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 (Lila Gold, J.), entered November 7, 2005. The order denied plaintiff’s motion for summary judgment.

Order affirmed without costs.

“The proponent of a summary judgment motion must make a prima facie showing of entitlement to judgment as a matter of law, tendering sufficient evidence to eliminate any material issues of fact from the case (see, Zuckerman v City of New York,
49 NY2d 557, 562; Sillman v Twentieth Century-Fox Film Corp., 3 NY2d 395, 404). Failure to make such showing requires denial of the motion, regardless of the sufficiency of the opposing papers” (Winegrad v New York Univ. Med. Center, 64 NY2d 851, 853 [1985]; see also Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).

In this action to recover assigned, first-party no-fault benefits, plaintiff’s moving papers did not establish that plaintiff ever submitted the subject claim form to defendant (see New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2006]). To the extent plaintiff’s counsel submitted a reply affirmation in which counsel attempted to introduce a purported verification request allegedly sent by defendant to plaintiff in an attempt to demonstrate, for the first time, a critical element of plaintiff’s prima facie case, such evidence was neither in admissible form nor properly before the court (see Canter v East Nassau Med. Group, 270 AD2d 381 [2000]; Fischer v Edward M. Weiland M.D.,
P.C., 241 AD2d 439 [1997]; Ritt v Lenox Hill Hosp., 182 AD2d 560 [1992]). As a result,plaintiff’s motion for summary judgment was properly denied. [*2]

Pesce, P.J., Golia and Belen, 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, Kings County (Eileen Nadelson, J.), entered September 9, 2005. The order denied plaintiff’s motion for summary judgment.

Order affirmed without costs.

In this action to recover assigned first-party no-fault benefits, plaintiff failed to establish a prima facie entitlement to summary judgment since it did not adequately establish that it submitted its claim forms to defendant (see A.B. Med. Servs. v State
Farm Mut. Auto. Ins. Co., 3 Misc 3d 130[A], 2004 NY Slip Op 50387[U] [App Term, 2d & 11th Jud Dists]). A plaintiff ordinarily establishes the “submission” of the claim forms by demonstrating proof of proper mailing, which gives rise to the presumption that the claim forms were received by the addressee. The presumption may be created either by proof of actual mailing, or by proof of a standard office practice or procedure designed to ensure that items are properly addressed and mailed (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]). Here, the affidavit of plaintiff’s corporate officer was insufficient to establish that plaintiff mailed the claims to defendant (see New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2006]). Moreover, plaintiff’s attorney’s affirmation was not based on personal knowledge that the claims were actually mailed to defendants and, as such, has no probative value (see e.g. Melbourne Med., P.C. v Utica Mut. Ins. Co., 4 Misc 3d 92 [App Term, 2d & 11th [*2]Jud Dists 2004]). Furthermore, plaintiff’s attempt to demonstrate defendant’s receipt of the claims in question by attaching to its moving papers two delay letters from defendant is unavailing since said letters did not specifically refer to the claims at issue in that they did not set forth the amounts of the claims. Accordingly, since plaintiff failed
to establish its prima facie entitlement to summary judgment, the lower court properly denied its motion.

Pesce, P.J., Weston Patterson and Belen, JJ., concur.
Decision Date: December 12, 2006

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 (Bernice Daun Siegal, J.), entered September 30, 2005. The order denied plaintiff’s motion for partial summary judgment.

Order affirmed without costs.

In this action to recover first-party no-fault benefits for medical services rendered to its assignor, plaintiff moved for summary judgment. Three of plaintiff’s five claim forms indicate that the treating health care providers were independent contractors. 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 health care 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 insurer (see Boai Zhong Yi Acupuncture Servs. P.C. v Allstate Ins. Co., 12 Misc 3d 137[A], 2006 NY Slip Op 51288[U] [App Term, 2d & 11th Jud Dists]; Rockaway Blvd. Med. P.C. v Progressive Ins., 9 Misc 3d 52 [App Term, 2d & 11th Jud Dists 2005]). The [*2]remaining two claim forms have “N/A” typed in the box in which the business relationship of the treating provider was to be provided. Such lack of specificity does not establish plaintiff’s prima facie entitlement to summary judgment as a matter of law inasmuch as it fails to exclude all triable issues of fact. Accordingly, plaintiff’s motion for partial summary judgment was properly denied.

We pass on no other issue.

Pesce, P.J., and Belen, J., concur.

Golia, J., concurs in a separate memorandum.
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS
PRESENT: PESCE, P.J., GOLIA and BELEN, JJ.
V.S. MEDICAL SERVICES, P.C.
A/A/O MIRIAM MALDONADO,
Appellant,

-against-

NEW YORK CENTRAL MUTUAL FIRE INSURANCE CO.,
Respondent.

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 emphasize that I am constrained to agree with certain propositions of law set forth in cases cited therein which are inconsistent with my prior expressed positions and generally contrary to my views.
Decision Date: December 11, 2006

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 (Peter Paul Sweeney, J.), entered January 31, 2005. The order denied the petition to vacate the master arbitrator’s award.

Order modified by adding thereto a provision confirming the master arbitrator’s award; as so modified, affirmed without costs.

Avenue N Medical, PC (Avenue) initiated this compulsory arbitration proceeding against New York Central Mutual Fire Insurance Company to recover $2,167.07 in first-party no-fault benefits for medical services rendered to its assignor for injuries he
sustained in an automobile accident. Following an arbitration hearing, by award dated February 18, 2004, the arbitrator denied Avenue’s claim, which decision Avenue appealed to the master arbitrator. By award dated August 13, 2004, the master arbitrator affirmed the arbitrator’s award. Avenue then commenced the instant special proceeding to vacate the award of the master arbitrator. By order entered January 31, 2005, the court below denied the petition.

Upon a review of the record, we find a rational basis for the determination of the master arbitrator (see e.g. Matter of Smith [Firemen’s Ins. Co.], 55 NY2d 224 [1982]; Matter of Petrofsky [Allstate Ins. Co.], 54 NY2d 207 [1981]; Matter of Shand [Aetna Ins. Co.], 74 AD2d [*2]442 [1980]). Consequently, the court below properly denied the petition to vacate the master arbitrator’s award. However, upon denying the petition, the court was required, pursuant to CPLR 7511 (e), to confirm the award (see Matter of Exclusive Med. & Diagnostic v Government Empls. Ins. Co., 306 AD2d 476 [2003]).

We note that a special proceeding should terminate in a judgment, not an order (see CPLR 411).

Pesce, P.J., Weston Patterson and Belen, JJ., concur.
Decision Date: December 11, 2006

[*1]

Supreme Court, Appellate Term, Second Department, December 11, 2006

APPEARANCES OF COUNSEL

Alden Banniettis, Brooklyn (Jeff Henle of counsel), for appellant. Romagnolo & Cambio, LLP, Staten Island (Michael Gullo of counsel), for respondent.

{**14 Misc 3d at 95} OPINION OF THE COURT

Memorandum.

Order modified by providing that plaintiff’s motion for summary judgment is granted to the extent of awarding it partial summary judgment in the principal sum of $357.94, and matter remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees thereon, and for all further proceedings on plaintiff’s remaining claims; as so modified, affirmed without costs.

In this action to recover first-party no-fault benefits for health care services rendered to its assignor, plaintiff established its prima facie entitlement to summary judgment by proof that it submitted claims, setting forth the fact and the amounts of the losses 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]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists 2003]). Defendant’s failure to timely object to the completeness of the claim forms or seek verification of the assignments constituted a waiver of any defenses based thereon (see Hospital for Joint Diseases v Allstate Ins. Co., 21 [*2]AD3d 348 [2005]; see also New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co., 8 AD3d 640 [2004]; A.B. Med. Servs. PLLC v Nationwide Mut. Ins. Co., 6 Misc 3d 70 [App Term, 2d & 11th Jud Dists 2004]). Defendant’s remaining contentions regarding plaintiff’s alleged failure to establish its prima facie entitlement to summary judgment similarly have no merit. The burden then shifted to defendant to demonstrate a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).{**14 Misc 3d at 96}

A review of the record indicates that defendant made verification requests of the assignor seeking chiropractic and orthopedic independent medical examinations (IMEs) by letters dated May 22 and 23, 2002, which was prior to its receipt of plaintiff’s $357.94 claim on May 30, 2002. Consequently, these were preclaim verification requests and the tolling provisions of the insurance regulations do not apply (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 18 [App Term, 2d & 11th Jud Dists 2004]). As a result, defendant’s July 11, 2002 denial of said claim was untimely (see e.g. A.B. Med. Servs. PLLC v Utica Mut. Ins. Co., 10 Misc 3d 50 [App Term, 2d & 11th Jud Dists 2005]). Defendant, however, timely denied, on the basis of the assignor’s failure to attend the preclaim IMEs, the $101.07 claim which it received on June 19, 2002 and denied on July 9, 2002, the $67.38 claim which it received on July 1, 2002 and denied on July 9, 2002, and the $67.38 claim which it received on August 5, 2002 and denied on August 30, 2002 (see e.g. A.B. Med. Servs. PLLC v American Tr. Ins. Co., 8 Misc 3d 139[A], 2005 NY Slip Op 51316[U] [App Term, 2d & 11th Jud Dists 2005]), and established such failure in admissible form in opposition to plaintiff’s motion for summary judgment. Consequently, the presumption of medical necessity which otherwise attached to these claim forms was rebutted and defendant raised a triable issue of fact as to the medical necessity of the services rendered (see e.g. S&M Supply Inc. v Peerless Ins. Co., 6 Misc 3d 127[A], 2004 NY Slip Op 51683[U] [App Term, 2d & 11th Jud Dists 2004]).

We are aware that defendant’s agent sent a letter to plaintiff dated June 5, 2002 in which it stated that it had “received your [$357.94] bill . . . [and] [t]here will be a delay in our consideration of the bills . . . because . . . the claimant involved is currently scheduled for independent medical examinations.” The agent also sent letters to the assignor dated June 11 and 14, 2002 by which it, respectively, reminded the assignor of the chiropractic IME scheduled for June 18, 2002 and the orthopedic IME scheduled for June 24, 2002. The assignor was apparently unable to attend the orthopedic IME scheduled for June 24, 2002, and contacted defendant’s agent. By letter dated June 18, 2002, defendant’s agent acknowledged the assignor’s request to reschedule the orthopedic IME due to his work schedule, and rescheduled said IME to July 2, 2002. By another letter dated June 18, 2002, defendant’s agent acknowledged defendant’s{**14 Misc 3d at 97} request to reschedule the chiropractic IME and rescheduled said IME to July 1, 2002. It is uncontroverted that the assignor did not attend the rescheduled IMEs.

Even were we to deem the letter of June 5, 2002 to be a valid postclaim request for additional verification pursuant to 11 NYCRR 65-3.5 (b), said request would not have tolled the time which defendant had to pay or deny the claims since defendant did not make follow-up verification requests pursuant to 11 NYCRR 65-3.6 (b) after the assignor failed to attend the July [*3]IMEs. We note that although the assignor apparently contacted defendant’s agent on July 5, 2002 “to advise that he was unable to attend the [previously scheduled] appointment[s],” he was not allowed to reschedule them again. Defendant subsequently issued denials, dated July 9, 2002, based on the assignor’s failure to attend the July IMEs.

Furthermore, unlike our dissenting colleague, we do not view the mutually agreed upon rescheduling of the initial IMEs, from June 18, 2002 to July 1, 2002 and from June 24, 2002 to July 2, 2002, as the equivalent of a failure to supply “any requested verification[]” (see 11 NYCRR 65-3.6 [b]). We, therefore, do not deem the rescheduled July IMEs as follow-up requests.

In the court below, plaintiff’s opposition to defendant’s cross motion to compel depositions was only on procedural grounds. Therefore, plaintiff’s contention that defendant’s cross motion should be denied on the merits because it was not entitled thereto was improperly raised for the first time on appeal, and will not be considered by this court (see e.g. First Nationwide Bank v Goodman, 272 AD2d 433 [2000]). Plaintiff’s remaining contentions have no merit.

Accordingly, plaintiff is awarded partial summary judgment in the principal sum of $357.94, and the matter is remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees thereon pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder, and for all further proceedings on plaintiff’s remaining claims.

Golia, J. (concurring in part and dissenting in part): I concur with the findings of my colleagues to the extent that they find defendant timely denied plaintiff’s $67.38, $101.07 and $67.38 claims. I also agree that defendant’s proof as to mailing of the various notices was sufficient. However, I disagree with and dissent from their finding that defendant’s denial of the $357.94 claim, which it received on May 30, 2002 and denied on July 11, 2002, was untimely.{**14 Misc 3d at 98}

An examination of the record in this case will reveal that this defendant did everything conceivable to meet and exceed the requirements and the spirit of the no-fault regulations.

Defendant, in accordance with the regulations, sent a notice for an independent medical examination (IME) to the eligible injured person on May 22, 2002 directing that he appear for IMEs on June 18, 2002 and June 24, 2002. This notice was sent prior to plaintiff’s filing this claim, which is permissible pursuant to the regulations (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 18 [App Term, 2d & 11th Jud Dists 2004]).

It is necessary to briefly examine the importance which the majority places on the fact that the initial notice for an IME was sent prior to the claim being filed. The majority in Fogel created, what I consider, a “forced” and unnecessarily complex interpretation of a very simple regulation. 11 NYCRR 65-1.1 states: “The eligible injured person shall submit to medical examination . . . when, and as often as, the Company may reasonably require” (emphasis added).

Nevertheless, Fogel created a bright-line distinction between an IME request that was sent before a claim was filed (preclaim) and one that was requested after the claim was filed (postclaim). Having invented this dichotomy, the Fogel majority held that if the assignor failed to appear at a preclaim IME, then such failure established, in itself, an issue of fact as to medical necessity. It further held that if the assignor failed to appear at a postclaim IME and the defendant had followed the protocols set forth in the regulations, then summary judgment would be granted to the defendant.

In the Fogel case, I dissented and found that the regulations do not establish such a distinction. In fact it is interesting to note that the Appellate Term of the First Department in Inwood Hill Med., P.C. v General Assur. Co. (10 Misc 3d 18, 20 [2005]) acknowledged and cited the Fogel decision but found that “we decline to follow the majority’s holding and find more persuasive the conclusion reached by . . . [the] dissent.”

Notwithstanding my belief that there should not be any distinction between preclaim and postclaim requests for an IME, I nevertheless find here that defendant has properly and timely met the requirements of the regulations, even as defined by the majority in Fogel. As is tacitly addressed in the majority’s decision, defendant’s “delay letter” of June 5, 2002 should serve as{**14 Misc 3d at 99} a postclaim verification request inasmuch as it contains all the elements required.

Plaintiff’s assignor did not appear for those “first” scheduled dates. Defendant, at assignor’s request, rescheduled the IMEs for July 1 and July 2, 2002 and then sent letters reminding the assignor of the mutually agreeable dates of the second appointments for IMEs. [*4]The assignor, nevertheless, failed to appear on either July 1st or July 2nd and defendant thereupon sent a timely denial (NF-10). I note that the assignor contacted defendant immediately prior to the first scheduled IME and requested rescheduling. There was no such request for a rescheduling of the July appearances; the assignor simply failed to appear. It was only after the assignor failed to appear on July 1st and then failed to appear on July 2nd that he contacted the defendant on July 5th to discuss rescheduling.

Consequently, even if one were to discount the June 18th and June 24th IME appointments, it would be absurd to require defendant to serve a second set of notices for IMEs when the original dates were previously rescheduled at the assignor’s request and upon which he intentionally failed to appear and failed to notify the defendant that he would be unable to appear.

If one were to follow the reasoning of the majority, then defendant would have been well served to ignore the assignor’s request for rescheduling of the June dates. Thereafter, upon the assignor’s failure to appear, the defendant would then send a “follow-up” request setting a date of defendant’s choosing and thereby inconvenience the assignor, and upon the assignor’s failure to appear, defendant could then “legitimately” issue an NF-10 denial of claim.

In the matter before us, defendant sent its request for an IME on May 22, 2002. Plaintiff, on May 28, 2002, filed this disputed claim for $357.94. On June 11, 2002 and on June 14, 2002, both dates well within the 30-day claim period, defendant sent “reminder” letters to the eligible injured person (assignor) which noticed him for examinations on June 18, 2002 and June 24, 2002. On June 17, 2002 defendant received requests to adjourn both June IMEs and rescheduled them to the mutually agreed upon dates of July 1 and 2, 2002. (See affidavit of Jeffrey Mehl, Executive Director HVMC, exhibit H, ¶ 5 of defendant’s cross motion.)

In addition, on June 5, 2002, defendant sent a “delay letter” to plaintiff (assignor) which stated specifically that the{**14 Misc 3d at 100} claim was being delayed due to a pending demand for an IME of plaintiff’s assignor. Certainly this postclaim “delay letter” must serve as a functional equivalent of an additional verification request pursuant to the regulations inasmuch as it specifically informed the plaintiff of what was required in order to complete the claim filed. In fact, the majority of the court then sitting in Ocean Diagnostic Imaging P.C. v Citiwide Auto Leasing Inc. (8 Misc 3d 138[A], 2005 NY Slip Op 51314[U] [App Term, 2d & 11th Jud Dists 2005]) held that a verification request will not serve to toll the 30-day period if it merely informs that the claim is delayed but fails to specify the particular information sought. Since this notice informs the plaintiff, with specificity, of the information sought, it is a functional equivalent and therefore qualifies as an additional verification request which in turn tolls the 30-day period. To me, that is substance over form.

I note that plaintiff’s attorney’s affirmation states at page 5 that “there are no notices . . . calling for any verification or cooperation whatsoever.” He claims that the assignor has no obligation to open any mail from an unknown source and since the notice did not come from the insurance company, it has no significance. How counsel can speak for the assignor who is not his client and without an affidavit in support of his assertions is beyond me. Clearly it has no significance and should be discounted.

Despite defendant’s well demonstrated willingness to accommodate the assignor, that individual willfully failed to appear either on July 1 or July 2, 2002. Nor did he request an [*5]adjournment prior to July 1, 2002. The fact that he requested yet another opportunity to appear for these IMEs was clearly a red herring used to give the assignor additional time to build up his no-fault claim and cost the defendant additional funds for “no-show” medical appointments.

There must be an end. The assignor’s failure to appear at either of the two appointments that he scheduled certainly constitutes a reasonable end.

Here, defendant used every reasonable means to assure compliance with the regulations and to give proper notice to plaintiff and its assignor. Indeed, it was only after the assignor failed to appear on the adjourned dates, the second of which was requested by the assignor himself, that the defendant sent an NF-10 denial of claim.

Clearly, in light of those delay letters and reminder notes sent by the defendant, the NF-10 denial of claim form sent on July{**14 Misc 3d at 101} 11, 2002 was timely and I would affirm the order of the court below.

Pesce, P.J., and Rios, J., concur; Golia, J., concurs in part and dissents in part in a separate memorandum.

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 (George J. Silver, J.), entered August 31, 2005. The order denied plaintiff’s motion for summary judgment.

Order affirmed without costs.

In an action to recover assigned first-party no-fault benefits, a plaintiff provider establishes a prima facie case by presenting proof that it submitted statutory claim forms, setting forth the fact and the amounts of the losses sustained, and that payment of no-fault benefits is overdue (Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; see also Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). In the
instant case, the affidavit executed by plaintiff’s corporate officer failed to establish submission of the claim form. Plaintiff’s assertion that defendant’s letter, annexed to the moving papers, acknowledging receipt of a claim constitutes an admission that the subject claim form was received, is without merit. Inasmuch as the letter does not set forth the amount sought by the claim form which defendant received, plaintiff did not establish its prima facie entitlement to summary judgment since it did not adequately establish that it submitted the subject claim form to defendant (see A.B. Med. Servs. v State Farm Mut. Auto. Ins. Co., 3 Misc 3d 130[A], 2004 NY Slip Op 50387[U] [App Term, 2d & 11th Jud Dists]). Accordingly, the burden never shifted to defendant (see Alvarez v Prospect Hosp., 68 NY2d 320 [1986]; Winegrad v New York Univ. Med. Center, 64 NY2d 851 [1985]; Liquore v Tri-Arc Mfg. Co., 32 AD3d 905 [2006]). [*2]

Weston Patterson, J.P., 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 emphasize that I am constrained to agree with certain propositions of law set forth in cases cited therein which are inconsistent with my prior expressed positions and generally contrary to my views.
Decision Date: December 8, 2006

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 (Gerald Dunbar, J.), entered May 2, 2005. The order, insofar as appealed from as limited by plaintiff’s brief, denied plaintiff’s cross motion for summary judgment.

Order, insofar as appealed from, affirmed without costs.

In an action to recover first-party no-fault benefits for medical services rendered to its assignor, a plaintiff generally establishes its prima facie entitlement to summary judgment by proof of the submission of a statutory claim form, setting forth the fact and
the amount of the loss sustained, and that payment of no-fault benefits is overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). Herein, plaintiff established submission of its claim by annexing defendant’s denial of claim form, dated July 25, 2003, to its moving papers which states that defendant received said claim on June 30, 2003 (see e.g. Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co., 11 Misc 3d 136[A], 2006 NY Slip Op 50491[U] [App Term, 2d & 11th Jud Dists]). Plaintiff asserts that defendant’s denial of claim form was insufficient in that it did not explicitly set forth the reason for the denial.

Defendant denied plaintiff’s claim on the basis of a peer review finding a lack of medical [*2]necessity. Upon a review of the denial and affirmed peer review report annexed to defendant’s opposition papers, we find that defendant “fully and explicitly” set forth the reasons for the denial (see e.g. Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co., 11 Misc 3d 136[A], 2006 NY Slip Op 50491[U], supra; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U], supra). Plaintiff’s remaining contentions regarding the denial lack merit.

Accordingly, we find that defendant raised a triable issue of fact and that the court below properly denied plaintiff’s cross motion for summary judgment.

Pesce, P.J., and Belen, J., concur.

Golia, J., concurs in a separate memorandum.

SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS
PRESENT : PESCE, P.J., GOLIA and BELEN, JJ.
DELTA DIAGNOSTIC RADIOLOGY, P.C.
A/A/O AURELIO RONDON,
Appellant,

-against-

STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY,
Respondent. [*3]

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 emphasize that I am constrained to agree with certain propositions of law set forth in cases cited therein which are inconsistent with my prior expressed positions and generally contrary to my views.
Decision Date: December 8, 2006

[*1]

Supreme Court, Appellate Term, Second Department, December 8, 2006

APPEARANCES OF COUNSEL

Rivkin Radler LLP, Uniondale (Evan H. Krinick, Cheryl F. Korman, Stuart M. Bodoff and Melissa M. Murphy of counsel), for appellant. Alden Banniettis, Brooklyn (Jeff Henle of counsel), for respondent.

{**14 Misc 3d at 75} OPINION OF THE COURT

Memorandum.

Order, insofar as appealed from, affirmed without costs.

In an action to recover first-party no-fault benefits for health care services provided to an assignor, a plaintiff establishes a prima facie entitlement to summary judgment by proof that it submitted a claim, setting forth the fact and amount of the loss sustained and that payment of no-fault benefits is overdue (Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists 2003]). While in its motion papers, plaintiff proved that it prepared a claim setting forth the fact and amount of the loss, plaintiff’s proof that it submitted the claim to defendant was inadequate. We have held that a no-fault benefits applicant may cure deficiencies in its proof of mailing by annexing to its motion papers an insurer’s denial of claim form wherein the insurer acknowledges the claim’s receipt (e.g. Fair Price Med. Supply Corp. v ELRAC Inc., 12 Misc 3d 119 [App Term, 2d & 11th Jud Dists 2006]). Where, as here, plaintiff failed to annex the defendant’s denial of claim form to its motion papers, and the defendant annexes the denial of claim form to its opposing papers, the deficiency is similarly cured.

We are aware of the well-established principle that the failure of a proponent of a motion for summary judgment to make a prima facie showing of entitlement to judgment as a matter of [*2]law requires denial of the motion regardless of the sufficiency of the opposing papers (Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]). Moreover, it has been said that where a movant fails to demonstrate its entitlement to judgment as a matter of law, it is unnecessary for the court to even consider{**14 Misc 3d at 76} the sufficiency of the opposition papers (see New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2006]). While opposition papers should not be reviewed for the sufficiency of the opposition, i.e., in order to determine whether a triable issue of fact has been raised, since in such cases the burden of proof will not have shifted to the party opposing the motion (see Alvarez v Prospect Hosp., 68 NY2d 320 [1986]), this is not to say that where a movant fails to establish a prima facie case, the court may never review the opposition papers. Where the missing elements of a movant’s prima facie showing of entitlement to judgment as a matter of law (such as here, plaintiff’s submission of the claim forms) are supplied in the opposition papers, it is our opinion that the court may, in its discretion and pursuant to its power to search the record (CPLR 3212 [b]), find that a prima facie case exists, thereby shifting the burden of proof, notwithstanding the evidentiary deficiencies in the moving papers. Indeed, CPLR 3212 (b) authorizes the court to grant a motion for summary judgment, if upon “all the papers and proof submitted, the cause of action or defense shall be established sufficiently to warrant the court as a matter of law in directing judgment in favor of any party” (emphasis added). The discretion of the court to review the opposition papers may be viewed as akin to the court’s discretionary power to grant reverse summary judgment in an appropriate case. This discretion exists both in the motion court and, in the first instance, in an intermediate appellate court (see e.g. Merritt Hill Vineyards v Windy Hgts. Vineyard, 61 NY2d 106, 112 [1984]). Thus, the opposition papers may, in the court’s discretion, be perused to determine whether the record as a whole establishes the movant’s prima facie entitlement to judgment. Were we to interpret the law otherwise, a court could not, for example, grant summary judgment to a plaintiff whose moving papers are insufficient, even where there has been a concession of liability in defendant’s opposition papers.

Accordingly, where a movant has not made out a prima facie entitlement to summary judgment, while a motion court need not consider the opposition papers, it is not necessarily an improvident exercise of discretion for it to do so in order to determine whether the record as a whole will establish a party’s prima facie case. In the instant case, we exercise our discretion to search the record, as we have done in prior cases (see e.g. Dilon Med. Supply Corp. v State Farm Mut. Ins. Co., 12 Misc 3d 140[A], 2006 NY Slip Op 51344[U] [App Term, 2d & 11th Jud{**14 Misc 3d at 77} Dists 2006]; M.G.M. Psychiatry Care P.C. v Utica Mut. Ins. Co., 12 Misc 3d 137[A], 2006 NY Slip Op 51286[U] [App Term, 2d & 11th Jud Dists 2006]; Vista Surgical Supplies, Inc. v State Farm Mut. Ins. Co., 12 Misc 3d 134[A], 2006 NY Slip Op 51189[U] [App Term, 2d & 11th Jud Dists 2006]; Vista Surgical Supplies, Inc. v Metropolitan Prop. & Cas. Ins. Co., 12 Misc 3d 130[A], 2006 NY Slip Op 51047[U] [App Term, 2d & 11th Jud Dists 2006]; First Help Acupuncture P.C. v State Farm Ins. Co., 12 Misc 3d 130[A], 2006 NY Slip Op 51043[U] [App Term, 2d & 11th Jud Dists 2006]; Careplus Med. Supply Inc. v State-Wide Ins. Co., 11 Misc 3d 29 [2005]; PDG Psychological P.C. v Utica Mut. Ins. Co., 11 Misc 3d 128[A], 2006 NY Slip Op 50246[U] [App Term, 2d & 11th Jud Dists 2006]), and find that plaintiff’s prima facie entitlement to summary judgment was established, thereby shifting the burden to defendant to raise a triable issue of fact (Alvarez v Prospect Hosp., [*3]68 NY2d 320, 324 [1986]).

Defendant’s denial was untimely (Insurance Law § 5106 [a]; 11 NYCRR 65.15 [g] [3], now 11 NYCRR 65-3.8 [c]), and defendant failed to establish a tolling of the statutory 30-day claim determination period (New York & Presbyt. Hosp. v Allstate Ins. Co., 31 AD3d 512 [2006]) by proof that it issued a proper and timely verification request (11 NYCRR 65.15 [d] [1], now 11 NYCRR 65-3.5 [a]). Defendant alleged that it requested that assignor submit to an examination under oath (EUO) in December 2001. However, “the insurance regulations in effect prior to April 5, 2002 did not provide for EUOs as a form of verification” (A.M. Med. Servs., P.C. v Nationwide Mut. Ins. Co., 12 Misc 3d 143[A], 2006 NY Slip Op 51425[U] [App Term, 2d & 11th Jud Dists 2006]; see also King’s Med. Supply v Kemper Auto & Home Ins. Co., 3 Misc 3d 131[A], 2004 NY Slip Op 50401[U] [App Term, 2d & 11th Jud Dists 2004]), and the absence of an EUO provision in the former verification scheme “may [not] be remedied by reference to policy provisions requiring that an insured cooperate with the insurer’s investigation of a claim, even if a clause therein explicitly provides for cooperation in that form” (Melbourne Med., P.C. v Utica Mut. Ins. Co., 4 Misc 3d 92, 93 [App Term, 2d & 11th Jud Dists 2004]).

While the untimely denial did not preclude defendant from interposing the defense that the assignor’s injuries did not arise from a covered incident, i.e., an incident alleged to have been staged to defraud defendant (Matter of Metro Med. Diagnostics v Eagle Ins. Co., 293 AD2d 751, 752 [2002]; see also State Farm Mut. Auto. Ins. Co. v Laguerre, 305 AD2d 490, 491 [2003]), it{**14 Misc 3d at 78} remained defendant’s burden to demonstrate “a founded belief” that the injuries did not result from an insured event (Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]), and we agree with the court below that defendant failed to establish a triable issue of material fact as to fraud. The facts set forth in the affirmation of defendant’s counsel were without probative value as she had no personal knowledge of those facts (e.g. Melbourne Med., P.C. v Utica Mut. Ins. Co., 4 Misc 3d 92, 94 [2004], supra), and none of the attached documents are sworn or supported by an affidavit by someone alleging personal knowledge of their preparation (A.B. Med. Servs. PLLC v Utica Mut. Ins. Co., 10 Misc 3d 50, 52 [App Term, 2d & 11th Jud Dists 2005]; see Rue v Stokes, 191 AD2d 245, 246 [1993]). In his affidavit, defendant’s claims representative likewise asserted no personal knowledge of defendant’s investigation into the incident and even if this case presented the “certain circumstances” meriting consideration of proof that would be inadmissible at trial (Kwi Bong Yi v JNJ Supply Corp., 274 AD2d 453 [2000]), the facts established little more than “unsubstantiated hypotheses and suppositions” (Penny v Pembrook Mgt., 280 AD2d 590, 591 [2001]), a “legally insufficient [basis] to support [a] defendant’s fraud allegation” (Amstel Chiropractic v Omni Indem. Co., 2 Misc 3d 129[A], 2004 NY Slip Op 50088[U], *1-2 [App Term, 2d & 11th Jud Dists 2004]).

Golia, J. (dissenting and voting to reverse the order, insofar as appealed from, and denying plaintiff’s motion for summary judgment). Initially, I note with dismay the finding of the motion court. That determination is patently incorrect. The determination, which granted plaintiff summary judgment, stated that “plaintiff proved that it submitted a timely and proper notice of claim pursuant to the No-Fault [*4]statute.” With regard to that fact, the Appellate Term unanimously disagrees and finds that plaintiff failed to prove that it submitted the claim at all.

I further note, although not addressed by the majority, that the notice of claim which plaintiff provided was not a “proper notice of claim pursuant to the No-Fault statute.” The majority responds that due only to defendant’s failure to request a timely verification or raise a defense as to the propriety of the claim form, the defendant was precluded from raising those issues. I submit that a defendant’s failure to contest improper forms is not the same as a finding that the forms were proper.

My dissent, however, is predicated primarily upon the inappropriate expansion of the majority’s willingness to assist the plaintiff to establish its prima facie case in this no-fault matter.{**14 Misc 3d at 79}

The plaintiff here did not even meet the relaxed standard of making out a prima facie case that was first enunciated by the Appellate Term in a previous no-fault proceeding (see Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists 2003]) and its progeny. That case held that a health care provider need only prove that it submitted a properly completed claim form to establish its prima facie entitlement to summary judgment. It need not establish any medical necessity for providing the medical supplies or services performed. Indeed, in the event the defendant is precluded from raising a defense as to the propriety of the claim form in whole or in part, the plaintiff is then not even required to affirmatively establish that the claim form was “properly completed.”

In supporting its claim that the Appellate Term has the authority to search the record in order to find missing elements to establish a prima facie case in plaintiff’s motion, the majority cites to CPLR 3212 (b); specifically, that the motion can be granted upon “all the papers and proof submitted” (emphasis added). They did not include the first two sentences of that section which read:

“A motion for summary judgment shall be supported by affidavit[s], by a copy of the pleadings and by other available proof, such as depositions and written admissions. The affidavit shall be by a person having knowledge of the facts . . . and it shall show that there is no defense to the cause of action or that the cause of action or defense has no merit.”

When read together, one should conclude that this section imposes upon the movant a minimum requirement in order to establish a prima facie case. I emphasize that a motion for summary judgment must be supported within the four corners of the motion itself. To lessen this burden, as the majority now does in this no-fault proceeding, I submit, is unsupported in the law.

There is an Appellate Division, First Department case, Bowery Sav. Bank v 130 E. 72nd St. Realty Corp. (173 AD2d 364 [1991]), which “appears” to support the majority’s contention that a court may grant summary judgment upon information in the record that was not provided by the moving party. However, a careful reading of that case and the record on appeal reveals that this issue was never briefed. More importantly, it was not{**14 Misc 3d at 80} even considered by the trial court. [*5]In fact the unpublished decision from the Supreme Court cites to Alvarez v Prospect Hosp. (68 NY2d 320 [1986]) for the proposition that the initial burden lies upon the movant. That court then goes on to indicate that the defendant does not dispute certain issues but fails to raise sufficient allegations to raise a triable issue of fact.

At no point does the Supreme Court or the Appellate Division assert that it has the right to search the record in order to bolster the movant’s applications. There is clearly a distinction between discounting a technical failure that is not at issue and, on the other hand, combing through the record in order to search for missing elements of plaintiff’s prima facie case.

Until now, a plaintiff did, at least, have the initial burden to prove that the claim form was actually sent to the defendant. The Appellate Term has long held that such proof could be established by annexing the defendant’s denial form thereby proving that the claim was received. My colleagues now no longer require that plaintiff establish a prima facie case within the four corners of its motion as long as the majority can find the proof upon a complete search of the record.

Although the majority acknowledges the “well-established principle that the failure of a proponent of a motion for summary judgment to make a prima facie showing of entitlement to judgment as a matter of law requires denial of the motion regardless of the sufficiency of the opposing papers (Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985])” (at 75), it nevertheless decided to search this record here and find that a prima facie case exists.

The majority then cites to the Court of Appeals case of Alvarez v Prospect Hosp. (68 NY2d 320 [1986]) which cites Winegrad, and which substantially stands for the same proposition. Nevertheless, the majority asserts that “this is not to say that where a movant fails to establish a prima facie case, the court may never review the opposition papers” (at 76). What they fail to explain is how they reached that conclusion given the following language in Alvarez: “As we have stated frequently, the proponent of a summary judgment motion must make a prima facie showing of entitlement to judgment as a matter of law . . . Failure to make such prima facie showing requires a denial of the motion, regardless of the sufficiency of the opposing papers” (Alvarez, 68 NY2d at 324 [emphasis added]).{**14 Misc 3d at 81}

For the majority now to say that Alvarez does not preclude them here from reviewing the opposition papers and finding a prima facie case for the movant upon the entire record is, in my opinion, misrepresenting the clear language enunciated by the Court of Appeals. That Court unequivocally stated that such failure mandates a denial of the motion despite the sufficiency of the opposing papers, a ruling which this court is duty bound to follow.

Finally, I submit, the majority engages in an argument of pure sophistry. It asserts that the Appellate Term has the authority to search the record and grant reverse summary judgment even in the absence of a cross motion or an appeal seeking such relief. I agree. It goes on to conclude that the Appellate Term must therefore have the authority to search this record in order to grant summary judgment even in the absence of the movant making out its prima facie case. I [*6]do not agree.

There is no question that this court has the authority to search the record and grant reverse summary judgment (see Merritt Hill Vineyards v Windy Hgts. Vineyard, 61 NY2d 106 [1984]). That does not mean, however, that the Appellate Term can use that authority to correct this no-fault movant’s failure to establish its prima facie entitlement to judgment. In my view, the majority’s decision would permit a trial court to exercise its discretion in an open and relaxed manner and would, consequently, result in varied and conflicting decisions based upon the same or similar facts. The result can only lead to confusion and increased appellate litigation. Clearly, in no-fault matters, where the Appellate Term has provided the plaintiff with the simplest of requirements to establish a prima facie case as a matter of law, it now holds that even less is required.

Pesce, P.J., and Rios, J., concur; Golia, J., dissents in a separate memorandum.

[*1]

District Court of Suffolk County, Third District, December 7, 2006

APPEARANCES OF COUNSEL

Freiberg & Peck, LLP, New York City (Michelle R. Kolodny of counsel), for defendant. Edward Shapiro, P.C., Wantagh (Jason A. Moroff of counsel), for plaintiff.

OPINION OF THE COURT

C. Stephen Hackeling, J.

It is ordered that this application by the defendant for summary judgment dismissing the plaintiff’s complaint is granted, and the plaintiff’s cross motion for summary judgment is denied as moot.

This is an action for first-party benefits (recovery of unpaid health services bill, statutory interest and statutory attorney’s fees) brought pursuant to the No-Fault Insurance Law by a health services provider who rendered medical services to a patient in exchange for the patient’s rights to collect no-fault benefits.

On a motion for summary judgment the test to be applied is whether triable issues of fact exist or whether on the proof submitted judgment can be granted to a party as a matter of law (Andre v Pomeroy, 35 NY2d 361 [1974]). It is incumbent on the proponent of the motion to set forth a prima facie showing of entitlement to judgment as a matter of law, tendering sufficient evidence to demonstrate the absence of any material issues of fact (Alvarez v Prospect Hosp., 68 NY2d 320 [1986]).

Upon the proponent making out a prima facie case, the burden shifts to the opponent of the motion to produce evidentiary proof in admissible form sufficient to establish the existence of material issues of fact (Zuckerman v City of New York, 49 NY2d 557 [1980]). [*2]

Issue Presented

Does the production of an electronic signature assignment of benefits and NF-3 claim form in response to an insurer’s verification demand recommence the running of a tolled 30-day no-fault insurance claim denial period?

Cause of Action Tolled Pending Verification

Under New York’s No-Fault Insurance Law, an insurance carrier is required to either pay or deny a claim for benefits within 30 days from its receipt of the claim (see, 11 NYCRR 65-3.8 [c]). “Such benefits are overdue if not paid within 30 days after the claimant supplies proof of the fact and amount of the loss sustained” (Insurance Law § 5106 [a]). For the defendant to properly deny a claim, it must generate its denial and mail it to the plaintiff within 30 days. This period may be extended by, inter alia, a timely demand by the insurer for further verification of a claim (see, 11 NYCRR 65-3.5 [b]). Such demands must be made within 10 business days of the receipt of a completed application (see, 11 NYCRR 65-3.5 [a]). If the demanded verification is not received within 30 days, the insurance company must issue a follow-up request within 10 calendar days of the applicant’s failure to respond (see, 11 NYCRR 65-3.6 [b]). Further, an insurer must request any additional verification it will require within 15 days after receipt of one or more completed verification forms in order to further toll the 30-day payment or denial period (see, 11 NYCRR 65-3.5 [b]). The 30-day period in which the insurer has to either pay or to deny the claim does not begin to run until all demanded verification is provided (see, 11 NYCRR 65-3.8 [a] [1]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568 [2004]). In fact, the insurer is precluded from issuing a denial while a verification request is outstanding (see, 11 NYCRR 65-3.8 [b] [3]).

The Undisputed Facts

In the case at bar, the plaintiff’s claim for medical services was received by the defendant insurer on August 11, 2005. The defendant made an initial verification request that was mailed on August 22, 2005. The additional verification requested the following information:

“Pursuant to regulation 68, 65-3.11 (B) a provider must submit either a properly executed prescribed assignment of benefits or authorization to pay in order to receive direct payment from the insurer. As you have not submitted a properly executed form, we are unable to consider reimbursement. Enclosed is a prescribed assignment of benefits form for you to complete in full, have signed by the patient, and return to the undersigned. Advise us immediately if you are unable to submit a properly executed assignment or authorization.

“1. The assignment submitted was not signed by the patient.

“2. The assignment submitted was not signed by the provider, electronic signatures are not acceptable.

“3. We are in receipt of your bill for services, however, we have not yet received the fully [*3]completed, prescribed verification of treatment by attending physician form (NF-3). Every box must be fully completed, blank boxes will not be accepted. The patient must elect either box 20 authorization to pay or 21 assignment of benefits, but not both. If the prescribed assignment of benefits or authorization to pay has previously been submitted, please indicate same in box 21. Be advised we require the physician’s original signature on said form. Signature stamps and/or electronic signatures will not be accepted. We require submission of said form, for each provider of service, before consideration of their claim for services. (Regulation 68, 65-3.5F).

“Consideration of your claim will remain delayed pending our receipt of said form and any other verification duly requested. (NF3 attached hereto).”

A follow-up verification request was sent by the defendant on September 22, 2005 as no verifications were supplied by the plaintiff within 30 calendar days of the original request (see, 11 NYCRR 65-3.6 [b]). It is unrefuted that the plaintiff has not responded to the defendant’s verification demands.

Electronic Signatures

The defendant contends, inter alia, that both the assignment of benefits (AOB) form and the NF-3 claim form contain electronic signatures of the assignor/patient Edison Alcantara. Further, the defendant states that both forms show the assignee/provider’s signature as “on file.” The defendant argues that it was entitled to verify the signatures of the assignor/patient and the assignee/provider of health care services. The plaintiff does not rebut the documentary and testimonial evidence demonstrating that the defendant timely requested verification of the signatures of the assignor and assignee on both forms.

The plaintiff argues in opposition that the New York State Electronic Signatures and Records Act (ESRA) and the federal Electronic Signatures in Global and National Commerce Act (E-Sign) require the defendant insurance company to accept the electronic signature of the assignor/patient Edison Alcantara as equivalent to an original signature. The plaintiff contends that the New York state and federal laws give electronic signatures the same validity and effect as handwritten ones. Further, the plaintiff claims that a signature indicated as being “on file” is sufficient, and is not the equivalent of being absent from the particular form.

The defendant submits the October 25, 2006 opinion of the General Counsel’s Office of the New York State Insurance Department regarding electronic record retention of no-fault insurance claim forms in support of its argument that an insurance company is “not obligated to accept an electronic signature.” (Ops Gen Counsel NY Ins Dept No. 06-10-05 [Oct. 2006].) The General Counsel’s opinion addresses two questions presented by a firm representing radiology facilities inquiring whether it may use electronic documents and electronic signatures in submitting no-fault insurance claims. The first question presented asks: “Do the New York State Electronic Signatures and Records Act (‘ESRA’) and the federal Electronic Signatures in Global and National Commerce Act (‘E-Sign’) obligate an insurer to accept electronic records and signatures with No-Fault insurance claim forms?” The General Counsel’s answer was no. The Counsel states that “Neither E-Sign nor ESRA obligates an insurer to accept electronic records or signatures.” The second question presented [*4]asks: “May a digitally reproduced NF-AOB serve as an original document for purposes of a verification request by an insurer under Section 65-3.11 (c) of NY Comp. Codes R. & Regs. tit.11, Part 65 (Regulation 68)?” The General Counsel’s answer was “[y]es, provided that it is accurate and accessible as required under Section 7001 (d) (1) of E-Sign, and the insurer consents to the use of an electronic record as an original document.”

The General Counsel’s office examined the New York State law (ESRA) and the federal law (E-Sign), and concluded that neither law “obligates any person, including an insurer, to accept the use of electronic records and signatures. Accordingly, an insurer is not required to accept electronic records and signatures and may require that such records and signatures are submitted in hard copy form.” Moreover, the regulatory interpretations of the New York State Insurance Department are entitled to a “great deference” (see, Bronx Med. Servs., PC v Lumbermans Mut. Cas. Co., 2003 NY Slip Op 51022[U], *3 [App Term, 1st Dept 2003]; Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854 [2003]; Matter of Medical Malpractice Ins. Assn. v Superintendent of Ins. of State of N.Y., 72 NY2d 753 [1988]). Consequently, it is the opinion of this court that, as the defendant contends, with regard to a no-fault claim, an insurance company may choose to accept an electronic signature, but it is not obligated to do so. Hence, the defendant’s verification request was proper. As the plaintiff has not yet provided the demanded hard copy verification, the statutory period for the defendant to pay or to deny the plaintiff’s claim continues to be tolled (see, Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533 [2d Dept 2004]; St. Vincent’s Hosp. of Richmond v American Tr. Ins. Co., 299 AD2d 338 [2d Dept 2002]). As a consequence, the plaintiff’s claim herein is premature.

Further, although the plaintiff argues that there is no requirement that a no-fault AOB form contain a signature by the provider and that a signature indicated as being “on file” is sufficient, the form that the plaintiff elected to use clearly requires a “signature of provider.” The plain language of the no-fault insurance regulations requires that the provider submit a “properly executed assignment” on whatever form it chooses to submit. “It is well established that the No-Fault law is in derogation of the common law and must be ‘strictly construed’ ” (Presbyterian Hosp. in City of N.Y. v Atlanta Cas. Co., 210 AD2d 210 [2d Dept 1994]). Consequently, it is the opinion of the court that the plaintiff’s “on file” signature is not sufficient for a properly executed AOB form. As the plaintiff has also failed to comply with the defendant’s request for additional verification, the court finds that the 30-day period within which the defendant had to either pay or to deny the claim for no-fault benefits did not begin to run.

Accordingly, the defendant’s motion to dismiss is granted, and the plaintiff’s cross motion is denied as moot.

Civil Court of the City of New York, Kings County

24656/05

Arlene P. Bluth, J.

Upon the foregoing cited papers and after argument, plaintiff moves for summary judgment pursuant to CPLR § 3212. For the following reasons, plaintiff’s motion is granted.

In this action, plaintiff Capri Medical, P.C. seeks to recover first-party No-Fault benefits in the amount of $4,204.33 and statutory interest, costs, and attorneys’ fees for medical services it allegedly rendered to its assignor, Nail Abusov. In its moving papers, plaintiff submits following five bills which are the subject are this lawsuit: $1,593.37 (for date of service 4/9/03); $1,566.40 (for date of service 3/26/03); $302.17 (for date of service 3/19/03); $302.17 (for date of service 4/2/03); and $440.22 (for date of service 4/24/03). Plaintiff also submits the affidavit of its billing manager, Yelena Medvedik, who asserts that she personally mailed out the subject bills to defendant and [*2]that defendant issued “unreasonable and untimely denials” in response thereto.

The Court finds that plaintiff has established a prima facie entitlement to summary judgment as a matter of law by submitting proof in admissible form that the prescribed statutory claim forms, setting forth the facts and amounts of the losses sustained, were submitted to defendant, and that payment of no-fault benefits is overdue. See NYCRR § 65-3.8(c); D.A.V. Chiropractic, P.C. v Amer. Transit Ins. Co., 7 Misc 3d 133(A) [App Term, 2d and 11th Jud Dists 2005]; Triboro Chiropractic and Acupuncture P.L.L.C. ex rel. Tacopino v. Electric Ins. Co., 2 Misc 3d 135(A) [App Term, 2d & 11th Jud Dists 2004]. The burden now shifts to defendant to raise a triable issue of fact.

In opposition to this motion, defendant Auto One Insurance Company contends that it timely denied plaintiff’s claims on the ground of lack of medical necessity. However, defendant’s opposition fails to establish by competent evidence that it timely mailed the denials in question. “Proof of proper mailing requires evidence of actual mailing or. . .a standard office practice or procedure designed to ensure that items are properly addressed and mailed.'” See Comprehensive Mental v. Lumbermans Mut. Ins. Co., 4 Misc 3d 133(A) [App Term, 9th & 10th Jud Dists 2004]. The affidavit of Travis Miller is deficient in several respects. First, Mr. Miller states that he is “currently employed as Line Unit Supervisor,” but he does not explain what that means or what his job entails. Second, while he states that he has worked for defendant since August 2002, he does not state in what capacity he was employed prior to becoming Line Unit Supervisor.

As for his attempt to establish that defendant timely mailed the denials of the subject claims, he does not state that he personally mailed the denials, nor does he make clear how he knows that the denials in this case were timely mailed. Mr. Miller also does not establish that it is his duty to ensure compliance with defendant’s mailing procedures. See Boai Zhong Yi Acupuncture Servs., P.C. v New York Cent. Mut. Fire Ins. Co., 12 Misc 3d 135(A), 820 NYS2d 841 [App Term, 2d &11th Jud Dists 2006]; Contemp. Med. Diag. & Treatment, P.C. v. GEICO, 6 Misc 3d 137(A), 800 NYS2d 344 [App Term, 2nd & 11th Jud Dists 2005]. He “merely state[s] that the claims were timely denied without asserting personal knowledge of the mailing or setting forth sufficient facts to create a presumption of mailing.”Prestige Med. & Surg. Supply, Inc. v Clarendon Natl. Ins. Co., 13 Misc 3d 127(A) [App Term, 2d &11th Jud Dists 2006]. Fair Price Med. Supply Corp. v Liberty Mut. Ins. Co., 12 Misc 3d 145(A) [App Term, 2d &11th Jud Dists 2006]. The Court further notes that Mr. Miller’s affidavit fails to make any reference to the $302.17 bill for date of service March 19, 2003.

Defendant also submits the affidavit of its Mailroom Supervisor, Jay Santiago, who describes defendant’s procedures for mail collection first by mailroom personnel from bins throughout the office, and then by the United States Postal Service. However, in the absence of competent proof that defendant timely generated denials of the subject bills and deposited them for pickup, Mr. Santiago’s affidavit is unavailing. Therefore, defendant has failed to meet its burden, and plaintiff is entitled to summary judgment.

Accordingly, plaintiff’s motion is granted, and plaintiff is awarded judgment in the amount of $4,204.33 plus statutory interest, costs, and attorneys’ fees.

This is the Decision and Order of the Court.

Dated:

ARLENE P. BLUTH

Judge, Civil Court

ASN by______ on _______