Term, 2d, 11th & 13th Jud Dists 2011]), plaintiff’s action is premature.
Accordingly, the order, insofar as appealed from, is reversed, the CPLR 3212 (g) findings in plaintiff’s favor are vacated, and defendant’s cross motion for summary judgment dismissing the complaint is granted.
Pesce, P.J., Aliotta and Solomon, JJ., concur.
Decision Date: August 20, 2014
Reported in New York Official Reports at Matter of Unitrin Direct/Warner Ins. Co. v Brand (2014 NY Slip Op 05887)
| Matter of Unitrin Direct/Warner Ins. Co. v Brand |
| 2014 NY Slip Op 05887 [120 AD3d 698] |
| August 20, 2014 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| In the Matter of Unitrin Direct/Warner Insurance
Company, Respondent, v Joseph Brand, Appellant. |
Elovich & Adell, Long Beach, N.Y. (A. Trudy Adell, Mitchel Sommer, and Darryn Solotoff of counsel), for appellant.
Breen & Clancy, Hauppauge, N.Y. (Anne Marie Caradonna of counsel), for respondent.
In a proceeding pursuant to CPLR 7503 to permanently stay arbitration of a claim for supplementary uninsured/underinsured motorist benefits, Joseph Brand appeals from an order of the Supreme Court, Nassau County (Diamond, J.), dated November 15, 2012, which granted the petition.
Ordered that the order is affirmed, with costs.
On October 17, 2011, Joseph Brand was operating a bicycle on Rockley Boulevard in Sarasota, Florida, when he was struck by a motor vehicle owned and operated by Thomas Collins. Brand sustained multiple serious injuries. Collins is a resident of Florida and his motor vehicle is registered in Florida. Brand is a resident of New York.
At the time of the accident, Collins maintained automobile liability insurance in Florida with Allstate Insurance Company with liability limits for bodily injury in the amount of $100,000 per person/$300,000 per occurrence and supplementary uninsured/underinsured motorist (hereinafter SUM) coverage for bodily injury in the amount of $100,000 per person/$300,000 per occurrence. Allstate tendered the bodily injury policy limit in the amount of $100,000 in settlement of Brand’s claim.
At the time of the accident, Brand maintained automobile insurance coverage with the petitioner Unitrin Direct/Warner Insurance Company (hereinafter Unitrin) with policy limits for bodily injury also of $100,000 per person/$300,000 per occurrence and SUM coverage for bodily injury also of $100,000 per person/$300,000 per occurrence. Brand claimed that his injuries exceeded the limits of Collins’ policy, and demanded from the American Arbitration Association in New York arbitration of a claim for SUM benefits under his Unitrin policy. In response to Brand’s demand for arbitration, Unitrin moved for a permanent stay of arbitration on the ground that the SUM coverage was not triggered under New York law because the offending vehicle was not underinsured since Collins’ bodily injury liability coverage under the Allstate policy equaled Brand’s bodily injury liability coverage under the Unitrin policy. Unitrin argues that the “center of [*2]gravity”/”grouping of contacts” analysis demonstrates that New York is the forum that has the most significant contact to the dispute such that New York law should govern this matter. Brand contends, however, that under the “center of gravity”/”grouping of contacts” analysis, Florida law should control.
It is undisputed that this conflict of law question, although arising in the context of a motor vehicle accident, must be resolved by the conflict of law rules relevant to contracts, not torts (see Matter of Eagle Ins. Co. v Singletary, 279 AD2d 56 [2000]). Generally, “the courts apply the more flexible ‘center of gravity’ or ‘grouping of contacts’ inquiry, which permits consideration of the ‘spectrum of significant contacts’ in order to determine which State has the most significant contacts to the particular contract dispute” (id. at 58-59, quoting Matter of Allstate Ins. Co. [Stolarz—New Jersey Mfrs. Ins. Co.], 81 NY2d 219, 226 [1993]). “In general, significant contacts in a case involving contracts, in addition to the place of contracting, are the place of negotiation and performance, the location of the subject matter of the contract, and the domicile or place of business of the contracting parties” (id. at 59). As to insurance contracts specifically, significance has been attached to the “ ’local law of the state which the parties understood was to be the principal location of the insured risk . . . unless with respect to the particular issue, some other state has a more significant relationship under the principles stated in § 6 [of the Restatement] to the transaction and the parties’ ” (Zurich Ins. Co. v Shearson Lehman Hutton, 84 NY2d 309, 318 [1994], quoting Restatement [Second] of Conflict of Laws § 193). In the case of a noncommercial vehicle, which is by its nature mobile, the principal location of the insured risk is the place where the vehicle is to be principally garaged (Matter of Eagle Ins. Co. v Singletary, 279 AD2d at 59).
Here, as the Supreme Court correctly noted, the insurance contract at issue was written to conform to the laws, rules and regulations of New York State, and was obtained in New York by Brand, a New York resident, from an insurance company doing business in New York. Furthermore, Brand served the demand for SUM arbitration upon the American Arbitration Association in New York. Applying the grouping of contacts inquiry to these facts, New York has the most significant contacts with the parties and the contract. Indeed, such a conclusion would be in conformity with the reasonable expectations of the contracting parties.
Brand’s reliance on Florida as the situs of the accident confuses the contacts that might be significant in a tort case with those that are material in a contract dispute (see Matter of Allstate Ins. Co. [Stolarz—New Jersey Mfrs. Ins. Co.], 81 NY2d 219 [1993]). New York law applies herein.
Under New York law, SUM coverage is only triggered where the bodily injury liability insurance limits of the policy covering the tortfeasor’s vehicle are less than the liability limits of the policy under which a party is seeking SUM benefits (see Insurance Law § 3420 [f] [2] [A]; Matter of Allstate Ins. Co. v Rivera, 12 NY3d 602, 607-608 [2009]; Matter of AIU Ins. Co. v Hibbert, 85 AD3d 779 [2011]). Here, Collins’ Allstate policy limits for bodily injury were identical to Brand’s Unitrin policy limits for bodily injury. Hence, Collins does not qualify as an underinsured driver.
Accordingly, the Supreme Court properly granted the petitioner’s application to permanently stay arbitration of a claim for SUM benefits.
Brand’s contention that Unitrin’s payment of first party benefits constituted an agreement that Florida law controls is without merit, as Unitrin’s payment of first party benefits in the first instance was required pursuant to 11 NYCRR 65-3.12 (a) (3) and (b). To the extent there was a dispute between Unitrin and Allstate as to the priority of first party benefits, that is a matter to be resolved between the insurers (see Insurance Law § 5105; 11 NYCRR 65-3.12 [b]; 65-4.11).
Brand’s remaining contentions are without merit. Skelos, J.P., Austin, Sgroi and LaSalle, JJ., concur.
Reported in New York Official Reports at Optimal Well-Being Chiropractic, P.C. v General Motors Assur. Co. (2014 NY Slip Op 51323(U))
[*1]| Optimal Well-Being Chiropractic, P.C. v General Motors Assur. Co. |
| 2014 NY Slip Op 51323(U) [44 Misc 3d 143(A)] |
| Decided on August 20, 2014 |
| 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 August 20, 2014
PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-685 K C
against
General Motors Assurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Kings County (Devin P. Cohen, J.), entered December 20, 2012. The order denied 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 appeals from an order of the Civil Court which denied its motion for summary judgment dismissing the complaint on the ground of lack of coverage.
In support of its motion, defendant’s investigator stated that, based on the vehicle identification number set forth in the police report of the accident in question, the vehicle at issue was not a covered vehicle under the applicable policy. However, the recitation of the vehicle identification number was inconsistent throughout the papers submitted in support of defendant’s motion, thus raising a question of fact as to whether the vehicle was not covered under the applicable insurance policy. In view of defendant’s conflicting evidentiary submissions, defendant failed to eliminate all triable issues of fact (see Alvarez v Prospect Hosp., 68 NY2d 320 [1986]; see generally Nocella v Fort Dearborn Life Ins. Co. of NY, 99 AD3d 877 [2012]; Millennium Med. Diagnostics v Liberty Mut. Ins. Co., 306 AD2d 388 [2003]; Balanca v Foschi & Sons, 302 AD2d 416 [2003]). Consequently, defendant’s motion was properly denied, regardless of the sufficiency of plaintiff’s papers in opposition (see Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]). Defendant’s remaining contention is unpreserved for appellate review.
Accordingly, the order is affirmed.
Pesce, P.J., Aliotta and Solomon, JJ., concur.
Decision Date: August 20, 2014Sky Med. Supply Inc. v ELRAC Inc. (2014 NY Slip Op 24232)
Reported in New York Official Reports at Sky Med. Supply Inc. v ELRAC Inc. (2014 NY Slip Op 24232)
| Sky Med. Supply Inc. v ELRAC Inc. |
| 2014 NY Slip Op 24232 [45 Misc 3d 450] |
| August 16, 2014 |
| Levine, J. |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| As corrected through Wednesday, November 5, 2014 |
[*1]
| Sky Medical Supply Inc., as Assignee of Robert Taylor, Plaintiff, v ELRAC Inc., Doing Business as Enterprise Rent-A-Car, Defendant. |
Civil Court of the City of New York, Kings County, August 16, 2014
Gary Tsirelman P.C., Brooklyn, for plaintiff.
Brand, Glick & Brand, P.C., Garden City, for defendant.
The sole issue presented to the court at trial is whether a medical service provider or its assignor can provide an insurance company with oral or telephonic notice of accident or whether such notice must be in writing.
The parties stipulated at trial that neither plaintiff Sky Medical Supply Inc., nor its assignor Robert Taylor, provided defendant ELRAC with a “written notice of claim” within 30 days of the alleged accident and that defendant was only provided with an oral or telephonic “notice of claim.” While plaintiff asserts that oral notification is sufficient, defendant asserts that the case law and [*2]regulations mandate that a written notice be tendered.
Both sides refer to the notice at issue as a “notice of claim” which must be received within 30 days of the motor vehicle accident. However, this nomenclature has spawned confusion since the no-fault regulations have different names for each of the notices that must be provided by the provider/assignor to the insurance company, and oftentimes both the parties and decisions generically refer to these different notices as a “notice of claim.”
In New York & Presbyt. Hosp. v Country-Wide Ins. Co. (17 NY3d 586, 590 [2011]), the Court of Appeals carefully distinguished between a “notice of accident” and “proof of claim,” both of which were “independent conditions precedent to . . . liability.” There, the plaintiff medical provider failed to submit a notice of accident to Country-Wide within 30 days but timely submitted a proof of claim for health care services 40 days after the accident. The Court first cited to the regulations implementing the No-Fault Law (Insurance Law art 51), which contains “circumscribed time frames for claim procedures” in furtherance of the No-Fault Law’s goal of ensuring “prompt compensation for losses incurred by accident victims” (id. at 589, citing Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 317 [2007]).
The revised mandatory personal injury protection endorsement in the revised no-fault regulations—11 NYCRR 65-1.1—contains two separate and distinct notice requirements under the subsection entitled “Conditions.” It provides that as a condition precedent to bringing an action against an insurance company, there must be:
“Notice. In the event of an accident, written notice{**45 Misc 3d at 452} setting forth details sufficient to identify the eligible injured person, along with reasonably obtainable information regarding the time, place and circumstances of the accident, shall be given by, or on behalf of, each eligible injured person, to the Company, or any of the Company’s authorized agents, as soon as reasonably practicable, but in no event more than 30 days after the date of the accident . . .New Capital Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 24277)“Proof of Claim. Medical, Work Loss, and Other Necessary Expenses. In the case of a claim for health service expenses, the eligible injured person or that person’s assignee or representative [e.g., a health care services provider] shall submit written proof of claim to the Company, including full particulars of the nature and extent of the injuries and treatment received and contemplated, as soon as reasonably practicable but, in no event later than 45 days after the date services are rendered” (11 NYCRR 65-1.1 [d] [emphasis added]).In Hospital for Joint Diseases, the Court of Appeals noted that these regulations [*3]require an accident victim to submit a written notice of claim[FN*] as soon as practicable but no later than 30 days after an accident; next, the injured party or assignee must submit a “proof of claim for medical treatment no later than 45 days after services are rendered.” (9 NY3d at 317; see New York & Presbyt. Hosp., 17 NY3d at 591 [“these regulations . . . cannot be interpreted to mean that a hospital/assignee’s timely submission of a proof of claim for health services within 45 days of discharge . . . excuses the insured/assignor’s failure to give the threshold notice of accident within 30 days of the accident, or that health care service providers are exempt from the written 30-day notice of accident requirement”]; see also Medical Select, P.C. v Allstate Ins. Co., 42 Misc 3d 851, 852 [Nassau Dist Ct 2013] [the two “notice” requirements are “separate and distinct” and different time limits apply to each requirement].)
While 11 NYCRR 65-1.1 mandates that both the notice of accident and proof of claim of health services be in writing, 11 NYCRR 65-3.4 (a) states that “[w]henever the insurer receives notice of claim by telephone, the party receiving such notice on behalf of the insurer shall be identified to the caller by name and title.” It further requires the insurer’s representative to take{**45 Misc 3d at 453} down the name, address and phone number of the applicant and policyholder along with information regarding the time, place and circumstances of the accident “which will enable the insurer to begin processing the claim.” Additionally, 11 NYCRR 65-3.2, which spells out the claim procedures “to be followed by all insurers,” provides in subdivision (d) that the insurer should “[h]asten the processing of a claim through the use of a telephone whenever it is possible to do so.”
While the courts recognize that these provisions permit an injured party to give an oral “notice of claim” to the insurer, they have not clarified whether the term “notice of claim” applies to proof of claim or notice of accident or both. (See Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 18, 20 [App Term, 2d Dept, 2d & 11th Jud Dists 2004] [“an insurer has a right to an IME following an oral or written notice of claim and prior to (its) receipt of the statutory claim forms” (pre-claim IME) (citations omitted)]; Medical Select, P.C., 42 Misc 3d at 853 [provision permitting insurer to receive “notice of claim” by telephone is part of the regulations goal “to facilitate the insurer’s receipt of timely written notice”]; but see Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 106 AD3d 157, 162 [2013] [pursuant to 11 NYCRR 65-2.4, the injured party or his assignee must submit a written notice of claim to an insurer no later than 45 days after services are rendered].)
The two reported decisions where an oral notice of accident was tendered reach opposite results and neither court directly discussed the applicability of 11 NYCRR 65-3.4. (See Meehan v City of New York, 295 AD2d 581, 582 [2d Dept 2002] [plaintiff’s “telephone report of accident, claim & no-fault,” completed shortly after the accident, did not provide the Transit Authority with “actual notice of the essential facts constituting the . . . claim” since they failed to suggest any connection between the accident and alleged negligence in operation of control of bus].) In Nationwide Mut. Ins. Co. v Acevedo-De La Cruz (2013 NY Slip Op 31452[U] [Sup Ct, NY County 2013]), the court did not directly rule on the issue before this court but rather refused to vacate a master arbitration award. The original arbitrator had dismissed a no-fault claim because he found that the insured’s telephonic notification of the accident violated a condition precedent of the contract which required, pursuant to 11 NYCRR 65.1-1, that notice of an accident be in writing. The court affirmed the master arbitrator’s award permitting the claim to go{**45 Misc 3d at 454} forward because he had rationally found that 11 NYCRR 65-3.2 (d) and (e) required that the carrier “[h]asten the processing of a claim through the use of a telephone whenever possible to do so,” and “[c]learly inform the applicant of the insurer’s position regarding any disputed matter.” (Nationwide Mut. Ins. Co. v Acevedo-De La Cruz at *4) The master arbitrator thus rationally determined that the insurer had violated the No-Fault Law by failing to inform the insured of its position regarding her oral notification by phone. Furthermore, the court found that 11 NYCRR 65-3.4 supported the master arbitrator’s finding that oral notification was sufficient.
This court finds that the tenets of statutory construction mandate that the right of an insured to orally notify the insurer of the notice of claim applies to both the proof of claim and the notice of accident. In construing administrative rules, the court must utilize the same canons of construction applicable to statutes. (Matter of Cortland-Clinton, Inc. v New York State Dept. of Health, 59 AD2d 228, 231 [4th Dept 1977]; see Matter of Garzilli v Mills, 250 AD2d 131 [3d Dept 1998].) One of the primary tenets of statutory construction is that “a statute or ordinance must be construed as a whole and . . . its various sections must be considered together and with reference to each other.” (People v Mobil Oil Corp., 48 NY2d 192, 199 [1979]; see East Acupuncture, P.C. v Allstate Ins. Co., 61 AD3d 202, 209 [2d Dept 2009].) As a corollary, statutes and regulations are to be harmonized, and not interpreted in a way that would leave one section without meaning or force. (McKinney’s Cons Laws of NY, Book 1, Statutes § 98; Matter of Albano v Kirby, 36 NY2d 526, 530 [1975]; Matter of Kaiser v Commissioner of N.Y.S. Dept. of Health, 13 Misc 3d 1211[A], 2006 NY Slip Op 51786[U] [Sup Ct, Nassau County 2006].) To that end, separate sections of a statute should be construed in connection with each other as if they were in the same section. (Statutes §§ 97, 130; see Friedman v Connecticut Gen. Life Ins. Co., 9 NY3d 105, 115 [2007].) Finally, regulations should be construed to avoid objectionable, unreasonable or absurd results. (Long v State of New York, 7 NY3d 269, 273 [2006]; Matter of ATM One v Landaverde, 2 NY3d 472, 477 [2004]; East Acupuncture, P.C., 61 AD3d at 208 [2d Dept 2009]; Pine Hollow Med., P.C. v Global Liberty Ins. Co. of N.Y., 25 Misc 3d 244, 250 [Civ Ct, Richmond County 2009]; Statutes § 145.)
The Superintendent of Insurance determined that the revised Regulation 68 (repealing and replacing the prior 11 NYCRR{**45 Misc 3d at 455} part 65) was “the most effective means of advancing the legislative intent of providing prompt payment of [no-fault] benefits as the loss is incurred, while reducing rampant abuse.” (Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854, 867 [2003].) It would frustrate the legislative intent of the No-Fault Law by reading one particular section of the no-fault regulations apart from the rest of the revised no-fault program—which sets tight deadlines for the submission and payment of claims and “stresses the justifying of claims.” (Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294, 300 [2007].) The [*4]no-fault regulations thus must be construed as a whole and the various sections must be considered in reference to each other; “any construction which deprives any part of a statute of effect and meaning, when it is susceptible of another interpretation giving effect to every part, is avoided” (East Acupuncture, P.C. v Allstate Ins. Co., 15 Misc 3d 104, 107 [App Term, 2d Dept, 2d & 11th Jud Dists 2007], citing Statutes § 231).
The term “notice of claim,” as contained in 11 NYCRR 65-3.4 (a), is not specifically defined in the regulations. The canons of statutory construction require a term of greater comprehension to include a lesser term in line with the axiom that the “whole includes all of its parts.” (Matter of DeTroia v Schweitzer, 87 NY2d 338, 341 [1996].) Furthermore, words and phrases should be interpreted with reference to the scheme of the entire section, and the “meaning of an undefined word depends on the meaning of the whole act.” (Matter of Charlotte’s Fancy Rest. v City of N.Y. Dept. of Consumer Affairs, 121 AD2d 969, 970-971 [1st Dept 1986], revd 69 NY2d 865 [1987]; All Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co., 38 Misc 3d 268, 272 [Civ Ct, Kings County 2012]; Statutes § 97.)
In Medical Select, the court followed this maxim in finding that the standards for excusing late filings applied to both the notice of accident and proof of claim. Thus, while the revised regulations reduced the time limits in which to submit the forms, the standards for excusing late filings for both forms were “relaxed” so that “bona-fide claims” would be considered if they were delayed due to bureaucratic delay or mishap. (Medical Select, 42 Misc 3d at 853; see Hempstead Pain & Med. Servs., P.C. v General Assur. Co., 13 Misc 3d 980 [Suffolk Dist Ct 2006].) The court interpreted the regulations’ use of the term “timely written notice of claim or timely submission of proof of claim,” as contained in the “safety valve provisions,” to apply to both the notice of accident and proof of claim. (Medical Select at 853-{**45 Misc 3d at 456}854, 857 [interpreting both 11 NYCRR 65-3.4 (a) and 65-3.3 (e); an insurer that denies a claim based upon failure to provide a timely written notice of claim or proof of claim must advise applicant that such late notice will be excused upon presentation of reasonable justification].)
In an analogous situation, the Second Department had to determine which type of claimant the term “applicant” applied to, in light of varying uses of the term in different subsections of the regulations. At issue in East Acupuncture, P.C. v Allstate Ins. Co. (61 AD3d 202, 209 [2d Dept 2009]) was whether the toll on the accrual of statutory interest on overdue no-fault claims, pursuant to 11 NYCRR 65-3.9 (c), applies solely to claims submitted directly by the injured party (assignor) or also to claims submitted by the medical providers as assignees of the injured parties. The lower court had determined that the interest toll applied only to claims of the injured persons and not to those of the provider assignee. 11 NYCRR 65-3.9 (a) provides in pertinent part that all overdue personal injury protection benefits due “an applicant or assignee” (emphasis added) bears an interest rate of 2% a month. Subdivision (c) however, provides that if the applicant did not request arbitration or institute a lawsuit within 30 days after receipt of a denial of claim form or payment, the accumulation of interest would toll on the disputed claim until such action was [*5]taken. Since subdivision (c) only referred to the applicant whereas subdivision (a) used the terms applicant and assignee, East Acupuncture argued that the interest toll could only apply to claims submitted by the assignor injured party. Allstate countered that for tolling purposes, there was no reason to distinguish between claims brought directly by the injured party and those submitted by the provider assignee because the term “applicant” utilized in subdivision (c) referred “generically” to both provider assignees and injured persons. (61 AD3d at 208.)
After reviewing the canons of statutory construction set forth above, the Second Department found that since the no-fault regulations failed to provide a general definition of the term applicant, “the plain meaning of this term in 11 NYCRR 65-3.9 (c) would seem to refer to any entity, whether an injured person or a provider/assignee, who submits a claim” or applies for no-fault benefits. (Id. at 210.) While noting that the no-fault regulations did not consistently and exclusively use the term “applicant” to refer to injured persons, and at times used the term to apply to both entities, the Court found that the no-fault{**45 Misc 3d at 457} regulations must be construed as a whole and their sections must be construed in reference to each other. (Id. at 211.) Consistent with the goal of the no-fault regulations—to ensure prompt payment of claims—it would be counterintuitive to find that the interest tolling provision applied only to injured persons and then allow a provider’s assignee, who delayed commencing legal proceeding, to continue to accrue interest. (Id.)
The same reasoning applies herein. Since the core objective of the no-fault regulations is to “provide a tightly timed process of claim, disputation and payment” (Hospital for Joint Diseases, 9 NY3d at 319-320), it begs all reason to adopt respondent’s position that a regulation which generically permits the receipt of “notices of claim” by telephone does not apply to the specific forms that an assignor must file in order to be eligible for no-fault benefits—the notice of accident and proof of claim. Furthermore, since all provisions of the regulations must be read in tandem, it would be absurd and irrational to permit an assignor to telephone in a proof of claim but mandate that the notice of accident be in writing.
In light of the above, this court finds that the claimant properly notified defendant and judgment should be rendered in favor of the plaintiff.
Footnotes
Footnote *:The Court of Appeals also referred to the notice of accident as the generic “notice of claim.”
Reported in New York Official Reports at New Capital Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 24277)
| New Capital Supply, Inc. v State Farm Mut. Auto. Ins. Co. |
| 2014 NY Slip Op 24277 [45 Misc 3d 758] |
| August 14, 2014 |
| Lebovits, J. |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| As corrected through Wednesday, November 26, 2014 |
[*1]
| New Capital Supply, Inc., as Assignee of Jacques Gladys, Plaintiff, v State Farm Mutual Automobile Ins. Co., Defendant. |
Civil Court of the City of New York, New York County, August 14, 2014
APPEARANCES OF COUNSEL
Rivkin Radler LLP, Uniondale (Shana Slawitsky of counsel), for defendant.
Gary Tsirelman P.C., Brooklyn (Irena Golodkeyer of counsel), for plaintiff.
{**45 Misc 3d at 758} OPINION OF THE COURT
Plaintiff brought this no-fault benefits action seeking {**45 Misc 3d at 759}reimbursement for $844.13 for medical services rendered to assignor, Jacques Gladys. Plaintiff submitted to defendant one bill for date of service May 31, 2011. Defendant denied the claim on the basis that the medical provider failed to appear for two scheduled examinations under oath (EUOs).
Defendant moves for summary judgment under CPLR 3212 on the ground that the medical provider failed to appear for two scheduled EUOs and, thus, that plaintiff breached a condition precedent to coverage. Plaintiff’s most persuasive argument in opposition is that defendant failed to prove the provider’s nonappearance for the EUOs. Plaintiff argues that Michael Sirignano’s affirmation is insufficient because, plaintiff argues, he has no personal knowledge of the provider’s nonappearance for the EUOs. (Golodkeyer affirmation, Sept. 12, 2013, ¶ 24.) Without moving for disclosure, plaintiff seeks disclosure about defendant’s special investigation unit (SIU) file and its SIU investigation and claims practices before, it urges, it can properly oppose defendant’s summary judgment motion. (Golodkeyer affirmation, Sept. 12, 2013, ¶ 16.)
[*2]After oral argument, the court asked the parties to submit memorandums of law about whether Sirignano’s affirmation comports with an Appellate Term, Second Department decision: Alrof, Inc. v Safeco Natl. Ins. Co. (39 Misc 3d 130[A], 2013 NY Slip Op 50458[U], *1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists, Mar. 21, 2013]). Since oral argument, only defendant submitted a memorandum of law on this issue.
In Alrof, the court determined that the “affidavit of defendant’s attorney was of no probative value as it lacked personal knowledge of the nonappearance of plaintiff.” (Alrof, 39 Misc 3d 130[A], 2013 NY Slip Op 50458[U], *1.) The court held that “[i]t is well settled that a motion for summary judgment must be supported by an affidavit from a person having knowledge of the facts (CPLR 3212 [b]). A conclusory statement from an attorney which fails to demonstrate his or her personal knowledge is insufficient to support summary judgment.” (Id. at *1-2.)
The proof the Alrof court considered was an affidavit from Vincent F. Gerbino, a partner at Bruno, Gerbino & Soriano, LLP. In his affidavit, Gerbino states that he has “personal knowledge of the facts at issue . . . based on [his] review of the file and [his] knowledge of office practices and procedures.” (Exhibit 2, Gerbino aff, Mar. 23, 2009, ¶ 3.) Gerbino states that {**45 Misc 3d at 760}the “office mailed correspondence to Jonathan Rosario [the assignor] notifying that he was scheduled for an EUO on July 18, 2008, at 10:00 AM. He did not appear on this date. Therefore, . . . this office . . . re-scheduled . . . [the] EUO on July 30, 2008, at 1:00PM.” (Exhibit 2, Gerbino aff, Mar. 23, 2009, ¶ 3.) Gerbino thus states that “Jonathan Rosario failed to appear at both . . . EUO’s.” (Exhibit 2, Gerbino aff, Mar. 23, 2009, ¶ 3.)
Since Alrof, the court revisited the issue of the sufficiency of an attorney’s affirmation to prove nonappearance at EUOs in Bright Med. Supply Co. v IDS Prop. & Cas. Ins. Co. (40 Misc 3d 130[A], 2013 NY Slip Op 51123[U], *1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists, July 5, 2013]). In Bright Med., the court held the court below properly denied defendant’s summary judgment motion because “defendant failed to submit proof by someone with personal knowledge of the nonappearance of plaintiff for the EUOs in question.” (Id., citing Alrof, 39 Misc 3d 130[A], 2013 NY Slip Op 50458[U], *1.)
The proof the Bright Med. court considered was the affirmation of Michael A. Callinan. (Defendant’s reply affirmation, exhibit 9.) Callinan states that the
“EUO for July 14, 2009, was scheduled at your affiant’s office, located at 445 Broad Hollow Road, Melville, New York 11747. I was present at your affiant’s office . . . on July 14, 2009, the date of the scheduled EUO. Further, had the EUO proceeded, I would likely have been the attorney assigned to conduct said EUO.” (Exhibit 9, Callinan affirmation, July 28, 2010, ¶¶ 15-16.)
Callinan states that “[b]ased on this personal knowledge, as well as a review of the file maintained by our office . . . I know that Plaintiff failed to appear for a scheduled EUO on July 14, 2009.” (Exhibit 9, Callinan affirmation, July 28, 2010, ¶ 16.) Callinan’s office scheduled the second EUO on August 10, 2009. (Exhibit 9, Callinan affirmation, July 28, 2010, ¶ 16.) Callinan states that he “was present at your affiant’s office, located at 445 Broad Hollow Road, Melville, New York 11747, the location of the scheduled EUO, on August 10, 2009, the date of the scheduled EUO. Further, had the EUO proceeded, I would likely have been the attorney assigned to conduct said [*3]EUO.” (Exhibit 9, Callinan affirmation, July 28, 2010, ¶ 17.) Callinan states that “[b]ased on this personal knowledge, as well as a review of the file maintained by our office . . . I know that Plaintiff, Bright Medical Supply Co., failed to appear for a scheduled EUO on August 10, 2009.” (Exhibit 9, Callinan affirmation, July 28, 2010, ¶ 17.)
{**45 Misc 3d at 761}Since Bright Med., the court determined that the affirmation of defendant’s attorney “who was present in his office to conduct plaintiff’s EUO on the scheduled dates . . . was sufficient to establish that plaintiff had failed to appear.” (Natural Therapy Accupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 42 Misc 3d 137[A], 2014 NY Slip Op 50134[U], *1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists, Jan. 28, 2014].) In Natural Therapy, the court considered the affirmation of Elizabeth Adels, a partner at McDonnell & Adels, PLLC. (Defendant’s additional submission, Adels affirmation, Oct. 12, 2011, ¶ 1.) Adels states that on “April 29, 2010, Plaintiff was scheduled to submit to an EUO . . . . I was present in the office on this date in order to conduct the EUO of Plaintiff. No one affiliated with Plaintiff appeared for the EUO scheduled for April 29, 2010.” (Defendant’s additional submission, Adels affirmation, Oct. 12, 2011, ¶ 3.) Adels states that defendant rescheduled the EUO for May 25, 2010. (Defendant’s additional submission, Adels affirmation, Oct. 12, 2011, ¶ 3.) Adels states
“I was present in the office on this date in order to conduct the rescheduled EUO of plaintiff. Once again, no one affiliated with Plaintiff appeared for the EUO rescheduled for May 25, 2010. If Plaintiff had appeared for the scheduled EUOs, I would have conducted the EUO of Plaintiff or assigned one of the other attorneys responsible for conducting EUOs to conduct the EUO of Plaintiff.” (Defendant’s additional submission, Adels affirmation, Oct. 12, 2011, ¶ 3.)
This court must decide whether Michael Sirignano’s affirmation is sufficient, under Alrof and its progeny,[FN*] to prove the provider’s nonappearance for the EUOs. Also, this court must also determine whether Sirignano has personal knowledge of the provider’s nonappearance at the EUOs.
Sirignano’s affirmation is sufficient to prove the provider’s nonappearance for the two EUOs. Sirignano has personal knowledge of the provider’s nonappearance at the EUOs. Sirignano states the following:{**45 Misc 3d at 762}
“3. On July 27, 2011, plaintiff was scheduled to submit to an EUO at the offices of Rivkin Radler located 926 RXR Plaza, Uniondale, New York 11556, at 10:00 o’clock in the forenoon of that day [sic]. I was present in the office on this date. No one affiliated with the Plaintiff appeared for the scheduled EUO. If Plaintiff had appeared for the scheduled EUO, I would have conducted the EUO [*4]of Plaintiff or assigned one of the other attorneys responsible for conducting EUOs to conduct the EUO of Plaintiff.
“4. Thereafter, State Farm rescheduled the EUO for August 30, 2011. I was present in the office on this date. Again, no one affiliated with the Plaintiff appeared for the scheduled EUO on August 30, 2011. If Plaintiff had appeared for the scheduled EUO, I would have conducted the EUO of Plaintiff or assigned one of the other attorneys responsible for conducting EUOs to conduct the EUO of Plaintiff.” (Notice of motion, exhibit 3, Sirignano affirmation, July 11, 2012, ¶¶ 3-4.)
Sirignano has personal knowledge: He was present on both dates, July 27, 2011 and August 30, 2011. Plaintiff did not appear on either date. Like the attorney in Natural Therapy, Sirignano was present on both dates that plaintiff was scheduled for the EUO. Had plaintiff appeared, Sirignano would have conducted plaintiff’s EUO. Or, he would have assigned one of the other attorneys responsible for conducting EUOs to conduct plaintiff’s EUO.
Unlike the attorney in Alrof who explained in conclusory language that plaintiff failed to appear for EUOs, Sirignano explains his basis for knowing that plaintiff failed to appear for two EUOs.
Sirignano does not equivocate like the attorney in Bright Med. did: “I would likely have been the attorney assigned to conduct said EUO.” (Exhibit 9, Callinan affirmation, July 28, 2010, ¶ 17.) Sirignano states that “[i]f Plaintiff had appeared for the scheduled EUO, I would have conducted the EUO of Plaintiff or assigned one of the other attorneys responsible for conducting EUOs.” (Notice of motion, exhibit 3, Sirignano affirmation, July 11, 2012, ¶ 4.)
Plaintiff argues that Sirignano’s “potential assignment [of plaintiff’s EUO] diminishes [his] credibility as to his personal knowledge that no one affiliated with Plaintiff appeared for the{**45 Misc 3d at 763} scheduled EUOs.” (Golodkeyer affirmation, Sept. 12, 2013, ¶ 24.) Sirignano’s statement does not diminish his credibility, in fact it highlights his credibility.
Plaintiff’s other arguments are also unpersuasive. That the EUO scheduling letters indicate that the EUOs were scheduled at Rivkin Radler LLP’s office in Uniondale, New York, “Attn. Barry Levy, Esq.” is of no consequence. (See notice of motion, exhibit 1.) Plaintiff’s argument—that based on the EUO letters Barry Levy, Esq. was the attorney who would conduct the EUO—is misplaced. (Golodkeyer affirmation, Sept. 12, 2013, ¶ 24.) Sirignano states that he was responsible for plaintiff’s EUO.
That the EUO scheduling letters indicate that the plaintiff call “JUDY AUBIN . . . no later than seven days prior to this examination to confirm your attendance” is also of no consequence. Sirignano states that he was responsible for plaintiff’s EUO. In any event, plaintiff does not allege that it attempted to confirm the EUO appointments with Ms. Aubin or anyone else at Rivkin Radler LLP.
Nor is it significant that Sirignano does not describe the “check-in procedure that is followed by the law firm regarding EUO attendance.” (Golodkeyer affirmation, Sept. 12, [*5]2013, ¶ 25.) Sirignano need not describe the firm’s check-in procedure for EUOs. Sirignano need only demonstrate, through his personal knowledge, that the plaintiff failed to appear for two scheduled EUOs.
Plaintiff did not respond to defendant’s request for EUOs. (See Concourse Chiropractic, PLLC v State Farm Mut. Ins. Co., 42 Misc 3d 131[A], 2013 NY Slip Op 52225[U], *1 [App Term, 2d Dept, 9th & 10th Jud Dists, Dec. 20, 2013] [“(P)laintiff did not respond in any way to the EUO scheduling letters sent by defendant. Since the opposing affirmation submitted by plaintiff’s counsel was insufficient to raise a triable issue of fact with respect to the claims denied on the ground that plaintiff had failed to appear at the EUOs . . . defendant is entitled to summary judgment”], citing Crescent Radiology, PLLC v American Tr. Ins. Co., 31 Misc 3d 134[A], 2011 NY Slip Op 50622[U], *1 [App Term, 2d Dept, 9th & 10th Jud Dists 2011].)
Plaintiff’s request for defendant’s special investigation unit file, the SIU investigation, and its claims practices is not necessary to oppose defendant’s summary judgment motion: “Since plaintiff does not claim to have responded in any way to the EUO request, its objections regarding the EUO requests will not now be heard . . . and therefore discovery relevant to the {**45 Misc 3d at 764}reasonableness of the EUO requests was not necessary to oppose the motion.” (Flatlands Med., P.C. v State Farm Mut. Auto. Ins. Co., 39 Misc 3d 142[A], 2013 NY Slip Op 50763[U], *2 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists, May 6, 2013], citing CPLR 3212 [f] and Crescent Radiology, 31 Misc 3d 134[A], 2011 NY Slip Op 50622[U], *1; Natural Therapy, 42 Misc 3d 137[A], 2014 NY Slip Op 50134[U], *1.) Plaintiff did not respond to defendant’s EUO requests; therefore, plaintiff cannot now object to defendant’s EUO requests. Also, plaintiff did not move to compel disclosure. Plaintiff’s request, raised only in its opposition papers, is denied.
Defendant proved that it timely and properly mailed the EUO letters to plaintiff. Defendant proved that plaintiff failed to appear for the EUOs on July 27, 2011, and August 30, 2011. Defendant also proved that it timely and properly mailed the denial, NF-10, to plaintiff.
Plaintiff’s counsel’s affirmation, coming from an individual without personal knowledge, has no probative value. Plaintiff’s counsel’s affirmation creates no material issue of fact for trial.
Defendant’s motion is granted.
Footnotes
Footnote *:One of the cases defendant attaches to its memorandum of law pre-dates Alrof. (Exhibit 1, Mega Supplies Billing, Inc. v State Farm Mut. Auto. Ins. Co., 36 Misc 3d 130[A], 2012 NY Slip Op 51276[U], *2 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012].) Also, in the cases defendant attaches on the Alrof issue—the sufficiency of an affirmation or affidavit to demonstrate personal knowledge of the assignor’s or the provider’s nonappearance at an EUO—the parties never raised the Alrof issue on appeal. (Exhibit 4.)
Reported in New York Official Reports at Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 05779)
| Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co. |
| 2014 NY Slip Op 05779 [120 AD3d 561] |
| August 13, 2014 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| Mount Sinai Hospital, as Assignee of Ana Rodriguez,
Appellant, v New York Central Mutual Fire Insurance Company, Respondent. |
Joseph Henig, P.C., Bellmore, N.Y., for appellant.
Freiberg, Peck & Kang, LLP, Armonk, N.Y. (Yilo J. Kang of counsel), for respondent.
In an action to recover no-fault benefits under a policy of automobile insurance, the plaintiff appeals from an order of the Supreme Court, Nassau County (McCormack, J.), dated October 16, 2012, which denied its motion for summary judgment on the complaint and granted the defendant’s cross motion for summary judgment dismissing the complaint.
Ordered that the order is reversed, on the law, with costs, the plaintiff’s motion for summary judgment on the complaint is granted, and the defendant’s cross motion for summary judgment dismissing the complaint is denied.
In March 2011, Ana Rodriguez, who was insured under a policy of automobile insurance issued by the defendant, New York Central Mutual Fire Insurance Company (hereinafter New York Central), allegedly was injured in an automobile accident. In November 2011, she received treatment at a hospital facility of the plaintiff, Mount Sinai Hospital (hereinafter Mount Sinai). In early December 2011, a few days after Mount Sinai rendered this treatment, it sought payment for it. Mount Sinai’s third-party biller, The Outsource Group (hereinafter Outsource), sent a Form UB-04 and a letter requesting payment to New York Central. Twenty days after New York Central received the request, it requested verification of Mount Sinai’s claim. Approximately one week after New York Central sent the verification request, it received from Outsource more than 100 pages of documents, including records of Rodriguez’s treatment at Mount Sinai and various forms Rodriguez had completed there. New York Central did not request further verification. On January 27, 2012, less than 30 days after it received these records, New York Central issued a denial of the claim on a Form NF-10. The Form NF-10 was, in all substantial respects, complete.
Two months later, on March 26, 2012, Mount Sinai, which was now represented by a different third-party biller, issued another request for payment of its bill for the treatment it had rendered to Rodriguez. This time, Mount Sinai’s third-party biller issued the request on a Form NF-5. New York Central ignored this request for payment, and, in May 2012, Mount Sinai, as assignee of Rodriguez, commenced this action seeking payment. Mount Sinai eventually moved for summary judgment on the complaint, and New York Central cross-moved for summary judgment dismissing [*2]the complaint. The Supreme Court denied Mount Sinai’s motion and granted New York Central’s cross motion. Mount Sinai appeals. We reverse.
In Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (106 AD3d 157 [2013]), this Court summarized the claim procedure under New York’s “no-fault” insurance scheme:
“Pursuant to the regulations promulgated by the Superintendent of Insurance to implement the No-Fault Law (Insurance Law art 51), an injured party, or that person’s assignee, must submit a written notice of claim to an insurer no later than 45 days after services are rendered (11 NYCRR 65-2.4). The written notice required to obtain first party benefits ‘shall be deemed to be satisfied by the insurer’s receipt of a completed prescribed application for motor vehicle no-fault benefits (NYS Form N-F 2) . . . or by the insurer’s receipt of a completed hospital facility form (NYS Form N-F 5)’ (11 NYCRR 65-3.3 [d]). ‘[P]roof of claim . . . shall include verification of all of the relevant information requested’ (11 NYCRR 65-3.8 [a] [1]). ‘An insurer must accept proof of claim submitted on a form other than a prescribed form if it contains substantially the same information as the prescribed form’ (11 NYCRR 65-3.5 [f]). However, 11 NYCRR 65-3.5 (g) provides that ‘[i]n lieu of a prescribed application for motor vehicle no-fault benefits submitted by an applicant [NYS Form N-F 2] and a verification of hospital treatment (NYS form NF-4), an insurer shall accept a completed hospital facility form (NYS form NF-5) (or an NF-5 and uniform billing form [UBF-1] which together supply all the information requested by the NF-5) submitted by a provider of health services with respect to the claim of such provider.’
“Within 30 calendar days after receipt of the proof of claim for no-fault benefits, an insurer can either pay the claim, in whole or in part, deny it, or seek verification of it (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [c]). A no-fault insurance carrier waives its defenses, other than those based on the complete absence of coverage (e.g., a defense to the effect that it never wrote a policy for the claimant), if it fails to deny a no-fault claim, or seek verification, within 30 calendar days after having received proof of claim (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [a] [1]; [c] . . . ).
“When a no-fault claim has been assigned to a hospital or medical provider and the hospital or medical provider sends an N-F 5 form to the no-fault insurer, the no-fault insurer’s receipt of an N-F 5 form triggers the running of the 30-day period within which the insurer has a duty to pay or to deny the claim, or to seek verification of it. Subsequent to the receipt of the N-F 5 form, if the insurer requires any additional information to evaluate the proof of claim, such request for verification must be made within 15 business days of the receipt of the N-F 5 form in order to toll the 30-day period (see 11 NYCRR 65-3.5 [b]). Where there is a timely original request for verification, but no response to the request for verification is received [*3]within 30 calendar days thereafter, or the response to the original request for verification is incomplete, then the insurer, within 10 calendar days after the expiration of that 30-day period, must follow up with a second request for verification (see 11 NYCRR 65-3.6 [b]). If there is no response to the second, or follow-up, request for verification, the time in which the insurer must decide whether to pay or deny the claim is indefinitely tolled. Thus, when a no-fault medical service provider fails to respond to the requests for verification, the 30 days in which to pay or deny the claim is tolled and does not begin to run. Accordingly, any claim for payment by the medical service provider after two timely requests for verification have been sent by the insurer subsequent to its receipt of an N-F 5 form from the medical service provider is premature, if the provider has not responded to the requests. Nothing in the rules requires a second follow-up, that is, a third request for verification.
“However, a request for verification that precedes a no-fault insurer’s receipt of the prescribed N-F 5 claim form does not trigger the tolling of the 30-day period within which an insurer must determine whether to pay or deny such a claim. The ‘UBF-1’ form referred to in 11 NYCRR 65-3.5 (g) is the predecessor of the current ‘UB-04’ form. Under 11 NYCRR 65-3.5 (g), a UBF-1/UB-04 form together with an N-F 5 form must be accepted by a no-fault insurer. The regulation does not state that a UBF-1/UB-04 form alone must be treated as the ‘functional equivalent’ of an N-F 5 form” (id. at 162-164 [citations omitted]).
Here, in reliance on Sound Shore, Mount Sinai contends that its billing through Outsource in December 2011 on a Form UB-04 did not commence the 30-day period in which New York Central was required to pay, deny, or request verification of Mount Sinai’s claim. Instead, Mount Sinai contends, the 30-day period commenced in March 2012, when Mount Sinai submitted a billing request on a Form NF-5. In effect, Mount Sinai contends, New York Central’s denial of claim in January 2012 did not deny anything; there was no claim submitted in December to deny. Finally, inasmuch as Mount Sinai established, prima facie, that New York Central did not pay, deny, or request verification of the March claim within 30 days after receiving it, New York Central had waived its defenses, so summary judgment on the complaint was required (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33, 41 [2013]).
New York Central, by contrast, contends that the 30-day period commenced when it received the Form UB-04 in December 2011, that it timely requested verification of the claim, and that, after it received the medical records, it timely denied the claim in January 2012. Mount Sinai could not commence the 30-day clock anew by submitting the same claim several months later (see Hospital for Joint Diseases v Allstate Ins. Co., 5 AD3d 441, 442 [2004]).
We conclude that the Supreme Court erred in denying Mount Sinai’s motion for summary judgment on the complaint and in granting New York Central’s cross motion for summary judgment dismissing the complaint. Under our decision in Sound Shore, the 30-day period for New York Central to pay or deny the claim did not begin to run until March 26, 2012, when Mount Sinai submitted the Form NF-5, which contained the information needed. Because New York Central did not pay or deny the claim within 30 days thereafter, it was precluded from raising defenses. In other words, the defective “claim” submitted in December 2011 did not start the 30-day clock, so New York Central’s denial in January 2012 was of no effect (see Mount Sinai Hosp. v Dust Tr., Inc., 117 AD3d 921, 921 [2014]).
In summary, in support of its motion for summary judgment on the complaint, Mount Sinai satisfied its prima facie burden of establishing that New York Central received its Form NF-5 in March 2012 and that payment of the no-fault benefits was overdue because the claim was neither [*4]paid nor denied within 30 days (see Westchester Med. Ctr. v Allstate Ins. Co., 114 AD3d 672, 672-673 [2014]; Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d at 40-41). In opposition, New York Central failed to raise a triable issue of fact (see Westchester Med. Ctr. v Allstate Ins. Co., 114 AD3d at 672-673).
Moreover, the Supreme Court should have denied New York Central’s cross motion for summary judgment dismissing the complaint. Mount Sinai’s complaint was predicated solely upon New York Central’s failure to pay or deny the March 2012 claim within 30 days of receipt. New York Central failed to establish, prima facie, that it paid or denied that claim within 30 days after receipt. Accordingly, New York Central was not entitled to summary judgment dismissing the complaint (see New York & Presbyt. Hosp. v Allstate Ins. Co., 31 AD3d 512, 513 [2006]; cf. Hospital for Joint Diseases v Allstate Ins. Co., 5 AD3d at 442).
In light of our determination, we need not address Mount Sinai’s remaining contention. Rivera, J.P., Balkin, Hinds-Radix and Maltese, JJ., concur.
Reported in New York Official Reports at Medcare Supply Inc. v Travelers Prop. Cas. Co. of Am. (2014 NY Slip Op 51421(U))
[*1]| Medcare Supply Inc. v Travelers Prop. Cas. Co. of Am. |
| 2014 NY Slip Op 51421(U) [45 Misc 3d 1202(A)] |
| Decided on August 13, 2014 |
| Civil Court Of The City Of New York, New York County |
| Lebovits, J. |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on August 13, 2014
Medcare
Supply Inc. a/a/o DAVID WEST, Plaintiff,
against Travelers Property Casualty Company of America, Defendant. |
CV 52560/11
Gary Tsirelman P.C, Brooklyn (Stephen Gurfinkel of counsel), for plaintiff.
Law Offices of Karen C. Dodson, New York (Saba S. Chughtai of counsel), for defendant.
Gerald Lebovits, J.
Plaintiff brought this no-fault-benefits action seeking reimbursement for $1,346.76 for medical services rendered to assignor, David West. Plaintiff submitted to defendant two bills for dates of service June 27, 2011, and July 15, 2011. Defendant denied the claim on the basis that the assignor failed to appear for two scheduled examinations under oath (EUOs) and that verification remained outstanding.
Defendant moves for summary judgment under CPLR 3212 on the ground that the assignor failed to appear for two scheduled EUOS and, thus, that plaintiff breached a condition precedent to coverage. Plaintiff’s most persuasive argument in opposition is that defendant failed to prove the assignor’s nonappearance for the EUOs. Plaintiff argues that Aloy O. Ibuzor’s affirmation is insufficient because, plaintiff argues, he has no personal knowledge of the assignor’s nonappearance for the EUOs. (Garfunkel Affirmation, July 9, 2013, at ¶ ¶ 15-16.)
Defendant proved that it timely and properly mailed the EUO letters to the assignor. Defendant also proved that it timely and properly mailed the denials, NF-10s. Defendant, however, did not prove that the assignor failed to appear for the EUOs on June 27, 2011, and July 15, 2011.
Aloy O. Ibuzor’s affirmation does not comport with an Appellate Term, Second Department, decision: Alrof, Inc. v Safeco Natl. Ins. Co., 39 Misc 3d 130 [A], *1, 2013 NY Slip Op 50458 [U], *1 [App Term 2d Dept, 11th & 13th Jud Dists Mar. 21, 2013].
In Alroft, the court determined that the “affidavit of defendant’s attorney was of no probative value as it lacked personal knowledge of the nonappearance of plaintiff. (Alroft, 39 Misc 3d 130 [A], at *1, 2013 NY Slip Op 50458 [U], at *1.) The court held that “[i]t is well settled that a motion for summary judgment must be supported by an affidavit from a person having knowledge of the facts. (CPLR 3212 [b].) A conclusory statement from an attorney which fails to demonstrate his or her personal knowledge is insufficient to support summary judgment.” (Id.)
The proof the Alroft court considered was an affidavit from Vincent F. Gerbino, a partner at Bruno, Gerbino & Soriano, LLP. In his affidavit, Gerbino states that he has “personal knowledge of the facts at issue . . . based on [his] review of the file and [his] knowledge of office practices and procedures.” (Affirmation in Opposition, Exhibit 1, Gerbino Affidavit, Mar. 23, 2009, at ¶ 3.) Gerbino states that the “office mailed correspondence to Jonathan Rosario [the assignor] notifying that he was scheduled for an EUO on July 18, 2008, at 10:00 AM. He did not appear on this date. Therefore, . . . this office . . . re-scheduled . . . [the] EUO on July 30, 2008, at 1:00PM.” (Affirmation in Opposition, Exhibit 1, Gerbino Affidavit, Mar. 23, 2009, at ¶ 3.) Gerbino thus states that “Jonathan Rosario failed to appear at both . . . EUO’s.” (Affirmation in Opposition, Exhibit 1, Gerbino Affidavit, Mar. 23, 2009, at ¶ 3.)
Since Alroft, the court revisited the issue of the sufficiency of an attorney’s affirmation to prove nonappearance at EUOs in Bright Med. Supply Co. v IDS Prop. & Cas. Ins. Co. (40 Misc 3d 130 [A], *1, 2013 NY Slip Op 51123 [U], *1 [App Term 2d Dept 11th & 13th Jud Dists July 5, 2013].) In Bright Medical, the court held the court below properly denied defendant’s summary- judgment motion because “defendant failed to submit proof by someone with personal knowledge of the nonappearance of plaintiff for the EUOs in question.” (Id. at *1, 2013 NY Slip Op 51123 [U], *1, citing Alrof, 39 Misc 3d 130 [A], *1, 2013 NY Slip Op 50458[ U], *1.)
Since Bright Medical, the court determined that the affirmation of defendant’s attorney “who was present in his office to conduct plaintiff’s EUO on the scheduled dates . . . was sufficient to establish that plaintiff failed to appear.” (Natural Therapy Accupuncture, P.C. v State Farm Mut. Ins. Co., 42 Misc 3d 137[A], *1, 2014 NY Slip Op 50134[U], *1 [App Term 2d Dept 11th & 13th Jud Dists Jan. 28, 2014].)
Ibuzor’s affirmation is insufficient, under Alroft and its progeny, to prove the assignor’s nonappearance for the two EUOs. Ibuzor has no personal knowledge of the assignor’s nonappearance at the EUOs. Ibuzor states the following: “I was assigned to conduct the Examination Under Oath of David West. As such, I have personal knowledge of the facts and circumstances set forth herein. . . . a scheduling letter was sent from this office to David West in care of [the assignor’s attorney] Andrew Hirschhorn, Esq.” (Ibuzor Affirmation, Aug. 3, 2011, at ¶ 4.) Ibuzor states that on June 27, 2011, “neither David West nor anyone else on his behalf appeared for the EUO.” (Ibuzor Affirmation, Aug. 3, 2011, at ¶ 5.) The EUO was rescheduled [*2]for July 15, 2011. (Ibuzor Affirmation, Aug. 3, 2011, at ¶ 6.) On July 15, 2011, “neither David West nor any on else [sic] on his behalf appeared for the scheduled EUO.” (Ibuzor Affirmation, Aug. 3, 2011, at ¶ 7.) At no point does Ibuzor state that he was present in the office on June 27, 2011, and July 15, 2011. Even though he was assigned to conduct the assignor’s EUO, it is unclear that had the assignor appeared whether Ibuzor, or another attorney, would have conducted the assignor’s EUO.
Like the attorney in Alroft, Ibuzor explains in conclusory language that the assignor failed to appear for EUOs. Ibuzor does not explain his basis for knowing that the assignor failed to appear for the EUOs.
At trial, defendant will have to prove the assignor’s nonappearance for the EUOs scheduled for June 27, 2011, and July 15, 2011.
Defendant’s motion is denied.
This is the court’s decision and order.
Dated: August 13, 2014
J.C.C.
Glenn Segal PT, P.C. v GEICO (2014 NY Slip Op 51301(U))Reported in New York Official Reports at Glenn Segal PT, P.C. v GEICO (2014 NY Slip Op 51301(U))
[*1]| Glenn Segal PT, P.C. v GEICO |
| 2014 NY Slip Op 51301(U) [44 Misc 3d 141(A)] |
| Decided on August 12, 2014 |
| 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 August 12, 2014
PRESENT: : PESCE, P.J., WESTON and ALIOTTA, JJ.
2012-1225 Q C
against
GEICO, Appellant.
Appeal from an order of the Civil Court of the City of New York, Queens County (Barry A. Schwartz, J.), entered April 9, 2012. The order, insofar as appealed from, upon denying plaintiff’s motion for summary judgment, made, in effect, CPLR 3212 (g) findings in plaintiff’s favor, and denied defendant’s cross motion for summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, the CPLR 3212 (g) findings in plaintiff’s favor are vacated, and defendant’s cross motion for summary judgment dismissing the complaint is granted.
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 on the ground that it had timely and properly denied the claim at issue based on a lack of medical necessity. Insofar as is relevant to this appeal, the Civil Court, upon denying plaintiff’s motion, made, in effect, CPLR 3212 (g) findings in plaintiff’s favor, denied defendant’s cross motion, and held that the only remaining issues for trial were “those that form the basis of the defendant’s denials, including but not limited to the medical necessity of the services at issue.”
In support of its cross motion, defendant submitted a sworn statement by the chiropractor who had performed an independent medical examination (IME) of plaintiff’s assignor, as well as an affirmed report by the doctor who had performed a second IME. Both of the IMEs were performed before the services at issue were rendered. Each IME report set forth a factual basis and medical rationale for the examiner’s conclusion that there was a lack of medical necessity for further treatment. In opposition to the cross motion, plaintiff submitted an affidavit from a doctor which failed to meaningfully refer to, let alone sufficiently rebut, the conclusions set forth in the chiropractor’s report, and further failed to sufficiently rebut the conclusions set forth in the doctor’s report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). In view of the foregoing, and as plaintiff has not challenged the Civil Court’s finding, in effect, that defendant is otherwise entitled to judgment, the order, insofar as appealed from, is reversed and defendant’s cross motion for summary judgment dismissing the complaint is granted (see Delta Diagnostic [*2]Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).
Pesce, P.J., Weston and Aliotta, JJ., concur.
Decision Date: August 12, 2014