SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Queens County (Diane A. Lebedeff, J.), entered March 8, 2007, deemed from a judgment of the same court entered April 26, 2007 (see CPLR 5501 [c]). The judgment, entered pursuant to the March 8, 2007 order granting plaintiff’s motion for summary judgment, awarded plaintiff the principal sum of $2,948.88.

Judgment affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment. Defendant opposed the motion, contending, inter alia, that issues of fact exist as to whether plaintiff timely submitted its claims to
defendant. The court granted plaintiff’s motion for summary judgment, finding that defendant waived its defense of untimeliness, since defendant failed to advise plaintiff that the claim would be reconsidered upon a showing of impossibility to timely submit the claims. This appeal by defendant ensued.

The affidavit of defendant’s claims representative submitted in opposition to plaintiff’s motion, and the denial of claim forms annexed thereto, demonstrate that defendant denied a number of plaintiff’s claims on the ground that they were not timely submitted (see generally Insurance Department Regulations [11 NYCRR] § 65.12). However, since none of the denial of claim forms correspond to the claim forms upon which plaintiff seeks summary judgment, defendant failed to establish that it timely denied the subject claims. As a result, defendant failed to raise a triable issue of fact with respect to the claims at issue (see Zuckerman v City of New York, 49 NY2d 557 [1980]). Accordingly, the judgment is affirmed, albeit on other grounds. [*2]

Weston Patterson, J.P., Rios and Steinhardt, JJ., concur.
Decision Date: January 08, 2009

Supreme Court, Kings County

5647/06

Plaintiff Attorney:Lawrence N. Rogak, LLC

Defendant Attorney:Brooke Lombardi, Esq.

Subin Associates LLP

Yvonne Lewis, J.

Counsel for Long Island Insurance Company has petitioned this court for a tripartite order to restore this action to the active calendar on the grounds that it was ministerially marked disposed by clerical error, amend the petition to include the affirmative defenses of fraud and lack of capacity to contract (renewal policies) since the insured is deceased, and grant it summary judgment on the basis of newly discovered evidence heretofore concealed by the respondent; to wit, the respondent, the pedestrian victim of a hit and run on November 16, 2005, intentionally failed to disclose (to the petitioner/insurer) that his father, who died on July 10, 2001, was the named insured under the insurance policy through which he asserts his claims for no-fault and uninsured motorist benefits and continued to renew bi-annually despite his passing. In addition, the petitioner notes that the subject policy itself provides, in salient part, that it may not be assigned without its written consent; that upon the death of the named insured, coverage will be provided for the legal representative (a role which the respondent has not established for himself herein) only with respect to the legal representative’s responsibility to maintain or use the covered vehicle; and, that the coverage will extend only until the end of the policy period, in this instance April 28, 2002. The petitioner notes further that Couch on Insurance, 3d Ed., §29:13 clearly provides that there is no contract to renew in the absence of a clear intent to that effect; that

“. . .because contract requires mutual assent of parties and meeting of minds, no contract can be formed between insurer and decedent (citing, Von Hillman v. colonial Penn Ins. Co., 19 Kan. App.2d 375, 869 P2d 248[1994]); and, that “a representative of a deceased insured’s estate has no authority to renew the policy in the insured’s behalf without informing the insurer of the insured’s death.”

As further evidence of the respondent’s duplicity, the petitioner notes that in December 2006, he cashed a partial premium refund with the “obviously” forged signature of his father, and that in an examination under oath conducted on May 16, 2008, the respondent testified that his [*2]father (who died on July 10, 2001) was the policyholder, furnished his father’s current address, and advised that he never owned a car and that he drove his father’s.

Counsel for petitioner furnished a supplemental affirmation in support of his request for summary judgement on the basis of the October 10, 2008 Appellate Division, Fourth Department case of Geico Ins. Co. v. Battaglia, 2008 NY Slip Op 07736, which held that the subject Insurance Company had “. . .established as a matter of law that its policy, as renewed, was void ab initio based on the material misrepresentation with respect to the [insured’s] status, i.e., that [the insured] was deceased” (referencing, Matter of Mercury Ins. Group v. Ocana, 46 AD3d 561). Counsel also notes that his initial October 11, 2007 motion to stay the arbitration had been denied without prejudice for his inadvertence in not having included a complete copy of the subject policy in his moving papers.

In opposition, counsel for Israel Greenfield, the respondent herein, asserts that the motion to restore should be denied inasmuch as the court repeatedly set motion schedules for petitioner to file orders to show cause on the ground of the insured’s undisclosed death, failed to adhere to the same, and instead filed the instant motion for summary judgment on the same ground. In addition, counsel argues that the request to amend the petition must also be denied as untimely inasmuch as CPLR §3024( c) clearly provides that a motion to correct pleadings shall be served within twenty days after service of the challenged pleading. Furthermore, counsel urges this court to deny the petitioner’s motions for a permanent stay of arbitration and for summary judgment as moot given that an arbitration hearing was held on September 10, 2008, the petitioner had a full and fair opportunity to participate therein, and the plain fact that an arbitrator’s award may not be vacated unless it is found that the arbitrator’s award lacked a rational basis (citing, Matter of Prudential Pro. & Cas. Ins. Co. v. Carleton, 145 AD2d 492 [2d Dept., 1988]). So too, CPLR Rule 3211 provides for dismissal of an action on the ground that an arbitration award has been rendered.

Respondent additionally argues that the petitioner’s allegation of fraud and lack of capacity to have renewed the subject insurance policy does not meet the separate standards for a stay of arbitration which requires a prima facie showing of non-coverage and summary judgment that necessitates a demonstration as to the absence of material issues of fact. To the contrary, the respondent maintains that though his father was the named insured he is nonetheless covered under the subject policy as a listed driver and hence an additional named insured on which basis he continued to renew the said policy rather than the imputed intent to wilfully conceal, deceive, misrepresent, or mislead that the petitioner alleges. The respondent also argues that his unfamiliarity with the terms of the policy and any requirement to disclose his father’s death is attributable solely to the fact that he was merely an additional insured and not a party to the initial contract; hence, a mistake or oversight, not fraud.

The petitioner has also moved this court, pursuant to CPLR 7511, for an order to vacate the arbitration award in the matter sub judice on the ground that there was no valid agreement to arbitrate. In fact, the petitioner asserts that the American Arbitration Association proceeded with its scheduled arbitration on September 10, 2008 despite having been advised that a request for a permanent stay of arbitration had been made to this court. In addition, the renewed policy under which the petitioner sought no-fault and uninsured motorists benefits was void ab initio (prior to the date of the subject accident) due to the policyholder’s unreported death. The petitioner also [*3]notes that its request for a temporary restraining order to stay the mentioned arbitration was denied by this court, following which on October 15, 2008, the respondent (son of the decedent policyholder) was awarded $100,000.00.

In opposition, the respondent asserts that none of the CPLR 7511 grounds for vacatur of an arbitration award has been met by the respondent who participated in the process by submitting discovery materials in connection therewith; to wit, respondent has not established that his rights were prejudiced by corruption, fraud, or misconduct in procuring the award; partiality of the arbitrator; the arbitrator exceeded his powers; the arbitrator failed to make a final and definite award; or a procedural failure that was not waived. In addition, the respondent contends that petitioner’s failure to have moved for a stay of arbitration prior to its conduct renders the present motion therefor untimely (citing, Bevona v. Valencia, 191 AD2d 192, 594 NYS2d 223 [1st Dept., 1993]) as does his participation in said proceeding via the discovery materials submitted and reviewed by the arbitrator who also gave the petitioner thirty days post arbitration to submit documentation in support of its contentions which identically undergird its motions for summary judgment and to vacate. Furthermore, the respondent notes that the purported affidavit in support of the petitioner’s motion to vacate is fatally defective in that its president’s signature is absent therefrom. In any event, the respondent argues that the failure to have apprised the insurer of the insured’s death in no way increased the former’s risk such that it can be said that the policy would not have been renewed in the respondent’s name. In this vein, the respondent asserts that cancellation of an automobile insurance policy may be prospective only, even if the application is deceptive or fraudulent (citing, Aetna Cas. & Surety Co. v. O’Connor, 8 NY2d 359; Matter of Liberty Mutual Ins. Co. v. McClellan, 127 AD2d 767; Middlesex Ins. Co. v. Carrero, 103 AD2d 694; and Teeter v. allstate Ins. Co., 9 AD2d 176, Aff’d 9 NY2d 655), and argues that “an insurer should not be permitted to raise fraud, which should have been discoverable upon a reasonable inquiry, as a basis for denying coverage to innocent third parties injured in an accident” (citing New Hampshire Indemnity Co. v. Flores, 2002 NY Slip Op 40024 [1]).

In addition to opposing the petitioner’s motion to vacate, the respondent has moved, pursuant to CPLR §7510, to confirm the above mentioned arbitration award decided on October 20, 2008. In support of that request, the respondent reasserts the fact that no stay had been in effect on September 10, 2008 when the arbitration was held, and that the petitioner’s request for a temporary restraining order on October 3, 2008 was denied. In addition to remaking its arguments in opposition to vacatur, the respondent notes that CPLR §7510 makes it clear that the court shall confirm such an award within one year after its delivery unless the same is vacated or modified upon a ground specified in CPLR §7511, none of which has been met by the petitioner, as discussed above.

In response, the petitioner reasserted its arguments in support of vacatur to the effect that the instant renewed insurance policy under which the arbitration was conducted was void ab initio as a result of the respondent having concealed the fact that his father, the policyholder, had died a little over four years prior to the subject accident.

This court agrees with the petitioner’s assertion that “because contract requires mutual assent of parties and meeting of minds, no contract can be formed between insurer and decedent (citing, Couch on Insurance, 3d Ed., §29:13 and Von Hillman v. colonial Penn Ins. Co., 19 Kan. [*4]App.2d 375, 869 P2d 248[1994]). It must also be conceded, as asserted by the respondent, that a stay of arbitration requires a prima facie showing of non-coverage and summary judgment necessitates a demonstration as to the absence of material issues of fact.

It is the respondent’s position that although his father was the named insured he is nonetheless covered under the subject policy as a listed driver and hence an additional named insured on which basis he continued to renew his father’s policy rather than the imputed intent to wilfully conceal, deceive, misrepresent, or mislead that the petitioner alleges. That the respondent was holding himself out as his father and had a fraudulent intent in renewing his father’s policy is made clear by his answers to the examination under oath wherein he identified his father as the insured, furnished his then deceased father’s current residential address, etc. and his earlier cashing of a refund check made out to his then deceased father.

In the Matter of Fireman’s Fund Insurance Company v. Freda, 156 AD2d 364, 548 NYS2d 319, the Appellate Division, Second Department, made it clear that the insurer waived any right to assert grounds not raised as a basis for denying coverage in its original letter of disclaimer in its petition to stay arbitration (citing, Insurance law §3420[d]; General Acc. Ins. Group v.Cirucci, 46 NY2d 862, 414 NYS2d 512). In said case the insurer had initially only asserted that the injured person was not a covered person and had not raised claims of untimely notice, failure to promptly send copies of legal papers, and settlement without its consent which were therefore deemed waived. The court went on to add, [h]owever, the first ground, that [the injured party] was not a “covered person,” constitutes a potentially valid basis for the denial of liability because Fireman’s Fund made no contract of insurance with the person injured in the accident (citing, United Serv. Auto. Assn. v. Meier, 89 AD2d 998, 454 NYS2d 319). Consequently, Fireman’s Fund was not required by Insurance law §3420(d) to give timely written notice of its first asserted ground for disclaiming coverage (citing, Zappone v. Home Ins. Co., 55 NY2d 131, 447 NYS2d 911; Matter of Aetna Cas. & Sur. Co. v. Facciponti, 133 AD2d 60, 519 NYS2d 3). The court thereupon remitted the matter for an evidentiary hearing to determine if in fact the injured party had been a resident of the household of the policyholder on the date of the accident as a condition precedent to arbitration.

In the instant case, there is no issue to be decided by evidentiary hearing since, assuming arguendo, that the respondent had effectively renewed the insurance policy herein, the plain fact is that he could not by any stretch of the imagination, much less contractual definition, logic, or common sense have been a resident of the decedent’s household since that is legally and factually impossible.

The issue of a stay of arbitration has been rendered moot since it was held and a decision rendered. However, an arbitrator’s award may be vacated on the grounds specified in CPLR 7511(b); to wit, (i)corruption, fraud, or misconduct in procuring the award; or (ii) partiality of an arbitrator appointed as a neutral, except where the award was by confession; or (iii) an arbitrator, or agency, or person making the award exceeded his power or so imperfectly executed it that a final and definite award upon the subject matter submitted was not made; or (iv) failure to follow the procedure of this article, unless the party applying to vacate the award continued with the arbitration with notice of the defect and without objection. In the matter sub judice, this court finds that the arbitrator did exceed his power in having made an award in an instance where no coverage existed. Put another way, the arbitrator in order to have arrived at his decision was [*5]necessarily required to make a finding that the respondent was a “covered person;” i.e., a member of the insured’s household which in this instance would have called for him to “absurdly” find that the respondent was resident of a Ghost’s household. Consequently, this court hereby vacates the arbitrator’s October 20, 2008 ruling, above referenced, on the basis of irrationality and grants summary judgment to the petitioner on the issue of non-coverage inasmuch as it has been irrefutably established that the respondent was not a covered person. The petitioner and respondent’s respective motions to confirm said award and to amend are accordingly denied as moot. This constitutes the decision and order of this Court.

_________________________________

JSC

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Kenneth P. Sherman, J.), entered October 26, 2007. The order, insofar as appealed from as limited by the brief, denied plaintiff’s motion for summary judgment upon its claims seeking the sums of $240.20 and $1,201.

Order, insofar as appealed from, reversed without costs, plaintiff’s motion for summary judgment granted to the extent of awarding it partial summary judgment on its claims for $240.20 and $1,201 and matter remanded to the court below for the calculation of statutory interest and attorney’s fees thereon.
In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment. Insofar as is relevant to this appeal, defendant
opposed the motion, asserting that it timely denied plaintiff’s claims seeking the sums of $240.20 and $1,201 based on the assignor’s failure to appear for two independent medical examinations (IMEs). The court below denied plaintiff’s motion for summary judgment. The instant appeal by plaintiff ensued.

Inasmuch as defendant raises no issue on appeal with respect to plaintiff’s prima facie case, we do not pass on the propriety of the implicit determination of the court below with respect thereto.

While defendant asserted that it timely denied plaintiff’s claims for the sums of $240.20 and $1,201 based on the assignor’s failure to appear for two scheduled IMEs, defendant failed to establish by proof in admissible form that the IME requests were timely mailed to the assignor and that the assignor failed to appear for the IMEs (see Stephen Fogel Psychological, P.C. v [*2]Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Consequently, plaintiff was entitled to summary judgment on these claims.
Accordingly, the matter is remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees due on its claims for $240.20 and $1,201 pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

Pesce, P.J., and Rios, J., concur.

Golia, J., concurs in a separate memorandum.
Golia, J., concurs with the result only, in the following memorandum:

While I agree with the ultimate disposition in the decision reached by the majority, I wish to note that I am constrained to agree with certain propositions of law set forth in the case cited therein which are inconsistent with my prior expressed positions and generally contrary to my views.
Decision Date: December 31, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Kenneth P. Sherman, J.), entered July 12, 2007. The order, insofar as appealed from, granted plaintiff’s motion to vacate an order granting, on plaintiff ‘s default, a motion by defendant for summary judgment, and, upon such vacatur, denied defendant’s motion for summary judgment.

Order, insofar as appealed from, reversed without costs and so much of plaintiff’s motion as sought to vacate the order granting defendant’s motion for summary judgment and, upon such vacatur, to deny defendant’s motion for summary judgment denied.

In this action by a provider to recover assigned first-party no-fault benefits, the court below granted defendant’s motion for summary judgment on default. Thereafter, plaintiff moved, inter alia, to vacate the order entered upon its default and, upon such vacatur, to deny defendant’s motion for summary judgment. Plaintiff’s counsel alleged in the moving papers that the default was due to law office failure. By order entered July 7, 2007, the Civil Court, insofar as relevant to this appeal, granted plaintiff’s motion to vacate the order entered upon its default and, upon such vacatur, denied defendant’s motion for summary judgment.

To be relieved of its default, plaintiff was required to demonstrate both a reasonable excuse for the default and a meritorious cause of action (see CPLR 5015 [a] [1]; Eugene Di Lorenzo, Inc. v A.C. Dutton Lbr. Co., 67 NY2d 138 [1986]). The conclusory, undetailed and uncorroborated claim of law office failure did not amount to a reasonable excuse (see Nurse v Figeroux & Assoc., 47 AD3d 778 [2008]). Plaintiff’s counsel offered no explanation in the motion papers as to why he failed to submit written opposition to the motion or appear on the adjourned date of the motion. Accordingly, the order, insofar as appealed from, is reversed and so much of plaintiff’s motion as sought to vacate the order entered upon its default and, upon [*2]such vacatur, to deny defendant’s motion for summary judgment is denied.

In view of the foregoing, we pass upon no other issue.

Pesce, P.J., Golia and Rios, JJ., concur.
Decision Date: December 31, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

Appeal from an order and decision (one paper) of the Civil Court of the City of New York, Kings County (Lila Gold, J.), dated May 16, 2007. The order and decision denied plaintiffs’ oral motion at trial for a finding that a prior order, which provided that plaintiffs’ motion for summary judgment made a prima facie showing, dispensed with plaintiffs’ need to establish a prima facie case at trial, and dismissed the complaint upon plaintiffs’ failure to present evidence following the denial of their motion.

Appeal dismissed.

When the instant action to recover assigned first-party no-fault benefits was called for trial, plaintiffs orally moved for a determination that a prior order, which stated that plaintiffs’ motion for summary judgment made a prima facie showing (although
plaintiffs’ motion was ultimately denied on the ground that an issue of fact had been raised), dispensed with plaintiffs’ need to establish a prima facie case at trial. The court denied plaintiffs’ motion and then dismissed plaintiffs’ complaint because plaintiffs presented no evidence. No judgment was entered. This appeal by plaintiffs from the court’s order and decision ensued.

To the extent the court denied plaintiffs’ oral motion, no appeal as of right lies from an order which does not decide a motion made on notice, and the instant motion, although not ex parte, was not made on notice (see CCA 1702 [a] [2]; CPLR 2211; 1223 Bushwick, LLC v Williams, 19 Misc 3d 128[A], 2008 NY Slip Op 50512[U] [App Term, 2d & 11th Jud Dists 2008]; Cucaj v Paramount Fee, L.P., 17 Misc 3d 130[A], 2007 NY Slip Op 51976[U] [App Term, 2d & 11th Jud Dists 2007]). To the extent the court dismissed plaintiffs’ complaint, no appeal lies from a decision (see Schicchi v Green Constr. Corp., 100 AD2d 509 [1984]). [*2]

Pesce, P.J., Golia and Rios, JJ., concur.
Decision Date: December 31, 2008

[*1]

Civil Court of the City of New York, Richmond County, December 31, 2008

APPEARANCES OF COUNSEL

Emilia I. Rutigliano, Brooklyn, for plaintiff. James F. Sullivan, New York City, for defendant.

{**23 Misc 3d at 240} OPINION OF THE COURT

Katherine A. Levine, J.

{**23 Misc 3d at 241}Plaintiff, Yklik Medical Supply, Inc., a medical supply provider, brings this action pursuant to Insurance Law § 5106 (a) to recover $317 in unpaid bills for medical equipment it provided to its assignor Tammy Agosto, with statutory interest and attorney fees. Yklik moves for summary judgment based upon a claimed prima facie showing that its bills were properly submitted and that the defendant Allstate Insurance Company failed to pay or deny the claim within 30 days. Plaintiff also asserts that defendant’s denial was untimely.

Defendant Allstate Insurance Company opposes the motion, asserting that plaintiff has failed to establish a prima facie case since the affidavit of plaintiff’s billing manager is not based on his personal knowledge of the plaintiff’s office practices and billing procedures. Of greater import, Allstate contends that since plaintiff’s claims were in excess of the fee schedule contained in the Workers’ Compensation Law, and since defendant made a partial payment to plaintiff, a triable issue of fact exists as to whether defendant paid the appropriate amount for medical services, hence mandating a denial of summary judgment.

A medical provider must limit its charges to those permitted by approved fee schedules (Insurance Law § 5108 [a]; 11 NYCRR 68.0 [f]) “which protects a patient from erosion of available benefits by inflated charges.” (Complete Orthopedic Supplies, Inc. v State Farm Ins. Co., 16 Misc 3d 996, 1005 n 13 [Civ Ct, Queens County 2007], citing Ops Gen Counsel NY Ins Dept No. 04-06-11 [June 2004].) The fees for services and procedures are governed by the workers’ compensation fee schedule (11 NYCRR 68.1) and durable medical goods fees are governed by the New York Medicaid fee schedule (11 NYCRR Appendix 17-C part F) (collectively referred to as fee schedule).

Ordinarily, a fee schedule dispute raises a triable issue of fact, hence defeating a plaintiff’s motion for summary judgment. (Complete Orthopedic Supplies at 1005.) However, plaintiff contends that defendant is barred from even raising the defense that the bills exceeded the fee schedule or partial payment of the claim because defendant failed to submit a timely denial. In its papers in opposition, defendant summarily asserts that it issued a timely denial. However, during oral argument, defendant asserted that since it paid the bills in accordance with the fee schedule, and since plaintiff is not entitled to be compensated in excess of the fee schedule, that it need not file a timely denial or any denial.

It is clear that plaintiff has established its prima facie case. The affidavit of plaintiff’s billing manager exhaustively details{**23 Misc 3d at 242} the record keeping procedures of the business, and clearly sets forth the procedures for the creation and retention of bills, of which he has personal knowledge. (See Manhattan Med. Imaging, P.C. v State Farm Mut. Auto. Ins. Co., 20 Misc 3d 1144[A], 2008 NY Slip Op 51844[U], *1 [Civ Ct, Richmond County 2008], citing Second Med., P.C. v Auto One Ins. Co., 20 Misc 3d 291, 294-295 [Civ Ct, Kings County 2008].) The affidavit further details that the bills at issue were made and kept in the ordinary course of business at the time the services were rendered and sets forth the precise mailing procedure that was followed. Moreover, the billing manager personally packaged, sealed, applied postage to and mailed the bill and supplies.

The burden then shifts to the defendant in a no-fault case to show a triable issue of fact. (Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986].) To defeat an award of summary judgment to plaintiff, defendant must provide proof, in evidentiary form, that it either paid or denied the claim within 30 days of receipt or that it asserts a nonprecludable defense. (Carle Place Chiropractic v New York Cent. Mut. Fire Ins. Co., 19 Misc 3d 1139[A], 2008 NY Slip Op 51065[U] [Nassau Dist Ct 2008]; see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]; Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 [1997].)

Pursuant to Insurance Law § 5106 (a) and 11 NYCRR 65-3.5, an insurer is required to either pay or deny a claim for no-fault automobile insurance benefits within 30 days from the date an applicant supplies proof of claim or it will be precluded from offering any defenses at trial (preclusion rule). (Park Slope Med. & Surgical Supply, Inc. v Country-Wide Ins. Co., 19 Misc 3d 1138[A], 2008 NY Slip Op 51063[U], *2 [Civ Ct, Richmond County 2008], citing Mount Sinai Hosp. v Chubb Group of Ins. Cos., 43 AD3d 889, 889-890 [2d Dept 2007]; Presbyterian Hosp., 90 NY2d at 278.)

As recently summarized by this court in Manhattan Med. (supra), the Court of Appeals has reaffirmed that there is only one narrow exception to the preclusion rule—where an insurance company raises the defense of lack of coverage. (See Fair Price Med. Supply Corp. v Travelers Indem. Co., 10 NY3d 556, 563-564 [2008]; Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 317-318 [2007].) In those cases the insurer who fails to issue a timely denial is not precluded from later raising this defense because “the insurance policy does not contemplate coverage in the first instance, and requiring payment{**23 Misc 3d at 243} of a claim upon failure to timely disclaim would create coverage where it never existed.” (Hospital for Joint Diseases at 318.)

Thus, the “key issue” in every case is whether the “facts fit within the narrow no-coverage exception to the preclusion rule” (10 NY3d at 564). A court, in determining whether a specific defense is precluded under the 30-day rule or falls within the exception, must assess whether the defense is more like a “normal exception” from coverage such as a policy exclusion or a lack of coverage in the first instance, i.e., a defense “implicat[ing] a coverage matter.” (10 NY3d at 565.)

The typical defenses that fall within the rubric of lack of coverage are that of a staged automobile accident (Fair Price Med. Supply Corp. v Travelers Indem. Co., 42 AD3d 277, 284 [2d Dept 2007]; Matter of Liberty Mut. Ins. Co. v Goddard, 29 AD3d 698, 699 [2d Dept 2006]; Melbourne Med., P.C. v Utica Mut. Ins. Co., 4 Misc 3d 92, 94 [App Term, 2d Dept 2004]); where the claimant’s injuries arose out of a prior work-related accident rather than a car accident (Chubb, 90 NY2d 195 [1997]); or where the insurance company has articulated a founded belief that the plaintiff is fraudulently incorporated (Bay Plaza Chiropractic, P.C. v State Farm Mut. Auto. Ins. Co., 21 Misc 3d 1102[A], 2008 NY Slip Op 51925[U] [Civ Ct, Richmond County 2008]; Matter of Andrew Carothers, M.D., P.C. v Insurance Cos. Represented by Bruno, Gerbino & Soriano LLP, 13 Misc 3d 970 [Civ Ct, Richmond County 2006]).

A medical provider must limit its charges to those permitted by approved fee schedules (Insurance Law § 5108 [a]; 11 NYCRR 68.0 [f]) “which protects a patient from erosion of available benefits by inflated charges.” (Complete Orthopedic Supplies, Inc. v State Farm Ins. Co., 16 Misc 3d 996, 1005 [2007], citing Ops Gen Counsel NY Ins Dept No. 04-06-11 [June 2004].) The fees for services and procedures are governed by the workers’ compensation fee schedule (11 NYCRR 68.1) and durable medical goods fees are governed by the New York Medicaid fee schedule (11 NYCRR Appendix 17-C part F). An insurer who raises this defense will prevail if it demonstrates that it was correct in its reading of the fee schedules unless the plaintiff shows that “an unusual procedure or unique circumstance justifies the necessity” for a charge above the schedules’ fee (11 NYCRR 68.4; Complete Orthopedic Supplies, 16 Misc 3d at 1005). However, before this defense can be invoked an insurer must prove a timely denial.{**23 Misc 3d at 244}

In Fair Price (10 NY3d 556 [2008]), the Court distinguished the defense that the assignor never received the medical supplies from the plaintiff from the defense raised by the insurance company in Chubb (supra)—that the claimant’s injuries arose out of a prior related accident rather than a car accident. Only the latter—”a lack of coverage” defense—fell outside the preclusion rule since if in fact the injuries were unrelated to the accident, the treatment would not have been covered by the automobile liability policy in the first instance. (10 NY3d at 564, quoting Chubb at 199.) The defense that the billed-for services were never rendered, on the other hand, was more akin to a normal exception from coverage, like the defense of billing for unnecessary procedures found by the Chubb court to fall within the preclusion rule. (10 NY3d at 564, citing Chubb, 90 NY2d at 199 [overbilling does not ordinarily implicate a coverage matter].) This is so because in both situations there was [*2]an actual accident and an actual injury, where “coverage legitimately came into existence.” (Id. at 565, quoting Fair Price, 42 AD3d at 285.)

The same reasoning applies to the defense that the claims were in excess of a fee schedule. The parties do not dispute that the assignor is entitled to no-fault insurance benefits. There was an actual accident where the assignor sustained real injuries; the assignor was covered by defendant under an actual insurance policy; and the assignor was prescribed medical equipment which Yklik provided and for which the insurer was billed. Thus, an insurer can only preserve a fee schedule defense by first complying with the 30-day rule and issuing a timely denial. (Complete Orthopedic Supplies at 1005; Jamil M. Abraham M.D. P.C. v Country-Wide Ins. Co., 3 Misc 3d 130[A], 2004 NY Slip Op 50388[U], *2 [App Term, 2d Dept 2004] [“by virtue of a timely claims denial an insurer is entitled” to raise a fee schedule defense and establish that charges exceeded those permitted by law]; see Forrest Chen Acupuncture Servs., P.C. v GEICO Ins. Co., 54 AD3d 996 [2d Dept 2008].)

In light of these opinions, it is clear that the defenses of fee schedule noncompliance and partial payment made in accordance with the fee schedule are precluded if defendant fails to disclaim coverage in timely a manner pursuant to the no-fault regulations. Here, the denial annexed to plaintiff’s papers as exhibit 3 reveals that defendant received the claims on July 10, 2007 and mailed the denial on September 4, 2007, waiting approximately{**23 Misc 3d at 245} 56 days to send out its denial. By failing to timely submit its denial, defendant is precluded from raising the defense of noncompliance with the fee schedule and summary judgment is granted to plaintiff.

[*1]

Supreme Court, Appellate Term, Second Department, December 31, 2008

APPEARANCES OF COUNSEL

Law Office of Alden Banniettis, Brooklyn (Jeff Henle of counsel), for appellant. Freiberg & Peck, LLP, New York City (Yilo J. Kang of counsel), for respondent.

{**22 Misc 3d at 71} OPINION OF THE COURT

Memorandum.

Judgment affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved, in effect, for summary judgment dismissing the complaint. In support of its motion, defendant submitted the two claim forms that are the subject of this action, which indicate that the billed-for services were rendered by independent contractors. Plaintiff’s opposition to defendant’s motion was based upon oral decisions set forth in trial transcripts, in three unrelated actions against another insurance company, in which the court found that plaintiff’s treating providers were employees. The court granted defendant’s motion, finding that plaintiff submitted claim forms that stated that the billed-for services were rendered by an independent contractor and implicitly holding that plaintiff was bound by the claim forms it submitted. Plaintiff appeals, arguing that an insurer may not be awarded summary judgment based upon the defense that the billed-for services were rendered by an independent contractor. Plaintiff argues further that the oral decisions by other judges of the same court contained in the trial transcripts are evidence that the treating providers were employees, thereby rebutting the information contained in plaintiff’s own claim forms and raising a triable issue of fact.

Contrary to plaintiff’s contention, the fact that health care services sued for by a professional corporation were rendered by an independent contractor is a proper basis upon [*2]which to award a no-fault defendant summary judgment dismissing the complaint made against it (see Health & Endurance Med., P.C. v Liberty Mut. Ins. Co., 19 Misc 3d 137[A], 2008 NY Slip Op 50864[U] [App Term, 2d & 11th Jud Dists 2008]). While plaintiff claims that Matter of Health & Endurance Med., P.C. v Deerbrook Ins. Co. (44 AD3d 857 [2007]) stands for the proposition that a plaintiff may recover even if services were rendered by an independent contractor, such an interpretation lacks merit.

A provider demonstrates its entitlement to collect assigned first-party no-fault benefits by proving the submission of its statutory claim forms, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]). Payment is overdue “if not paid within thirty days after the claimant supplies proof of{**22 Misc 3d at 72} the fact and amount of loss sustained” (Insurance Law § 5106 [a]). A claim form seeking reimbursement for services rendered by an independent contractor does not supply proof of a loss, because

“where a billing provider seeks to recover no-fault benefits for services which were not rendered by it or its employees, but rather by a treating provider who is an independent contractor, it is not a ‘provider’ of the medical services rendered within the meaning of [11 NYCRR 65-3.11 (a)] and is therefore not entitled to recover ‘direct payment’ of assigned no-fault benefits from the defendant insurer” (Rockaway Blvd. Med. P.C. v Progressive Ins., 9 Misc 3d 52, 54 [App Term, 2d & 11th Jud Dists 2005]).

In the case at bar, the claim forms at issue state that the treating professionals were independent contractors. Contrary to plaintiff’s contention, the allegation that said treating professionals were actually employees, and that the claim forms contain misinformation, is irrelevant. Plaintiff did not submit bills that entitled it to payment, and correction of the defect involved herein should not be permitted once litigation has been commenced (see generally Mount Sinai Hosp. v Chubb Group of Ins. Cos., 43 AD3d 889 [2007] [litigation that was commenced prior to payment becoming overdue was premature and the cause of action was dismissed]). The independent contractor defense is nonprecludable (see Rockaway Blvd. Med. P.C., 9 Misc 3d at 54). An insurer should be able to rely on the assertions in the claim form, and, in keeping with the aim of “provid[ing] substantial premium savings to New York motorists” (Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854, 860 [2003]), should be able to handle a claim for services rendered by an independent contractor accordingly without engaging in further consideration of the claim. An insurer is not obliged to issue a denial in order to assert the nonprecludable, independent contractor defense. Consequently, if a provider were to be permitted to demonstrate during litigation that the claim form was incorrect and services were, in fact, rendered by an employee, not only would the insurer, which exercised its option not to expend further efforts to defend a facially meritless claim, have lost its opportunity to conduct meaningful claims verification, but also its decision not to issue a denial would result in its preclusion from introducing most defenses (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 [1997]). Moreover, upon a court’s finding that services were rendered by{**22 Misc 3d at 73} an employee, and not an independent contractor as stated on the claim form prepared by the provider, an award of interest beginning to accrue 30 days after the submission of the claim form, as mandated by the no-fault regulations (see Insurance Department Regulations [11 NYCRR] § 65-3.8 [a] [1]; § 65-3.9 [a]; East Acupuncture, P.C. v Allstate Ins. Co., 15 Misc 3d 104 [App Term, 2d & 11th Jud Dists 2007]), would be inequitable. Furthermore, an insurer might have [*3]timely paid a claim, had the claim form prepared by the provider not stated that the services were rendered by an independent contractor, thereby avoiding the need to retain counsel to defend an action that might have been avoided. If the provider is allowed to amend the claim form, on the other hand, plaintiff would be entitled to recover its attorney’s fees from defendant for unnecessary litigation (see Insurance Department Regulations [11 NYCRR] § 65-3.10 [a]).

In view of the foregoing, the Civil Court properly granted defendant’s motion to dismiss the complaint (but see Atlantis Med., DC v Liberty Mut. Ins. Co., 19 Misc 3d 131[A], 2008 NY Slip Op 50584[U] [App Term, 1st Dept 2008]).

We note that, under appropriate circumstances, a provider who has submitted a claim form that improperly designates the treating provider as an independent contractor could, upon realizing its mistake, submit a new claim form with the proper designation along with “written proof providing clear and reasonable justification for the failure” to submit the claim within 45 days of the rendering of services (see Insurance Department Regulations [11 NYCRR] § 65-1.1 [Proof of Claim]). We do not pass upon whether the circumstances presented in this case would constitute “reasonable justification” for plaintiff’s failure to timely submit a proper claim.

Pesce, P.J., Golia and Rios, JJ., concur.

—[*1] Bruno, Gerbino & Soriano, LLP, Melville, N.Y. (Charles W. Benton of counsel), for appellant.

Joseph Henig, P.C., Bellmore, N.Y., for respondents.

In an action to recover no-fault medical benefits under two insurance contracts, the defendant appeals from an order of the Supreme Court, Nassau County (McCarty, J.), dated February 28, 2008, which denied its motion pursuant to CPLR 5015 (a) (1) to vacate a judgment of the same court dated September 18, 2007, entered upon its default in appearing or answering the complaint, which was in favor of the plaintiffs and against it in the principal sum of $43,030.53.

Ordered that the order is affirmed, with costs.

The Supreme Court providently exercised its discretion in denying the defendant’s motion pursuant to CPLR 5015 (a) (1) to vacate a judgment entered upon its default in appearing or answering the complaint since it failed to demonstrate a reasonable excuse for the default (see Eugene Di Lorenzo, Inc. v A.C. Dutton Lbr. Co., 67 NY2d 138, 141 [1986]; Giovanelli v Rivera, 23 AD3d 616 [2005]). The plaintiffs established that they effectuated service upon the defendant through delivery of the summons and complaint upon the Assistant Deputy Superintendent and Chief of Insurance (see Insurance Law § 1212; Hospital for Joint Diseases v Lincoln Gen. Ins. Co., 55 AD3d 543 [2008]; New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 968 [2006]; Kaperonis v Aetna Cas. & Sur. Co., 254 AD2d 334 [1998]; see also CPLR 311 [a] [1]). The defendant did not contend that the address on file with the Superintendent of Insurance was incorrect, and the mere denial of receipt of the summons and complaint was insufficient to rebut the presumption of proper service created by the affidavit of service (see Commissioners of State Ins. Fund v Nobre, Inc., 29 AD3d 511 [2006]; [*2]Carrenard v Mass, 11 AD3d 501 [2004]; Truscello v Olympia Constr., 294 AD2d 350, 351 [2002]). Even if the defendant’s motion were treated as one made pursuant to CPLR 317 (see Eugene Di Lorenzo, Inc. v A.C. Dutton Lbr. Co., 67 NY2d 138, 143 [1986]; Mann-Tell Realty Corp. v Cappadora Realty Corp., 184 AD2d 497, 498 [1992]), the defendant failed to meet its burden of showing that it did not receive actual notice of the summons in time to defend the action (see General Motors Acceptance Corp. v Grade A Auto Body, Inc., 21 AD3d 447 [2005]; cf. Hospital for Joint Diseases v Lincoln Gen. Ins. Co., 55 AD3d 543 [2008]). Skelos, J.P., Dillon, Carni and Leventhal, JJ., concur.

[*1]

Second Department, December 30, 2008

Globe Surgical Supply v GEICO Ins. Co., 12 Misc 3d 1185(A), 2006 NY Slip Op 51446(U), appeal dismissed.

APPEARANCES OF COUNSEL

Locks Law Firm, PLLC, New York City (Seth R. Lesser and Andrew P. Bell of counsel), and Manoussos & Associates, Garden City, for appellant (one brief filed).

O’Melveny & Myers, LLP, New York City (Ralph P. DeSanto, Paul R. Koepff and Benjamin B. Bianco of counsel), for respondent.

{**59 AD3d at 130} OPINION OF THE COURT

Dickerson, J.

These appeals require us to address whether it is appropriate to certify a class action challenging the validity, under regulations in effect prior to October 6, 2004, of a no-fault insurer’s use of the prevailing geographic rate or the reasonable and customary rate for health care services in calculating first-party benefits due to a claimant or health-care provider.

In 2004 the plaintiff, Globe Surgical Supply (hereinafter Globe), as assignee of Remy Gallant, commenced the instant class action alleging, inter alia, that the defendant, GEICO Insurance Company (hereinafter GEICO), violated the regulations promulgated by the New York State Insurance Department (hereinafter the Insurance Department) pursuant to the no-fault provisions of the Insurance Law, by systematically reducing its reimbursement for medical equipment and supplies, specifically, durable medical equipment (hereinafter DME), based on what it deemed to be “the prevailing rate in the geographic location of the provider,” or “the reasonable and customary rate for the item billed.” Specifically, Globe alleges that GEICO wrongfully adjusted or reduced reimbursement payments of claims for DME subject to former part E (11{**59 AD3d at 131} NYCRR Appendix 17-C) (hereinafter former Part E) of the 23rd Amendment to Insurance Department Regulation 83 (11 NYCRR part 68), to an amount less than the amount charged in the proof of claim.

[*2]No-Fault Statutory and Regulatory Scheme

The Comprehensive Motor Vehicle Reparations Act (Insurance Law §§ 5101-5109 [hereinafter the No-Fault Law]) provides for the payment of first-party benefits to persons injured in automobile accidents involving New York State residents and/or vehicles registered in the state (see Insurance Law § 5103 [a]). “First party benefits” are defined as “payments to reimburse a person for basic economic loss” (Insurance Law § 5102 [b]). “Basic economic loss” includes “all necessary expenses incurred for . . . medical, hospital . . . and prosthetic services,” such as DME (Insurance Law § 5102 [a] [1]). “Payments hereunder for necessary medical expenses shall be subject to the limitations and requirements of section 5108 of the New York Insurance Law” (11 NYCRR 65-1.1 [d]). Insurance Law § 5108 authorizes the Superintendent of Insurance (hereinafter the Superintendent) to establish a fee schedule for DME, which had been, at all times relevant to this appeal, set forth in former Part E. Former Part E regulated and set the amount of reimbursement to providers of DME as follows: “[f]or medical equipment and supplies (e.g., TENS units, soft cervical collars) provided by a physician or medical equipment supplier, the maximum permissible charge is 150 percent of the documented cost of the equipment to the provider.”^[FN1]

Regulation 68

The Superintendent also promulgated Regulation 68, codified at 11 NYCRR part 65, to provide the specific procedural details for the payment of benefits. Under Regulation 68, the injured party is required to notify the insurer and to submit a written proof of claim for medical treatment no later than 45 days after services are rendered. Typically, as is the case here, the insured party orders DME from the supplier (e.g. Globe) and the supplier is assigned the right to claim reimbursement. Upon receipt of proof of claim, an insurer has 15 business days within which{**59 AD3d at 132} to request “any additional verification required by the insurer to establish proof of claim” (11 NYCRR 65-3.5 [b]). An insurance company must pay or deny the claim within 30 calendar days after receipt of the proof of claim (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [c]). “In the event any person making a claim for first-party benefits and the Company do not agree regarding any matter relating to the claim, such person shall have the option of submitting such disagreement to arbitration” (11 NYCRR 65-1.1 [d]).

The Litigation

In a complaint dated July 19, 2004, Globe alleged that GEICO

“[a]t some point in time . . . ceased paying claims in accordance with the terms of the [no-fault] regulations and . . . instituted a systematic pattern and practice of reviewing claims for reimbursement against what it deemed to be the ‘prevailing rate in the geographic location of the provider,’ ‘the reasonable and customary rate for [the] item billed,’ or similar rationales . . . There is nothing in [former] Part E which permits an insurer to reduce reimbursements for [DME] by such factors as reasonable and customary charges or geographically prevailing rates. Yet, that is precisely what defendant GEICO is doing and has been doing.”

Specifically, Globe alleged that its assignor, Remy Gallant, was injured in an accident on February 10, 2001, with a GEICO policyholder. According to the complaint, Gallant purchased a transcutaneous electrical nerve stimulator (hereinafter the TENS unit) from Globe, which cost $340. Globe submitted the claim to GEICO, as assignee of Gallant, in the amount of $510 (representing [*3]150% of the actual cost). On May 23, 2001, GEICO denied the claim for that amount and only reimbursed Globe in the amount of $200. As noted on Gallant’s claim form, GEICO partially denied the claim because the cost submitted was “far in excess of the industry average which is $107.82 . . . Based on this, a reasonable reimbursement is 150% over this amount which is $161.73. However, in consideration of the potential range, $200.00 will be reimbursed.”

Globe sought injunctive relief and asserted four causes of action sounding in (1) violation of the No-Fault Law, (2) breach of contract, (3) violation of General Business Law § 349, and (4) unjust enrichment. The Supreme Court granted that branch of GEICO’s motion which was to dismiss the first cause of action{**59 AD3d at 133} for failure to state a cause of action, and those branches of GEICO’s motion which were to dismiss the third and fourth causes of action for lack of standing. In denying that branch of GEICO’s motion which was to dismiss the second cause of action alleging breach of contract, the Supreme Court noted that the

“plaintiff’s claim is based upon Insurance Department Regulations, which are part of the policy as a matter of law (see Insurance Law § 5103 [h]) and which are specifically set forth in plaintiff’s complaint . . . Insurance policies covering other members of the proposed class need not be identified at this stage of the action.”

Globe purportedly commenced this action on behalf of itself and all members of a class “consisting of all persons who had reimbursement payments of claims for medical equipment and supplies subject to [former] Part E of the Twenty-Third Amendment to Regulation No. 83 (11 NYCRR 68) (‘Part E Reimbursements’) adjusted or reduced by Geico.”

GEICO answered the complaint and set forth numerous affirmative defenses and counterclaims alleging fraud and unjust enrichment against Globe and the class. In particular, GEICO asserted that Globe and other prospective class members committed fraud by

“engag[ing] in a scheme to exploit the payment formula . . . in order to collect fraudulent charges for [DME] purportedly provided to individuals who were injured in automobile accidents . . . Among other things, Globe . . . charged grossly inflated prices for the supplies it purportedly sold . . . and submitted false ‘documentation’ of its costs . . . GEICO [seeks] to recover the money that Globe . . . has stolen from the GEICO Companies (and if this case is certified as a class action, that other members of the purported class have stolen) by submitting thousands of fraudulent charges for DME.”

Prior to the submission of the motion at issue on this appeal, the parties conducted discovery, which included the depositions of Globe’s principal, Jean M. Francois, and a supervisor at GEICO, Valerie Coffey. Francois testified that he owned Globe, which dispenses DME to patients. Francois acknowledged that P.Z.F. Management Company, Inc., was the actual name of the company doing business as Globe. During his deposition, Francois invoked the Fifth Amendment to the United States Constitution{**59 AD3d at 134} when asked questions about shareholders’ meetings, tax preparation, his arrest for insurance fraud,^[FN2] and his knowledge of other supply companies. Francois stated that, during the normal course of business, he paid for DME by check. Repeatedly throughout his deposition, [*4]Francois was shown documents that had the same invoice number and dates but represented the purchase of two different items of DME. Francois was also shown documents from Allstate Insurance Company representing the same invoice numbers submitted for various DME items. Francois had no explanation as to why he submitted the same invoice number numerous times to GEICO, representing the purchase of different items of DME. When asked to explain why the same invoice for the purchase of one lumbosacral support custom fabric was submitted 15 times to both GEICO and Allstate, Francois responded: “since that’s what I pay for it and I stick with that one invoice and send it out . . . it wasn’t required or specifically by any insurance company to ask me to send that specific invoice that matches the claim.”

Valerie Coffey averred that she was the personal injury protection manager and supervisor at GEICO’s Woodbury office, which processed no-fault claims during the relevant time period. Coffey testified that state guidelines required receipt of proof of claim. She acknowledged that, once received, GEICO had 30 days to deny or pay the bill. Coffey testified that it was her understanding that the 150% reimbursement for DME supplies should be based on reasonable cost, which she defined as a “bona fide arm’s length transaction.” Coffey stated that in cases where GEICO saw inflated pricing for DME supplies, it performed a survey of multiple vendors and wholesalers and provided reimbursement based on the amount determined by the market survey, rather than 150% of the amount set forth on the submitted invoice. The first survey applied to the TENS unit and the second survey covered cervical collars, pillows, back massagers, lumbosacral support, and thermophore. Coffey{**59 AD3d at 135} explained that, based on the survey, the average price for a TENS unit was in the $160 range. Coffey stated that, to be on the “fair side,” GEICO decided to reimburse them at the rate of $200 per unit, but that GEICO did not reimburse up to 150% of the amount set forth on the invoice.

Coffey stated that there were more than 10 DME suppliers who submitted claims to GEICO for reimbursement. When asked if the suppliers who submitted claims for reimbursement numbered more than 100, Coffey responded “once you get to a hundred, I’d be speculating.”

On March 3, 2006, Globe moved, inter alia, pursuant to CPLR 901 and 902 for class certification on behalf of a class of all persons who had reimbursement payments of claims for medical equipment and supplies subject to former Part E adjusted or reduced by GEICO to an amount less than the amount charged in the proof of claim,^[FN3] specifically to a “reasonable reimbursement of 150%” of either the “industry average” or “of the average retail price.” GEICO opposed the motion. The Supreme Court denied the motion and, upon granting that branch of Globe’s subsequent motion which was for leave to reargue, adhered to the original determination.

Class Certification: Burden of Proof and Liberal Construction

Article 9 of the CPLR is to be “liberally construed” (Beller v William Penn Life Ins. Co. of N.Y., 37 AD3d 747, 748 [2007]; Wilder v May Dept. Stores Co., 23 AD3d 646, 649 [2005]; Jacobs v Macy’s E., Inc., 17 AD3d 318, 319 [2005]; Kidd v Delta Funding Corp., 289 AD2d 203 [2001]; Friar v Vanguard Holding Corp., 78 AD2d 83, 91 [1980]; see generally 3 Weinstein-Korn-Miller, NY Civ Prac ¶¶ 901.04, 901.05, 901.20 [2d ed]) in favor of the granting of class certification if all of the prerequisites of CPLR 901 (a) (1)-(5) (see Matter of Colt Indus. Shareholder Litig., 77 NY2d 185, 194 [1991]; Klein v Robert’s Am. Gourmet Food, Inc., 28 AD3d 63, 69 [2006]; Ackerman v Price Waterhouse, 252 AD2d 179, 191 [1998]; Friar v Vanguard Holding Corp., 78 AD2d at 90-91) and CPLR [*5]902 (1)-(5) (see Ackerman v Price Waterhouse, 252 AD2d at 191) are met.

The prerequisites articulated in CPLR 901 (a) include proof that the proposed class is so numerous that joinder of all members is impracticable, that common questions of law and{**59 AD3d at 136} fact applicable to the class predominate over questions affecting only individual members, that claims or defenses of the representative parties are typical of the claims or defenses of the class, and that the class action is superior to other available methods for the fair and efficient adjudication of the controversy.

The proposed class action must also meet the prerequisites of CPLR 902 (1)-(5). The relevant factors articulated in CPLR 902 (1) (“[t]he interest of members of the class in individually controlling the prosecution or defense of separate actions”), CPLR 902 (2) (“[t]he impracticability or inefficiency of prosecuting or defending separate actions”) and CPLR 902 (3) (“[t]he extent and nature of any litigation concerning the controversy already commenced by or against members of the class”) may, under the circumstances of this case, be subsumed under the prerequisite of superiority (see CPLR 901 [a] [5]). CPLR 902 (4) requires consideration of “[t]he desirability or undesirability of concentrating the litigation of the claim in the particular forum.” The selected forum is Nassau County, which is appropriate given the nature of the claims asserted (see Galdamez v Biordi Constr. Corp., 13 Misc 3d 1224[A], 2006 NY Slip Op 51969[U], *5 [2006], affd 50 AD3d 357 [2008] [“(T)he forum is appropriate, as the Public Works Projects were located in New York”]; Mazzocki v State Farm Fire & Cas. Co., 170 Misc 2d 70, 72 [1996] [“under the New York venue statute a class action is properly venued if at least one member of the class resides in the county where the action was brought”]) and the absence of a forum selection clause (see Boss v American Express Fin. Advisors, Inc., 6 NY3d 242, 247 [2006] [“Forum selection clauses are enforced because they provide certainty and predictability in the resolution of disputes”]; Rocco v Pension Plan of N.Y. State Teamsters Conference Pension & Retirement Fund, 5 Misc 3d 1027[A], 2004 NY Slip Op 51580[U], *2 [2004] [motion to transfer purported class action from Kings County to Onondaga County as a more convenient forum granted as “the rules of the Pension Fund mandate that any action brought against it be commenced in the County of Onondaga”]). Finally, CPLR 902 (5) requires consideration of “[t]he difficulties likely to be encountered in the management of a class action.” The determination to grant class action certification rests in the sound discretion of the trial court (see Small v Lorillard Tobacco Co., 94 NY2d 43, 52-53 [1999]; Tosner v Town of Hempstead, 12 AD3d 589, 590 [2004]; Liechtung v Tower Air, 269 AD2d 363, 364 [2000]). The primary issue on a motion for class certification{**59 AD3d at 137} is whether the claims as set forth in the complaint can be efficiently and economically managed by the court on a classwide basis. The class representative has the burden of establishing the prerequisites of certification (see Kings Choice Neckwear, Inc. v DHL Airways, Inc., 41 AD3d 117 [2007]; Beller v William Penn Life Ins. Co. of N.Y., 37 AD3d 747, 748 [2007]; Rabouin v Metropolitan Life Ins. Co., 25 AD3d 349, 350 [2006]; Rallis v City of New York, 3 AD3d 525, 526 [2004]; Liechtung v Tower Air, 269 AD2d at 364; Ackerman v Price Waterhouse, 252 AD2d 179 [1998]; Canavan v Chase Manhattan Bank, 234 AD2d 493, 494 [1996]).

Class Definition

On a motion for class certification, the court must be convinced that the proposed class is capable of being identified (see Colbert v Rank Am., 1 AD3d 393, 394-395 [2003]; Lichtman v Mount Judah Cemetery, 269 AD2d 319, 320-321 [2000]; Mitchell v Barrios-Paoli, 253 AD2d 281, 291 [1999]; Canavan v Chase Manhattan Bank, 234 AD2d at 494). Here, the class has been clearly defined as

“all persons who had reimbursement payments of claims for medical equipment and supplies subject to [former] Part E of the Twenty-Third Amendment to Regulation No. 83 (11 NYCRR 68) . . . adjusted or reduced by Geico based upon an ‘industry average’ to a ‘reasonable reimbursement of 150%’ of the ‘industry average’ or ‘of the average retail price,’ to an amount less than the amount charged in the proof of claim.”

[*6]Numerosity

CPLR 901 (a) provides that a class action may be maintained if, inter alia, “1. the class is so numerous that joinder of all members, whether otherwise required or permitted, is impracticable.” GEICO did not challenge numerosity in its opposition to Globe’s original motion, but instead first raised the issue in its opposition to Globe’s motion for leave to reargue. As such, GEICO has waived any challenge to numerosity (cf. Friar v Vanguard Holding Corp., 78 AD2d at 96).

Nonetheless, the minimum number permissible may depend on a variety of factors. “There is no ‘mechanical test’ to determine whether . . . numerosity . . . has been met, nor is there a set rule for the number of prospective class members which must exist before a class is certified” (id. at 96 [citations{**59 AD3d at 138} omitted]). “Each case depends upon the particular circumstances surrounding the proposed class and the court should consider the reasonable inferences and commonsense assumptions from the facts before it” (id. [citations omitted]). In any event, the proposed class herein is, at a minimum, between 10 and 100 DME providers and, hence, the numerosity requirement is met (see Klakis v Nationwide Leisure Corp., 73 AD2d 521, 522 [1979] [class certification properly denied where putative class consisted of only 21 individuals]; Caesar v Chemical Bank, 118 Misc 2d 118, 119 [1983], affd 106 AD2d 353 [1984], mod 66 NY2d 698 [certified class of 39 bank employees]; Pajaczek v CEMA Constr. Corp., 18 Misc 3d 1140[A], 2008 NY Slip Op 50386[U], *3 [2008] [“Here, the numerosity requirement has been satisfied with forty class members. The class, as defined, is narrowly defined to avoid being over inclusive, but large enough that joinder is not practicable”]; Galdamez v Biordi Constr. Corp., 13 Misc 3d 1224[A], 2006 NY Slip Op 51969[U], *2 [2006], quoting Dornberger v Metropolitan Life Ins. Co., 182 FRD 72, 77 [1998] [“It has, however, been held that ‘the threshold for impracticability of joinder seems to be around forty’ “]; see also Philadelphia Elec. Co. v Anaconda Am. Brass Co., 43 FRD 452 [1968] [class of 25 members certified]; Bernstein v American Family Ins. Co., 2005 WL 1613776, *2 [Ill Cir Ct 2005] [“If the class has more than forty people in it, numerosity is satisfied; if the class has less than twenty-five people in it, numerosity is probably lacking, if the class has between twenty-five and forty, there is no automatic rule and other factors . . . become relevant”]).

Common Questions of Law or Fact

CPLR 901 (a) (2) provides that there must be “questions of law or fact common to the class which predominate over any questions affecting only individual members.” Since the enactment of CPLR article 9 in 1975, there has been some reluctance on the part of New York courts to certify some types of class actions, e.g., (1) physical injury and property damage mass tort class actions (see Catalano v Heraeus Kulzer, Inc., 305 AD2d 356 [2003]; Lieberman v 293 Mediterranean Mkt. Corp., 303 AD2d 560 [2003]; Aprea v Hazeltine Corp., 247 AD2d 564 [1998]; cf. Osarczuk v Associated Univs., Inc., 36 AD3d 872 [2007]; Fleming v Barnwell Nursing Home & Health Facilities, 309 AD2d 1132 [2003]; Godwin Realty Assoc. v CATV Enters., 275 AD2d 269 [2000]; Matter of Arroyo v State of New York, 12 Misc 3d 1197[A], 2006 NY Slip Op 51606[U] [2006]; Cunningham v{**59 AD3d at 139} American Home Prods. Corp., NYLJ, Sept. 21, 1999, at 26, col 5), (2) class actions challenging governmental operations (see Mahoney v Pataki, 98 NY2d 45 [2002]; Jamie B. v Hernandez, 274 AD2d 335 [2000]; Davis v Croft, 237 AD2d 163 [1997]; cf. New York City Coalition to End Lead Poisoning v Giuliani, 245 AD2d 49 [1997]; Chalfin v Sabol, 247 AD2d 309 [1998]; Yusuf v City of New York, 309 AD2d 721 [2003]; Matter of Holcomb v O’Rourke, 255 AD2d 383 [1998]; Watts v Wing, 308 AD2d 391 [2003]), and (3) class actions seeking a penalty or minimum recovery, which are prohibited by CPLR 901 (b), including class actions commenced under General Business Law § 340 (the Donnelly Antitrust Act) (see Sperry v Crompton Corp., 8 NY3d 204 [2007]) and the Federal Telephone Consumer Protection Act of 1991 (47 USC § 227) (see e.g. J. A. Weitzman, Inc. v Lerner, Cumbo & Assoc., Inc., 46 AD3d 755 [2007]; Giovanniello v Carolina Wholesale Off. Mach. Co., Inc., 29 AD3d 737 [2006]; Rudgayzer & Gratt v Cape Canaveral Tour & Travel, Inc., 22 AD3d 148 [2005]). As [*7]to the third category of actions, however, if only actual damages are sought, a court may certify a class in actions asserting a violation of General Business Law § 349 (see e.g., Cox v Microsoft Corp., 8 AD3d 39, 40 [2004]; Ridge Meadows Homeowners’ Assn. v Tara Dev. Co., 242 AD2d 947 [1997]; Super Glue Corp. v Avis Rent A Car Sys., 132 AD2d 604, 606 [1987]; Lawlor v Cablevision Sys. Corp., 15 Misc 3d 1111[A], 2007 NY Slip Op 50580[U] [2007]) and the Federal Telephone Consumer Protection Act of 1991 (see e.g. J. A. Weitzman, Inc. v Lerner, Cumbo & Assoc., Inc., 46 AD3d 755, 756 [2007]). Nonetheless, the courts have uniformly certified breach of contract class actions, notwithstanding differing individual damages (see discussion below on damages within the context of the requirements of CPLR 901 [a] [2]), where, as here, there is uniformity in contractual agreements and/or statutorily imposed obligations (see Beller v William Penn Life Ins. Co. of N.Y., 37 AD3d 747, 748 [2007]; Wilder v May Dept. Stores Co., 23 AD3d 646, 649 [2005]; Jacobs v Macy’s E., Inc., 17 AD3d 318, 320 [2005]; Cherry v Resource Am., Inc., 15 AD3d 1013 [2005]; Freeman v Great Lakes Energy Partners, L.L.C., 12 AD3d 1170, 1171 [2004]; Englade v HarperCollins Publs., 289 AD2d 159, 160 [2001]; Broder v MBNA Corp., 281 AD2d 369, 371 [2001]; Colbert v Rank Am., 295 AD2d 302 [2002]; Makastchian v Oxford Health Plans, 270 AD2d 25, 26 [2000]; Liechtung v Tower Air, 269 AD2d at 364; Taylor v American Bankers Ins. Group, 267 AD2d 178 [1999]; Hoerger v Board of Educ. of Great Neck Union{**59 AD3d at 140} Free School Dist., 98 AD2d 274, 283 [1983]; Gross v Ticketmaster, 5 Misc 3d 1005[A], 2004 NY Slip Op 51199[U] [2004]; Amalfitano v Sprint Corp., 4 Misc 3d 1027[A], 2004 NY Slip Op 51076[U] [2004]; Gilman v Merrill Lynch, Pierce, Fenner & Smith, 93 Misc 2d 941, 944 [1978]; Guadagno v Diamond Tours & Travel, 89 Misc 2d 697, 699 [1976]; Feldman v Quick Quality Rests., Inc., NYLJ, July 22, 1983, at 12, col 5).

Predominance of Common Questions

This Court held, in Friar v Vanguard Holding Corp. (78 AD2d at 97), that the determination of whether there is a common predominating issue of fact or law should be based on “whether the use of a class action would achieve economies of time, effort, and expense, and promote uniformity of decision as to persons similarly situated” (internal quotation marks omitted).

GEICO contends that the following individual issues predominate over any common questions of law or fact: (1) whether GEICO had individual defenses to the various claims of putative class members, based on the timeliness of its coverage determinations or lack of coverage in the first instance, (2) whether the DME claims arose from a fraudulent accident, (3) whether the DME class member can prove its “documented costs,” and (4) individual damages.

The Supreme Court found that “the timeliness of GEICO’s denial of all or part of a class member’s claim must be considered in order to determine whether defenses other than lack of coverage can be raised.” (12 Misc 3d 1185[A], 2006 NY Slip Op 51446[U], *2 [2006].) However, Globe contends that GEICO is precluded from raising any affirmative defenses because it failed to do so within the statutory time period. Also, Globe argues that GEICO waived any lack of coverage claim because GEICO never raised the claim in its answer or counterclaims, and, in any event, the claim is based on unsupported conclusions and speculations. GEICO counters that all defenses relating to lack of coverage are not subject to the waiver rule.

Recently, the Court of Appeals reviewed the fundamental principles embodied in the No-Fault Law (see Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312 [2007]). In that case, the Court addressed whether the plaintiff’s failure to offer a validly-executed assignment equated to a “lack of coverage” defense which is not subject to the “30-day rule” (id. at 317).{**59 AD3d at 141}

The Court stated:

“[A] carrier that fails to deny a claim within the 30-day period is generally precluded from asserting a defense against payment of the claim. This Court has recognized a narrow exception to this preclusion remedy for situations where an insurance company raises a defense for lack of coverage. In such cases, an insurer who fails to issue a timely disclaimer is not prohibited from later raising the defense because the [*8]insurance policy does not contemplate coverage in the first instance, and requiring payment of a claim upon failure to timely disclaim would create coverage where it never existed” (id. at 318 [citations and internal quotation marks omitted]; see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 [1997]; Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]).

The majority in Hospital for Joint Diseases rejected the insurer’s argument that any deficiency of the assignment implicated a lack of coverage defense warranting exemption from the preclusion rule. The Court reiterated that the “tradeoff of the no-fault reform still allows carriers to contest ill-founded, illegitimate and fraudulent claims, but within a strict, short-leashed contestable period and process designed to avoid prejudice and red-tape dilatory practices” (Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d at 320).

Similarly, this Court, in Fair Price Med. Supply Corp. v Travelers Indem. Co. (42 AD3d 277 [2007], affd 10 NY3d 556 [2008]), addressed the preclusion rule and the lack of coverage exception. In Fair Price, the insurer failed to comply with the 30-day rule and attempted to equate a “failure to furnish services” (id. at 284) defense with the lack of coverage defense. This Court found that the defense was precluded because “[t]he defendant’s allegation, i.e., that the plaintiff billed for supplies it never furnished, is more akin to a claim of overbilling (albeit an extreme form thereof)” (id. at 283). The Court stated that while the insurer “was entitled to contest the plaintiff’s claim as fraudulent, it was required to do so within the rules of the no-fault system” (id. at 286).

Thus, contrary to GEICO’s contention, it follows that, in the instant case, GEICO would not be able to present a defense based on fraudulent billing or the inability of the class members{**59 AD3d at 142} to establish “documented costs.” In the proposed class action it is clear that the factor common to all potential class members is that the DME claims were denied because GEICO found them to be in excess of the industry average. As this Court and the Court of Appeals have made clear, overbilling and invoice recycling do not give rise to a lack of coverage defense. GEICO’s failure to claim the fraud defenses within the required 30-day period thus precludes it from raising it in the class action (see e.g. Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312 [2007]).

Globe correctly contends that the potential for different individual damages claims is not a valid reason for denying class action status, because damages are easily calculated based on the information contained in the denial-of-claim forms. GEICO argues that the calculation of damages is not subject to a simple formula, and that the trier of fact will have to determine if each claim is excessive or if it meets 150% of documented costs. Contrary to GEICO’s assertions, the calculation of individual damages within a breach of contract class action is not dispositive of the issue of class certification, and is clearly manageable in the instant controversy (see Englade v HarperCollins Publs., 289 AD2d 159, 160 [2001] [“That individual authors may have different levels of damages does not defeat class certification”]; Broder v MBNA Corp., 281 AD2d 369, 371 [2001] [“particular damages of each individual class member can be easily computed”]; Godwin Realty Assoc. v CATV Enters., 275 AD2d 269, 270 [2000] [“To the extent that there may be differences among the class members as to the degree in which they were damaged, the court may try the class aspects first and have the individual damage claims heard by a Special Master”]; see also Weinberg v Hertz Corp., 116 AD2d 1, 6-7 [1986], affd 69 NY2d 979 [1987]; Lamarca v Great Atl. & Pac. Tea Co., Inc., 16 Misc 3d 1115[A], 2007 NY Slip Op 51424[U], *3 [2007], affd 55 AD3d 487 [2008]; Matter of Arroyo v State of New York, 12 Misc 3d 1197[A], 2006 NY Slip Op 51606[U], *4 [2006]; Cox v Microsoft Corp., 10 Misc 3d 1055[A], 2005 NY Slip Op 51968[U], *5 [2005]; Matter of Coordinated Tit. Ins. Cases, 2 Misc 3d 1007[A], 2004 NY Slip Op 50171[U] [2004]; Gilman v Merrill Lynch, Pierce, Fenner & Smith, 93 Misc 2d 941, 944 [1978]; Guadagno v Diamond Tours & Travel, 89 Misc 2d 697, 699 [1976]).

Establishing an Individual Class Member’s Prima Facie Case [*9]

Upon reargument, the Supreme Court, although adhering to its initial determination, nonetheless did so despite rejecting its{**59 AD3d at 143} initial conclusion that each DME transaction must be examined separately to determine whether each individual class member has a prima facie case. Rather, the court found that each potential class member would not have to set forth a prima facie case proving facts, such as “documented costs,” or providing invoices or cancelled checks, but that class certification was still not warranted even if such a standard were applied.

With respect to this issue, the Supreme Court properly found, upon reargument, that a prima facie case can be easily made out by the class members and that proof of documented costs is not a requirement (see Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742, 742-743 [2004] [“plaintiff hospitals made prima facie showing of their entitlement to judgment as a matter of law by submitting evidentiary proof that the prescribed statutory billing forms had been mailed and received, and that payment of no-fault benefits was overdue”]; King’s Med. Supply Inc. v Country-Wide Ins. Co., 5 Misc 3d 767, 770 [2004] [“to establish a prima facie case, a plaintiff medical supplier must submit proof that it timely transmitted its claim for no-fault benefits, that the defendant insurer received the claim but failed to pay or validly deny the claim within the permissible 30 days or to request verification”]). This is true, given that GEICO did not seek verification of the documented costs for the invoices submitted (see Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d at 320 [“(e)ven assuming that (assignment of benefits is a necessary component of the hospital’s prima facie case) (the) form stating that the patient’s signature is ‘on file’ satisfies that burden where the carrier does not timely take action to verify the existence of a valid assignment”]).

Typicality

CPLR 901 (a) (3) provides that the “claims or defenses of the representative parties are typical of the claims or defenses of the class.” Typical claims are those that arise from the same facts and circumstances as the claims of the class members (see Ackerman v Price Waterhouse, 252 AD2d at 201 [claims “arose out of the same course of conduct and are based on the same theories as the other class members, they are plainly typical of the entire class”]; Pruitt v Rockefeller Ctr. Props., 167 AD2d 14, 22 [1991]; Friar v Vanguard Holding Corp., 78 AD2d at 99; Galdamez v Biordi Constr. Corp., 13 Misc 3d 1224[A], 2006 NY Slip Op 51969[U] [2006]; Cox v Microsoft Corp., 10 Misc 3d 1055[A], 2005 NY Slip Op 51968[U], *2 [2005]; Fiala v Metropolitan Life Ins. Co., NYLJ, June 2, 2006, at 22, col 1, 2006 NY Slip Op{**59 AD3d at 144} 30068[U] [2006]). Typicality can overlap with the predominance of common questions of law or fact (see CPLR 901 [a] [2]) and the adequacy of representation (see CPLR 901 [a] [4]; Matter of Coordinated Tit. Ins. Cases, 2 Misc 3d 1007[A], 2004 NY Slip Op 50171[U], *12 [2004]; 3 Weinstein-Korn-Miller, NY Civ Prac ¶ 901.24).

Adequacy of Representation

The three essential factors to consider in determining adequacy of representation are potential conflicts of interest between the representative and the class members, personal characteristics of the proposed class representative (e.g. familiarity with the lawsuit and his or her financial resources), and the quality of the class counsel (see generally Ackerman v Price Waterhouse, 252 AD2d 179 [1998]; Pruitt v Rockefeller Ctr. Props., 167 AD2d at 25-26; Matter of Coordinated Tit. Ins. Cases, 2 Misc 3d 1007[A], 2004 NY Slip Op 50171[U], *12 [2004]).

Adequacy of Class Counsel

In order to be found adequate in representing the interests of the class, class counsel should have some experience in prosecuting class actions (see Galdamez v Biordi Constr. Corp., 13 Misc 3d 1224[A], 2006 NY Slip Op 51969[U], *4 [2006]; Matter of Arroyo v State of New York, 12 Misc 3d 1197[A], 2006 NY Slip Op 51606[U], *6 [2006]; Cox v Microsoft Corp., 10 Misc 3d 1055[A], 2005 NY Slip Op 51968[U], *3 [2005]; Fiala v Metropolitan Life Ins. Co., NYLJ, June 2, 2006, at 22, col 1, 2006 NY Slip Op 30068[U] [2006]). There is no question that Globe’s counsel is highly competent in prosecuting class actions.

[*10]Adequacy of Class Representative

However, Francois, the owner of Globe, was properly rejected by the Supreme Court as an adequate representative for the class. Although Globe attempts to couch Francois’s problems in terms of “amorphous and generalized suppositions,” it is clear that Francois was charged with insurance fraud for attempting to stage accidents and thereafter bill insurance companies. While he may have only pleaded guilty to disorderly conduct, he displayed his attempt to put his interest above others by invoking his Fifth Amendment rights at his deposition, although he later withdrew his invocation of the Fifth Amendment in a subsequently-filed reply affidavit. Moreover, there was adequate evidence that Francois was engaged in recycling invoices. In addition, Francois and the class are subject to a class action{**59 AD3d at 145} counterclaim which may or may not be meritorious.^[FN4] In any event, Francois’s attempt to defend himself against any such counterclaim by GEICO would preoccupy him and detract from his representation of the class.

Therefore, Globe failed to show that it is an adequate representative of the class. “Other [appellate courts] emphasize, as do we, the challenge presented by a defense unique to a class representative—the representative’s interests might not be aligned with those of the class, and the representative might devote time and effort to the defense at the expense of issues that are common and controlling for the class” (Beck v Maximus, Inc., 457 F3d 291, 297 [2006]). In other words, a class should not be certified if Globe is the class representative, as “there is a danger that absent class members will suffer if their representative is preoccupied with defenses unique to it” (Hanon v Dataproducts Corp., 976 F2d 497, 508 [1992] [citations omitted]; see Koos v First Nat. Bank of Peoria, 496 F2d 1162, 1165 [1974]; Folding Cartons, Inc. v America Can Co., 79 FRD 698 [1978]; Weisman v Darneille, 78 FRD 669, 671 [1978]; Di Pace v Linsco/Private Ledger Corp., 2004 WL 1410046 [Cal Ct App 2004]; Benzing v Farmers Ins. Exch., 179 P3d 103 [Colo Ct App 2007], cert granted 2008 WL 434677, 2008 Colo LEXIS 160 [2008]; cf. Lamarca v Great Atl. & Pac. Tea Co., Inc., 16 Misc 3d 1115[A], 2007 NY Slip Op 51424[U] [2007]; Galdamez v Biordi Constr. Corp., 13 Misc 3d 1224[A], 2006 NY Slip Op 51969[U] [2006]).

Superiority

CPLR 901 (a) (5) provides that a class may be certified only if “a class action is superior to other available methods for the{**59 AD3d at 146} fair and efficient adjudication of the controversy.” The No-Fault Law provides claimants with the option of commencing a plenary action or submitting the dispute to arbitration (see Insurance Law § 5106 [b]). In addition, the No-Fault Law provides that the claimant may recover penalty interest at a rate of 24% (see Insurance Law § 5106 [a]), a remedy [*11]not available in a class action. However, the availability of an arbitration alternative does not mean such a proceeding is superior to a class action which, through the aggregation of many similar claims, provides an incentive to the legal profession to expend the resources necessary to fully litigate often complex cases such as the instant matter, including the pursuit of this very appeal. The “very core of the class action mechanism is to overcome the problem that small recoveries do not provide the incentive for any individual to bring a solo action prosecuting his or her rights” (Amchem Products, Inc. v Windsor, 521 US 591, 617 [1997]; see Pruitt v Rockefeller Ctr. Props., 167 AD2d at 21; Super Glue Corp. v Avis Rent A Car Sys., 132 AD2d 604, 607-608 [1987]; Yollin v Holland Am. Cruises, 97 AD2d 720, 721 [1983]; Friar v Vanguard Holding Corp., 78 AD2d at 98-99; Matter of Arroyo v State of New York, 12 Misc 3d 1197[A], 2006 NY Slip Op 51606[U], *6 [2006]; see also Bell v Superior Ct., 69 Cal Rptr 3d 328, 349 [Ct App 2007]). In addition, should individual class members wish to pursue arbitration, and thereby recover statutory penalties unavailable in a class action, they may do so by opting out of the class sought to be certified (see Cox v Microsoft Corp., 8 AD3d at 40; Ridge Meadows Homeowners’ Assn. v Tara Dev. Co., 242 AD2d 947, 947 [1997]; Super Glue Corp. v Avis Rent A Car Sys., 132 AD2d at 606).

Moreover, as with the requirements of CPLR 901 (a) (2), referable to the issues of liability and damages calculations, the prosecution of this proposed class action is fairly straightforward and quite manageable. Thus, although the motion to certify a class was properly denied because of Globe’s inadequacy as a class representative, upon reargument, the denial of the motion should have been without prejudice to renewal.

Accordingly, the appeal from the order entered July 21, 2006, is dismissed, as that order was superseded by the order entered November 8, 2006, made upon reargument. The order entered November 8, 2006, is reversed insofar as appealed from, on the facts and in the exercise of discretion, upon reargument, so much of the order entered July 21, 2006, as denied that branch of the plaintiff’s motion which was to certify a class action pursuant{**59 AD3d at 147} to CPLR article 9 is vacated, and that branch of the plaintiff’s motion is denied without prejudice to renewal.

Spolzino, J.P., Florio and Miller, JJ., concur.

Ordered that the appeal from the order entered July 21, 2006, is dismissed, as that order was superseded by the order entered November 8, 2006, made upon reargument; and it is further,

Ordered that the order entered November 8, 2006, is reversed insofar as appealed from, on the facts and in the exercise of discretion, upon reargument, so much of the order entered July 21, 2006, as denied that branch of the plaintiff’s motion which was to certify a class action pursuant to CPLR article 9 is vacated, and that branch of the plaintiff’s motion is denied without prejudice to renewal; and it is further,

Ordered that one bill of costs is awarded to the appellant.

Footnotes

Footnote 1: Regulation 83 was amended, effective October 6, 2004, and now states that where there is no specific schedule for reimbursement, the insurer must pay the “lesser of: (1) the acquisition cost . . . to the provider plus 50 percent; or (2) the usual and customary price charged to the general public” (11 NYCRR Appendix 17-C, part F [a]). All the parties agree that the former Part E governs in this case.

Footnote 2: In his affidavit sworn to April 21, 2006, Christopher J. Jones, a “Detective with the NYPD’s Fraudulent Accident Investigation Squad . . . for the past 2½ years,” stated that “[f]raud by DME suppliers against no-fault insurance companies is widespread. It has been a principal focus of our Squad’s investigation . . . On or about June 1, 2005, Mr. Francois was arrested as the result of an undercover investigation in which I was involved. He was arrested for offering to pay an undercover agent to stage a phony automobile accident and refer the alleged ‘victims’ to a medical clinic. The specific charges were insurance fraud in the third degree and conspiracy in the fifth degree . . . Subsequently, Mr. Francois entered into a plea agreement, pleading guilty to disorderly conduct.”

Footnote 3: For other examples of insurer “repricing” of medical bills, see Reyher v State Farm Mut. Auto. Ins. Co. (171 P3d 1263 [Colo Ct App 2007]) and LaBerenz v American Family Mut. Ins. Co. (181 P3d 328 [Colo Ct App 2007], cert denied 2008 WL 1701094, 2008 Colo LEXIS 414 [Sup Ct 2008]).

Footnote 4: Counterclaims against the class representative and/or the members of the class may be asserted to discourage class participation and render the named class representatives inadequate by creating a seemingly unique defense. The courts must carefully examine the merits and purpose of class action counterclaims (see Van Gemert v Boeing Co., 590 F2d 433 [1978], affd 444 US 472 [1980] [absent class members who are not parties are not subject to counterclaims under Federal Rules of Civil Procedure rule 13 since such counterclaims may be used to encourage class members to opt out of the class]; Equity Residential Props. Trust v Yates, 910 So 2d 401, 404 [Fla Ct App 2005] [“we find no error in the trial court’s denial of the landlord’s motion to bring a class-wide counterclaim”]; Purcell & Wardrope Chartered v Hertz Corp., 175 Ill App 3d 1069, 530 NE2d 994 [1988] [dismissing counterclaim against class representative for lack of evidence]; Shaver v Standard Oil Co., 89 Ohio App 3d 52, 623 NE2d 602 [1993] [assertion of counterclaim against named plaintiff does not destroy ability of representative to comply with typicality requirements; the counterclaim should be treated as a request for a setoff against the named plaintiff’s individual claim]; see also 3 Weinstein-Korn-Miller, NY Civ Prac ¶ 901.19 [2d ed]).

—[*1] Moira A. Doherty, Uniondale, N.Y. (Janice P. Rosen of counsel), for appellant.

Joseph Henig, P.C., Bellmore, N.Y., for respondent.

In an action to recover no-fault medical payments under insurance contracts, the defendant appeals, as limited by its brief, from so much of an order of the Supreme Court, Nassau County (Brandveen, J.), dated December 3, 2007, as granted that branch of the plaintiff’s motion which was for summary judgment on the first cause of action.

Ordered that the order is reversed insofar as appealed from, on the law, with costs, and that branch of the plaintiff’s motion which was for summary judgment on the first cause of action is denied.

The plaintiff, as assignee of two insureds under policies issued by the defendant, commenced this action to recover no-fault medical payments. The plaintiff moved for summary judgment on the complaint, arguing that the defendant had failed to timely pay or deny the claim of either insured under the relevant no-fault regulations (see 11 NYCRR 65-1.1 et seq.). The defendant thereafter paid the claim of Edward Caruso (the subject of the second cause of action) and made partial payment on the claim of Josh Logan (the subject of the first cause of action). In the order appealed from, the Supreme Court, inter alia, granted that branch of the plaintiff’s motion which was for summary judgment on the first cause of action regarding Logan’s claim. We reverse the order insofar as appealed from.

The plaintiff demonstrated its prima facie entitlement to judgment as a matter of law on the [*2]first cause of action regarding Logan’s claim with evidence that the claim was neither paid nor denied within 30 days of the defendant’s receipt of the prescribed claim forms (see Westchester Med. Ctr. v Progressive Cas. Ins. Co., 51 AD3d 1014 [2008]; Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co., 44 AD3d 750 [2007]; 11 NYCRR 65-3.8 [a] [1], [c]). However, in opposition, the defendant raised a triable issue of fact as to whether it timely and properly denied the claim based on Logan’s alleged intoxication at the time of the accident by issuance of a denial of coverage on that ground within 30 days of the receipt of additional verification it requested concerning the claim (see Westchester Med. Ctr. v Progressive Cas. Ins. Co., 51 AD3d 1014 [2008]; Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co., 44 AD3d 750 [2007]; 11 NYCRR 65-3.5; 11 NYCRR 65-3.8 [e], [g]). Thus, that branch of the plaintiff’s motion which was for summary judgment on the first cause of action should have been denied.

The plaintiff’s remaining contention is without merit. Ritter, J.P., Florio, Miller and Carni, JJ., concur.