Civil Court of the City of New York, Queens County

37719 QCV2007

Attorneys for plaintiff:

Baker, Sanders, Barshay, Grossman, Fass,

Muhlstock & Neuwirth

150 Herricks Road

Mineola, NY 11501

( By: Todd Muhlstock, Esq.)

Attorneys for defendant:

Nicolini, Paradise, Ferretti & Sabella

114 Old Country Road, Ste. 500

Mineola, NY 11501

( By: Mitchell Lustig, Esq.)

William A. Viscovich, J.

Plaintiff health care provider brought the within No-Fault action against defendant insurer to recover for services rendered on August 15, 2002 to the insured, Jose Rodriguez, as assignor, relating to injuries allegedly arising out of a motor vehicle accident involving a vehicle owned and operated by Rodriguez on July 31, 2002. The parties stipulated as to the timely and proper submission by plaintiff to defendant of the underlying NF-3 proof of claim, that said claim is unpaid and as to the assignment of benefits from Rodriguez to plaintiff. Hence, plaintiff’s prima facie case was proven and the plaintiff rested.While acknowledging that there was no timely denial in this matter, defendant asserted the affirmative defense of lack of coverage, premised on its contention that the alleged loss did not arise out of a covered accident. Instead, the defendant premises its defense upon the argument that the accident in question was a [*2]staged, intentional collision. A staged, deliberate collision is not a covered accident under no-fault (see Liberty Mutual Insurance Company -v- Goddard, 29 AD 3rd 698 [ 2nd Dept. 2006]; Eagle Insurance Company -v- Davis, 22 AD 3rd 846 [ 2nd Dept. 2005]; State Farm Mutual Automobile Insurance Company -v- Laguerre, 305 AD 2nd 490 [ 2nd Dept. 2003]). Moreover, the Appellate Division, Second Department has held that the basic issue in such case is whether the loss arose from a deliberate occurrence outside the scope of coverage. (GEICO -v- Shaulskaya, 302 AD 2nd 522 [ 2nd Dept. 2003]; see also Fair Price Medical Supply v. Travelers Indemnity Company, 42 AD3rd 277 [ 2nd Dept. 2007]. As such, defendant would not be bound by the 30 day rule for issuance of denials normally mandated by Insurance Law § 5106(a) and the applicable No-fault regulations (Central General Hospital -v- Chubb Group of Insurance Companies, 90 NY 2nd 195 [1997]).

In support of its affirmative defense, the defendant called as witnesses both the assignor, Jose Rodriguez, and an investigator in its Special Investigations Unit.

The investigator testified that he had only reviewed this file for the first time a few weeks before the trial and, in fact, was not totally prepared to testify. In sum and substance, his investigation consisted of running a prior claim history on Mr. Rodriguez, but he could not recall the amount of dollars that Mr. Rodriguez had allegedly made claims for in the past. In addition, he testified that he himself had not made the final determination as to the possibility of fraud in this matter but instead a “committee” organized by the defendant had determined that it was not a meritorious claim.

Ironically, it was Mr. Rodriguez’s testimony itself that had the potential to prove that the accident in question had been staged. He not only testified as to the accident itself, but also as to both a previous and subsequent accident in which he was involved, occurring respectively on September 18, 2000 and August 5, 2002.

When defense counsel attempted to question Rodriguez as to the specifics of the treatment received from plaintiff provider following the underlying alleged accident of July 31, 2002, plaintiff objected, citing Fair Price, supra, arguing that evidence of non-treatment could not be used to prove a staged accident. This court reserved its decision on the objection and permitted Mr. Rodriguez to answer this line of questioning subject to a later ruling on the issue, which is the primary subject of this decision, along with other commentary.

Through the use of an official Spanish Court Interpreter, Mr. Rodriguez testified as to the accident, how it happened, where it happened and what he did thereafter, including seeking out medical attention. Perhaps because of the difficulties of translation or because of nervousness, the witness often appeared uncertain and confused about, or unable to recall, the exact date and place of his visits to the plaintiff. Mr. Rodriguez was clear about one thing, however- he never saw a nurse or doctor and never received any medical treatment whatsoever. All he could recall was going to a doctor’s office, having the staff fill out some forms based upon an accident report that he had provided to them and then leaving because he did not think the doctor would help him since he had no money. Mr. Rodriguez was adamant that he received no care or treatment and that all he did was go home and take some Advil.

As to the substance of the plaintiff’s objection to Mr. Rodriguez’s testimony regarding a lack of treatment, the court overrules plaintiff’s objection and allows the [*3]testimony as to non-treatment to be used by the defense. The Fair Price decision, according to the plaintiff, stands for the proposition that in a case where the fraud alleged by the defendant insurer pertains to the lack of services billed for (or more specifically in the Fair Price case- the failure to provide medical supplies billed for), such fraud is “not related to the existence of coverage in the first instance” ( 42 AD 3rd, at 284) and, thus, is not an affirmative Chubb defense.

This court, however, has no intention whatsoever of determining if plaintiff is entitled to recover no-fault benefits based on the extent to which the claimed medical services were actually provided. The court agrees with the plaintiff and recognizes that, pursuant to Fair Price, the extent to which the medical services billed for in this action were actually rendered is not the ultimate issue for the court to decide – to make it so would constitute a total disregard for the unequivocal appellate law that controls this issue. Moreover, as both parties have stipulated to plaintiff’s prima facie case, plaintiff has been deemed to have met its burden as to the medical necessity of the services rendered- which burden defendant has elected neither to rebut by way of any requisite timely denial nor by the specific affirmative defense asserted. As such, this court is bound by same, notwithstanding the assignor’s testimony which is extremely credible as to the possibility that the claimed services were never provided.

Unfortunately, the only issue which this court may address under Fair Price is whether there was a lack of coverage as contended by defendant on the basis that the alleged July 31, 2002 accident was ” staged”. Any testimony by Rodriguez regarding his treatment or lack thereof is being used by the court solely as evidence as to whether the loss in question resulted from an actual “covered” accident or arose from a staged collision. Any evidence that Mr. Rodriguez was not treated as claimed by the plaintiff provider or was treated to a lesser extent than claimed, has relevance only to the extent that common sense dictates that it is less likely that the participants in such a “staged” collision would actually receive treatment than in a true accident. It also follows that the alleged victim of a “staged” accident would be less likely to actually accept the risk of real injury arising from an unnecessary course of treatment (Keep in mind that this court does concede that a real injury may arise from a staged accident, but does not believe this to be the case herein).

Given the weakness of the SIU investigator’s testimony, however, the testimony of Mr. Rodriguez as to a lack of treatment alone is not enough for defendant to meet its burden in rebutting plaintiff’s prima facie case. As one court has noted, ” [W]hile some intentional collisions are the products of insurance fraud schemes, others are not. In all such cases, it is the deliberate, non-accidental character of the incident that makes it ineligible for No-Fault coverage.”(V.S. Medical Services, P.C. -v- Allstate Insurance Company,11 Misc 3rd 334, at 338 [ Civil Court, City of New York, Kings Co. 2006]; see, also Universal Open MRI of the Bronx ,P.C. -v- State Farm Mutual Automobile Insurance, 12 Misc 3rd 1151(A) [ Civil Court, City of New York, Kings Co. 2006]). Therefore, defendant’s burden of proof is a preponderance of the credible evidence, which has not been established.

What distresses the court is that while the defendant was not able to meet its burden of proof as to a “staged accident”, there was credible evidence of provider fraud. While a full trial on that issue may reveal that there was no fraud and that services were [*4]in fact rendered. the holding in Fair Price assures that neither the court nor the defendant are able to delve further into that issue. The end result is that this court is put in the potential position of having to make an award to a possibly unethical provider.

This is exactly the concern expressed by Justice Joseph Golia in his dissent in the Appellate Term rendering of Fair Price Medical Supply Corp. a/a/o Nivelo v. Travelers Indemnity Company, 9 Misc 3rd 76 [ App. Term, 2nd & 11th Jud. Dists. 2005], in which the majority decision was upheld by the Appellate Division in the Fair Price decision that controls herein. Like Justice Golia, this court is “under the firm and unshakable belief that neither the Legislature nor the Insurance Department ever intended for an insurance carrier, or anyone else for that matter, to be forced to pay for medical equipment [or in this case, medical treatment] that was never provided “(Fair Price, supra, dissent at 82). But, alas, that is the potential outcome all but acknowledged by both the Appellate Term and Appellate Division Fair Price holdings.

As such, this court, as constrained by higher authority, regretfully awards judgment to the plaintiff in the sum of $ 899.43, plus statutory interest, statutory attorneys fees, costs and disbursements.

The foregoing constitutes the decision and order of this court.

_____March 19, 2008___________________________________DateWilliam A. Viscovich

Judge, Civil Court

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Richard Velasquez, J.), dated December 7, 2006. The order granted that branch of defendant’s motion seeking to dismiss the complaint based on the pendency of a prior action in Queens County Civil Court only to the extent that the court deemed the prior action discontinued, and in effect denied that branch of defendant’s motion seeking the imposition of costs pursuant to part 130 of the Rules of the Chief Administrator (22 NYCRR).

Order modified by striking the provision deeming the prior action in Queens County Civil Court discontinued and by providing that defendant’s motion is granted to the extent of dismissing the complaint; as so modified, affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved to dismiss the complaint based on the pendency of a prior action for the same cause of action (CPLR 3211 [a] [4]). The court granted defendant’s motion only to the extent that the court in essence deemed discontinued the prior action in Queens County Civil Court.

In our view, the court should properly have dismissed the instant complaint. The record demonstrates that both lawsuits are predicated on the same cause of action, and that the prior action had proceeded to discovery. Moreover, as a general matter, deference is accorded to the first action filed (see Reckson Assoc. Realty Corp. v Blasland, Bouck & Lee, 230 AD2d 723 [1996]; Matter of Wallach, 130 AD2d 495, 496 [1987]), and no sufficient reason was shown to depart from this rule here. Accordingly, we modify the order to provide for the dismissal of the instant complaint (see Packes v Cendant Mtge. Corp., 19 AD3d 386 [2005]).

The branch of defendant’s motion seeking costs pursuant to part 130 of the Rules of the Chief Administrator (22 NYCRR) was properly denied as plaintiff’s actions, under the circumstances presented, do not rise to the level warranting the imposition of such costs. [*2]

Pesce, P.J., Weston Patterson and Rios, JJ., concur.
Decision Date: March 13, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Genine D. Edwards, J.), entered August 24, 2006. The order, insofar as appealed from, denied the petition to vacate a master arbitrator’s award.

Order, insofar as appealed from, reversed without costs, awards of the master arbitrator and arbitrator vacated, and matter remitted for a rehearing before a different arbitrator.

R.J. Professional Acupuncturist, P.C. (R.J.) commenced this proceeding pursuant to CPLR 7511 to vacate a master arbitrator’s award which upheld the denial of its claim for assigned first-party no-fault benefits. The insurer opposed the petition, asserting, inter alia, that the arbitrator properly found that R.J. failed to make a prima facie showing of its entitlement to reimbursement since it did not provide documentation to support the bills for the services which it rendered. The insurer also cross-petitioned for confirmation of the master arbitrator’s award. The court denied the petition and the cross petition. This appeal by R.J. ensued.

The standard applicable to judicial review of a compulsory arbitration proceeding is whether the award was “supported by a reasonable hypothesis’ and was not contrary to what could be fairly described as settled law” (Matter of State Farm Mut. Auto. Ins. Co. v Lumbermens Mut. Cas. Co., 18 AD3d 762, 763 [2005], citing Matter of Motor Veh. Acc. Indem. Corp. v Aetna Cas. & Sur. Co., 89 NY2d 214, 224 [1996]; see Matter of Hanover Ins. Co. v State Farm Mut. Auto. Ins. Co., 226 AD2d 533, 534 [1996]; Matter of Adams v Allstate Ins. Co., 210 AD2d 319, 320 [1994]). Applying this standard to the instant proceeding, we find that the master arbitrator’s award and the arbitrator’s award were irrational (see Matter of State Farm [*2]Mut. Auto. Ins. Co., 18 AD3d at 763; Matter of Hanover Ins. Co., 226 AD2d at 534) since they were contrary to settled law.

It is well settled that a provider seeking to recover assigned first-party no-fault benefits makes a prima facie showing by demonstrating that a complete proof of claim setting forth the fact and amount of the loss sustained was submitted to the insurer and payment of no-fault benefits was overdue (see Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]). Notwithstanding the foregoing, the arbitrator held that R.J. failed to make a prima facie showing because it did not submit sufficient additional evidence to substantiate its bills for the services rendered. Consequently, the
court below should have vacated the master arbitrator’s award as well as the arbitrator’s award (see e.g. Matter of Pradip Das/N.Y. Med. Rehab v Allstate Ins. Co., 297 AD2d 321 [2002]; Matter of Nyack Hosp. v Government Empls. Ins. Co., 139 AD2d 515 [1988]). Accordingly, the matter is remitted for a new hearing before a different arbitrator (see Matter of Health & Endurance Med., P.C. v Deerbrook Ins. Co., 44 AD3d 857 [2007]).

Weston Patterson, J.P., and Rios, J., concur.

Golia, J., concurs in a separate memorandum.

Golia, J., concurs in the following memorandum:

I concur for the reasons stated in my concurrence in Metropolitan Radiological Imaging, P.C. v Country-Wide Insurance Company (___ Misc 3d ____, 2008 NY Slip Op _______ [No. 2006-1670 K C], decided herewith).
Decision Date: March 13, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from a judgment of the Civil Court of the City of New York, Kings County (Loren Baily-Schiffman, J.), entered July 31, 2006. The judgment granted the petition to vacate the master arbitrator’s award and awarded petitioner unpaid no-fault benefits in the principal sum of $1,791.73.

Judgment affirmed without costs.

Metropolitan Radiological Imaging, P.C. (Metropolitan) commenced this proceeding pursuant to CPLR 7511 to vacate a master arbitrator’s award which upheld the denial of its claim for assigned first-party no-fault benefits. The insurer opposed the petition, asserting that the master arbitrator’s award was not irrational. The court granted the petition to vacate the master arbitrator’s award, and awarded petitioner the principal sum of $1,791.73. The instant appeal by the insurer ensued.

The standard applicable to judicial review of a compulsory arbitration proceeding is whether the award was “supported by a reasonable hypothesis’ and was not contrary to what could be fairly described as settled law” (Matter of State Farm Mut. Auto. Ins. Co. v Lumbermens Mut. Cas. Co., 18 AD3d 762, 763 [2005], citing Matter of Motor Veh. Acc. Indem. Corp. v Aetna Cas. & Sur. Co., 89 NY2d 214, 224 [1996]; see Matter of Hanover Ins. Co. v State Farm Mut. Auto. Ins. Co., 226 AD2d 533, 534 [1996]; Matter of Adams v Allstate Ins. Co., 210 AD2d 319, 320 [1994]). Applying this standard to the instant proceeding, we find that the master arbitrator’s award was irrational (see Matter of State Farm Mut. Auto. Ins. Co., 18 AD3d at 763; Matter of Hanover Ins. Co., 226 AD2d at 534) since he upheld the arbitrator’s determination which was contrary to settled law (see Mount Sinai Hosp. v Joan Serv. Corp., 22 AD3d 649 [2005]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]). [*2]

It is well settled that a provider seeking to recover assigned first-party no-fault benefits makes a prima facie showing by demonstrating that a complete proof of claim setting forth the fact and amount of the loss sustained was submitted to the insurer and that payment of no-fault benefits was overdue (see Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004], supra). Notwithstanding the foregoing, the arbitrator held that Metropolitan failed to make a prima facie showing because it did not submit sufficient additional evidence to establish the medical necessity of the services rendered. Consequently, the court properly granted the petition and vacated the master arbitrator’s award.

Under the circumstances presented, we affirm the judgment (Matter of Pradip Das/N.Y. Med. Rehab v Allstate Ins. Co., 297 AD2d 321 [2002]; cf. Matter of Health & Endurance Med., P.C. v Deerbrook Ins. Co., 44 AD3d 857 [2007]).
Pesce, P.J., and Weston Patterson, J., concur.

Golia, J., concurs in a separate memorandum.

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

I am constrained to agree with the ultimate disposition in the decision reached by the majority. I, however, wish to note that I do not agree with certain propositions of law relied on by the majority which I find inconsistent with higher court precedents and generally contrary to my views.

Most specifically, I am referring to what appears to be the standard of review which was utilized by the majority in this case. The majority herein applies the more exacting standard applicable to judicial review of “compulsory” arbitration proceedings. It applies this standard without addressing the fact that in this case it is the claimant-provider which is seeking judicial review and not the defendant insurance carrier. The reason that I raise this distinction is that a claimant-provider has the unfettered choice to elect to bring its claim before the court or an arbitrator, whereas a defendant insurance carrier is compelled to submit to an arbitration proceeding if the claimant chooses to prosecute its claim in that forum.

Although I find this distinction, between one party which has a choice and the other which does not, to be vital, I nevertheless raise my concerns by way of a concurrence and not in dissent by reason of the Appellate Division, Second Department’s holding in Matter of Shand (Aetna Ins. Co.) (74 AD2d 442 [1980]), which, I submit, provides the support for the finding of the majority on this issue.

The Appellate Division, in Matter of Shand (Aetna Ins. Co.), held that all no-fault arbitration determinations are to be reviewed as if they were “compulsory arbitration” regardless of whether the review is requested by the insurance carrier, which is compelled to submit to arbitration, or the claimant, which is not compelled to submit to arbitration. The Appellate Division relied upon two cases for the principle that a clamant’s application to review a no-fault arbitrator’s award should be determined by the higher standard of compulsory arbitration even though the claimant had freely elected to have the matter heard by an arbitrator.

The Shand court cites to Matter of Conroy v Country Wide Ins. Co. (75 AD2d 852 [1980]), which was decided in the same court exactly one week earlier and without any specific reference to this issue. It also cites to a Supreme Court, Bronx County case, Matter of Hicks (Royal Globe Ins. Co.) (96 Misc 2d 477 [1978]). In Hicks, it appears that the court may have [*3]been confused regarding the distinction between “binding” arbitration and “compulsory” arbitration. The reason stated by the Hicks court is the belief that “parties to voluntary arbitration waive their due process right to judicial review, while the parties to compulsory arbitration do not” (id. at 478-479). This appears to be a valid expression of the difference between binding and non-binding arbitration and not between voluntary and compulsory arbitration.
The Appellate Division, Second Department, appropriately ruled in Matter of Shand (Aetna Ins. Co.) (74 AD2d at 446):
“When a part of a controversy is compelled by statute to submit to arbitration. . . and thereby loses the right of initial resort to a judicial forum. . . the right to review the resulting arbitration award cannot in turn be overly limited in scope without involving a due process issue” (emphasis added).
Unfortunately, the Shand court also found that “insurers [must] submit to binding arbitration of no-fault claims at the option of the insured. Such compelled submissions are classified as compulsory arbitrations . . . even if (as here), it is the assured who complains after exercising the option to pursue [his right to] arbitration instead of legal action. . .” (Matter of Shand [Aetna Ins. Co.], 74 AD2d at 446 [emphasis added]).

I interpret the Shand court as saying that even a claimant, who has the free election to choose to bring his claim in court or by arbitration, must receive the benefit of the higher standard of review which is accorded to those subjected to compulsory arbitration because he “is compelled by statute to submit to arbitration” (Matter of Shand [Aetna Ins. Co.], 74 AD2d at 446).

I submit this holding, within two consecutive paragraphs, is internally conflicting and does not comport with the holdings of the Court of Appeals.

In Matter of Furstenberg (Aetna Cas. & Sur. Co. – – Allstate Ins. Co.) (49 NY2d 757 [1980]), cited by the Shand court, the Court of Appeals clearly states that since “Aetna Casualty & Security Co. was obliged under the statute to accept the arbitral forum for the resolution of the claim against it, we agree that the standard for judicial review of the award is more exacting than in voluntary arbitration” (Matter of Furstenberg [Aetna Cas. & Sur. Co. – – Allstate Ins. Co.], 49 NY2d at 758 [emphasis added and citations omitted]). Indeed, this statement merely amplifies the standard presented by the Appellate Division, First Department, which opined (in the same case) that “[a]t least as to the insurance company, arbitration under the no-fault insurance law
is compulsory and not voluntary” (Matter of Furstenberg [Aetna Cas. & Sur. Co.], 67 AD2d 580, 583 [1979], revd 49 NY2d 757 [1980]).

I would only hope that the Appellate Division, if again confronted with this anomaly, would re-examine this issue and find that a claimant which voluntarily and freely elects to have its no-fault claim brought before an arbitrator is not deemed to be one which was subjected to compulsory arbitration.
Decision Date: March 13, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Bernard J. Graham, J.), entered October 17, 2006. The order, insofar as appealed from as limited by the brief, denied defendant’s motion for summary judgment.

Appeal dismissed.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground that the action was premature as defendant’s time to pay or deny the claim was tolled due to plaintiff’s failure to adequately respond to timely verification and follow-up verification requests. Plaintiff cross-moved for summary judgment. The court denied defendant’s motion and plaintiff’s cross motion. The instant appeal by defendant ensued.

Upon oral argument of this appeal on February 13, 2007, this court was informed that, by order dated July 31, 2007, the court below had granted a motion by defendant to reargue, and, upon reargument, had granted defendant’s motion for summary judgment dismissing the complaint. In light of the order dated July 31, 2007, the instant appeal has been rendered moot. Accordingly, the appeal is dismissed.

This court reminds the parties’ counsel and the bar in general of the affirmative obligation to immediately notify an appellate court when an underlying action has been settled or the appeal otherwise rendered moot (cf. Rules of App Div, 2d Dept [22 NYCRR] § 670.2 [g]).

Weston Patterson, J.P., Golia and Rios, JJ. [*2]
Decision Date: March 12, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Kathy J. King, J.), entered November 3, 2006. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Order affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff’s motion for summary judgment was supported by an affirmation from plaintiff’s counsel, an affidavit by an officer of plaintiff, and various documents annexed thereto. The affidavit executed by plaintiff’s corporate officer stated in a conclusory manner that
the documents attached to plaintiff’s motion papers were plaintiff’s business records. Defendant cross-moved for summary judgment on the ground of lack of medical necessity. The court below denied plaintiff’s motion and granted defendant’s cross motion, finding that defendant established its defense of lack of medical necessity. This appeal by plaintiff ensued.

Since the affidavit submitted by plaintiff’s officer was insufficient to establish that said officer possessed personal knowledge of plaintiff’s practices and procedures so as to lay a foundation for the admission, as business records, of the documents annexed to plaintiff’s moving papers, plaintiff failed to make a prima facie showing of its entitlement to summary judgment (Dan Med., P.C. v New York Cent. Mut. Fire Ins. Co., 14 Misc 3d 44 [App Term, 2d & 11th Jud Dists 2006]). Consequently, plaintiff’s motion for summary judgment was properly denied.

There is no merit to plaintiff’s argument that defendant’s cross motion should have been denied because its NF-10 denial forms, which were based upon peer review reports, did not assert sufficient facts and a medical rationale based thereon to set forth the reason for the denials (see A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779 [2007]). Further, the sworn [*2]papers submitted in support of defendant’s cross motion, including detailed peer review reports, established prima facie that there was no medical necessity for the MRIs performed by plaintiff, which evidence was unrebutted. As a result, the court properly granted defendant’s cross motion for summary judgment (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 Patterson and Rios, JJ., concur.
Decision Date: March 12, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Genine D. Edwards, J.), entered August 24, 2006. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Order affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary
judgment dismissing the complaint. The court denied plaintiff’s motion for summary judgment and granted defendant’s cross motion, holding that defendant established a lack of medical necessity and that defendant’s denial of claim form interposing said defense was timely. The instant appeal by plaintiff ensued.

Since defendant raised no issue in the court below or on appeal with respect to plaintiff’s establishment of its prima facie case, we do not pass on the propriety of the implicit determination of the court below with respect thereto.

Turning to the merits of defendant’s cross motion for summary judgment, defendant established that it timely denied plaintiff’s claim on the ground that the supplies provided were not medically necessary based on an affirmed peer review report. Since the peer review report submitted by defendant in support of its cross motion established prima facie that the supplies provided by plaintiff were not medically necessary and plaintiff did not present any evidence refuting defendant’s prima facie showing, the court below properly granted defendant’s cross motion for summary
judgment dismissing the complaint (see 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 [*2]NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

Pesce, P.J., Weston Patterson and Rios, JJ., concur.
Decision Date: March 12, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

Appeal from an order of the District Court of Suffolk County, Third District (C. Steven Hackeling, J.), dated September 15, 2006. The order denied defendant’s motion for partial summary judgment dismissing the first, second, fifth, sixth, seventh, eighth, ninth, tenth, eleventh and twelfth causes of action asserted in the complaint.

Order reversed without costs and defendant’s motion for partial summary judgment dismissing the first, second, fifth, sixth, seventh, eighth, ninth, tenth, eleventh and twelfth causes of action asserted in the complaint granted.

In this action by providers to recover assigned first-party no-fault benefits, defendant moved for partial summary judgment dismissing the first, second, fifth, sixth, seventh, eighth, ninth, tenth, eleventh and twelfth causes of action asserted in the complaint on the ground that the claims giving rise to said causes of action were submitted to defendant beyond the 45-day deadline set forth in the automobile insurance policy’s Mandatory Personal Injury Protection Endorsement (Endorsement). The sole basis upon which plaintiff opposed defendant’s motion was that defendant did not establish that the 45-day deadline was contained in the Endorsement [*2]which was part of the applicable automobile insurance policy. The court denied defendant’s motion, holding that defendant failed to prove that plaintiff’s claims were subject to the 45-day deadline. This appeal by defendant ensued.

The Endorsement, which was required to be included in automobile insurance policies issued or renewed after April 5, 2002, reduced the time within which claims were to be submitted to insurers after the date services were rendered from 180 days to 45 days (Insurance Department Regulations [11 NYCRR] § 65.12 [e], now Insurance Department Regulations [11 NYCRR] § 65-1.1 [b]; see S & M Supply v State Farm Mut. Auto. Ins. Co., 4 Misc 3d 130[A], 2004 NY Slip Op 50693[U] [App Term, 9th & 10th Jud Dists 2004]). Pursuant to Insurance Law § 3425 (a) (8), the policy period for newly issued and renewed automobile insurance policies is one year (see also Rosner v Metropolitan Prop. & Liab. Ins. Co., 96 NY2d 475 [2001]). In the instant case, the plaintiffs’ assignor was allegedly injured in an automobile accident on November 12, 2004 and defendant received plaintiff’s claims for the services at issue more than 45 days after the services were rendered. Since an automobile insurance policy which contained the prior version of the Endorsement would have expired no later than in April 2003 (see Insurance Law § 3425 [8]), the automobile insurance policy applicable to the claims at issue in the instant case was required to contain the current Endorsement which sets forth the 45-day time limit for the submission of claims (Insurance Department Regulations [11 NYCRR] § 65-1.1 [b]; see S & M Supply v State Farm Mut. Auto. Ins. Co., 4 Misc 3d 130[A], 2004 NY Slip Op 50693[U] [App Term, 9th & 10th Jud Dists 2004], supra) and defendant need not prove that the instant automobile insurance policy contained such Endorsement.

In view of the foregoing, defendant’s motion for partial summary judgment dismissing the first, second, fifth, sixth, seventh, eighth, ninth, tenth, eleventh and twelfth causes of action asserted in the complaint should have been granted since it was undisputed that defendant’s timely denial of claim forms denied the subject claims based upon plaintiff’s failure to submit said claims within 45 days after the date the services were rendered and the record reveals that plaintiffs failed to proffer admissible evidence demonstrating that there was a “reasonable justification” for the untimely submission of the claims (St. Vincent’s Hosp. & Med. Ctr. v Country Wide Ins. Co., 24 AD3d 748 [2005]; Nir v MVAIC, 17 Misc 3d 134[A], 2007 NY Slip Op 52124[U] [App Term, 2d & 11th Jud Dists 2007]; NY Arthroscopy & Sports Medicine PLLC v Motor Veh. Acc. Indem. Corp., 15 Misc 3d 89 [App Term, 1st Dept 2007]).

McCabe, J.P., Tanenbaum and Molia, JJ., concur.
Decision Date: March 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Bernard J. Graham, J.), entered January 16, 2007. The order denied plaintiff’s motion for summary judgment.

Order affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, the court denied plaintiff’s motion for summary judgment finding that defendant raised an issue of fact by demonstrating that its time to pay or deny plaintiff’s claim was tolled due to timely verification requests. The instant appeal by plaintiff ensued.

On appeal, defendant asserts that the affidavit by plaintiff’s corporate officer, submitted in support of plaintiff’s motion, failed to lay a proper foundation for the documents annexed to plaintiff’s moving papers and that, as a result, plaintiff failed to establish a prima facie case. We agree. The affidavit submitted by plaintiff’s corporate officer was insufficient to establish that said officer possessed personal knowledge of plaintiff’s practices and procedures so as to lay a foundation for the admission, as business records, of the documents annexed to plaintiff’s moving papers. Accordingly, plaintiff failed to make a prima facie showing of its entitlement to summary judgment (see Bath Med. Supply Inc. v Deerbrook Ins. Co., 14 Misc 3d 135[A], 2007 NY Slip Op 50179[U] [App Term, 2d & 11th Jud Dists 2007]; Dan Med., P.C. v New York Cent. Mut. Fire Ins. Co., 14 Misc 3d 44 [App Term, 2d & 11th Jud Dists 2006]). Consequently, the order denying plaintiff’s motion for summary judgment is affirmed, albeit on other grounds.

Weston Patterson, J.P., Golia and Rios, JJ., concur.

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Queens County (Joseph Esposito, J.), entered May 8, 2006. The order granted plaintiff’s motion for summary judgment.

Order reversed without costs and plaintiff’s motion for summary judgment denied.

In this action by a provider to recover first-party no-fault benefits, plaintiff moved for summary judgment. The court below granted the motion, and this appeal by defendant ensued.

On appeal, defendant asserts that the affidavit of plaintiff’s corporate officer, submitted in support of the motion, failed to lay a proper foundation for the admission of the documents annexed to plaintiff’s moving papers and that, as a result, plaintiff failed to establish a prima facie case. We agree. The affidavit submitted by plaintiff’s corporate officer was insufficient to establish that said officer possessed personal knowledge of plaintiff’s practices and procedures so as to lay a foundation for the admission, as business records, of the documents annexed to plaintiff’s moving papers. Accordingly, plaintiff failed to make a prima facie showing of its entitlement to summary judgment (see Bath Med. Supply, Inc. v Deerbrook Ins. Co., 14 Misc 3d 135[A], 2007 NY Slip Op 50179[U] [App Term, 2d & 11th Jud Dists 2007]; Dan Med., P.C. v New York Cent. Mut. Fire Ins. Co., 14 Misc 3d 44 [App Term, 2d & 11th Jud Dists 2006]). Accordingly, the order is reversed and plaintiff’s motion for summary judgment denied.

Pesce, P.J., Weston Patterson and Rios, JJ., concur.
Decision Date: March 10, 2008