Reported in New York Official Reports at RX Warehouse Pharm., Inc. v 21st Century Ins. Co. (2021 NY Slip Op 50151(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
21st Century Insurance Company, Appellant.
Law Offices of Buratti, Rothenberg & Burns (Argyria A.N. Kehagias of counsel), for appellant. Law Office of Damin J. Toell, P.C. (Damin J. Toell of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (John J. Kelley, J.), entered September 12, 2016. The order denied defendant’s motion for summary judgment dismissing the complaint and granted plaintiff’s cross motion for summary judgment.
ORDERED that the order is reversed, with $30 costs, defendant’s motion for summary judgment dismissing the complaint is granted and plaintiff’s cross motion for summary judgment is denied.
Plaintiff, RX Warehouse Pharmacy, Inc. (RX Warehouse), commenced this action on February 17, 2015 to recover assigned first-party no-fault benefits for services rendered to plaintiff’s assignor, who had allegedly been injured in a motor vehicle accident on December 17, 2009. Defendant 21st Century Insurance Company (21st Century) moved for summary judgment dismissing the complaint on the ground that the issue of whether 21st Century was required to provide no-fault coverage for the claim in dispute had been decided in a Supreme Court, Nassau County, declaratory judgment action, by order entered August 23, 2012 granting 21st Century’s motion for the entry of a default judgment. RX Warehouse opposed the motion in the Civil Court and cross-moved for summary judgment. 21st Century, in further support of its motion in the Civil Court, proffered an order of the Supreme Court, entered May 6, 2015, which had granted 21st Century’s motion for summary judgment, and a judgment entered February 4, 2016 pursuant to the May 6, 2015 order, declaring, insofar as is relevant, that the insurance policy at issue was null and void with respect to the December 17, 2009 collision, and that 21st Century has no duty to defend or indemnify any person under the policy in any action or proceeding brought for damages as a result of the December 17, 2009 collision. RX Warehouse’s attorney argued in an affirmation that the judgment is not applicable to this provider, and that, in any [*2]event, the judgment had not been served on this provider.
By order entered September 12, 2016, the Civil Court denied 21st Century’s motion and granted RX Warehouse’s cross motion, finding that the Supreme Court’s August 23, 2012 order is not a conclusive final determination, as it did not make any declarations determining a lack of coverage. The Civil Court further found that the Supreme Court’s February 4, 2016 judgment had not been served on RX Warehouse’s counsel, and even if the Civil Court considered the judgment, the “judgment does not declare any rights or obligations that pertain to the plaintiff or plaintiff’s claims in this action.”
A defendant’s default admits all the factual allegations of the complaint and all reasonable inferences to be drawn therefrom (see Lamm v Stevenson, 276 AD2d 531 [2000]). Here, by defaulting in the declaratory judgment action, RX Warehouse admitted all the facts alleged in the complaint in that action regarding the staged nature of the accident in question. An order, such as the August 23, 2012 order granting 21st Century’s motion for the entry of a default judgment in the declaratory judgment action, “provides such a ‘judgment’ as will bar relitigation under the doctrines of res judicata or collateral estoppel so long as the requisites of identity of issue and opportunity to contest are present” (Vavolizza v Krieger, 33 NY2d 351, 356 [1974]; see also Slater v American Min. Spirits Co., 33 NY2d 443 [1974]).
Consequently, in light of the August 23, 2012 order, 21st Century’s motion in the Civil Court for summary judgment dismissing the complaint should have been granted under the doctrine of res judicata (see EBM Med. Health Care, P.C. v Republic W. Ins., 38 Misc 3d 1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]), as any judgment in favor of RX Warehouse in the present action would destroy or impair rights or interests established by the order in the declaratory judgment action (see Schuylkill Fuel Corp. v Nieberg Realty Corp., 250 NY 304 [1929]; Healing Art Acupuncture, P.C. v 21st Century Ins. Co., 59 Misc 3d 139[A], 2018 NY Slip Op 50583[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]; Flushing Traditional Acupuncture, P.C. v Kemper Ins. Co., 42 Misc 3d 133[A], 2014 NY Slip Op 50052[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]).
Accordingly, the order is reversed, defendant’s motion for summary judgment dismissing the complaint is granted and plaintiff’s cross motion for summary judgment is denied.
ALIOTTA, P.J., ELLIOT and TOUSSAINT, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: February 26, 2021
Reported in New York Official Reports at Alleviation Med. Servs., P.C. v Allstate Ins. Co. (2021 NY Slip Op 08159)
| Alleviation Med. Servs., P.C. v Allstate Ins. Co. |
| 2021 NY Slip Op 08159 [191 AD3d 934] |
| February 24, 2021 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| Alleviation Medical Services, P.C., as Assignee of Ali Al
Rahabi, Respondent, v Allstate Insurance Company, Appellant. |
Peter C. Merani, P.C., New York, NY, for appellant.
Gary Tsirelman, P.C., Brooklyn, NY (Stefan Belinfanti and David M. Gottlieb of counsel), for respondent.
Rivkin Radler LLP, Uniondale, NY (Evan H. Krinick, Barry I. Levy, and Henry M. Mascia of counsel), for amici curiae New York Insurance Association, Inc., and another.
In an action to recover no-fault benefits, the defendant appeals, by permission, from an order of the Appellate Term of the Supreme Court for the Second, Eleventh, and Thirteenth Judicial Districts dated March 29, 2017. The order affirmed an order of the Civil Court of the City of New York, Queens County (Terrence C. O’Connor, J.), entered April 1, 2015, denying the defendant’s motion for summary judgment dismissing the complaint.
Ordered that the order dated March 29, 2017, is affirmed, with costs.
In June 2011, the plaintiff commenced the instant action against the defendant in the Civil Court of the City of New York, Queens County, seeking to recover the sum of $4,748.69 for treatment provided to its assignor in April 2011, following a motor vehicle accident that occurred on October 20, 2010. The plaintiff alleged, among other things, that a no-fault claim and verification were sent to the defendant on April 19, 2011, and that the defendant failed to properly deny the claim or request additional verification in compliance with no-fault regulations.
In May 2014, the defendant moved for summary judgment dismissing the complaint, arguing that the benefits under the no-fault policy had been exhausted. The Civil Court denied the defendant’s motion, and the Appellate Term of the Supreme Court for the Second, Eleventh, and Thirteenth Judicial Districts affirmed. The defendant appeals, and we affirm, albeit on different grounds than those relied upon by the Civil Court or the Appellate Term.
“Under the no-fault system, payments of benefits ‘shall be made as the loss is incurred’ ” (Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854, 860 [2003], quoting Insurance Law § 5106 [a]). Under this regulatory scheme, “an insurer shall pay benefits directly to the ‘applicant,’ or, upon assignment by the applicant, ‘shall pay benefits directly to providers of health care services’ ” (East Acupuncture, P.C. v Allstate Ins. Co., 61 AD3d 202, 207 [2009], quoting 11 NYCRR 65-3.11 [a]). In addition, “an insurer is required to either pay or deny a claim for no-fault automobile [*2]insurance benefits within 30 days from the date an applicant supplies proof of claim” (Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 278 [1997]; see Insurance Law § 5106 [a]). However, “[a]n insurer is not required to pay a claim where the policy limits have been exhausted” (see Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533, 534 [2004]) since, where payments made by an insurer meet or exceed the policy limits, “its duties under the contract of insurance cease” (Presbyterian Hosp. in City of N.Y. v Liberty Mut. Ins. Co., 216 AD2d 448, 448 [1995]; see 11 NYCRR 65-3.15).
“[A]n insurer must pay or deny only a verified claim—that is, a claim that has been verified to the extent compliance with section 65-3.5 dictates in the particular case—within 30 calendar days of receipt; and, conversely, is not obligated to pay any claim until it has been so verified” (Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294, 299 [2007]). Once claims have been verified they are subject to the priority of payment regulation, 11 NYCRR 65-3.15 (see Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d at 300).
While the defendant submitted records indicating that the subject no-fault policy had been exhausted in 2013, the defendant’s submissions failed to establish its prima facie entitlement to judgment as a matter of law. Although the defendant submitted an affidavit from one of its employees that set forth the defendant’s ordinary business practice of receiving, recording, and denying no-fault claims from medical providers, the affidavit is bereft of any specific information regarding this claim. The defendant failed to submit the no-fault application, verification, any request for verification, or any denial associated with the plaintiff’s claim for payment. “While a witness may read into the record from the contents of a document which has been admitted into evidence, a witness’s description of a document not admitted into evidence is hearsay” (Wells Fargo Bank, N.A. v Sesey, 183 AD3d 780, 783 [2020] [citation and internal quotation marks omitted]). Because “a review of records maintained in the normal course of business does not vest an affiant with personal knowledge” (JPMorgan Chase Bank, N.A. v Grennan, 175 AD3d 1513, 1517 [2019]), the employee’s assertions as to the contents of the no-fault file are inadmissible hearsay (see Wells Fargo Bank, N.A. v Sesey, 183 AD3d at 783; U.S. Bank N.A. v 22 S. Madison, LLC, 170 AD3d 772, 774 [2019]). Accordingly, there are issues of fact remaining as to when the claim was denied, and the basis and efficacy of the denial (see Paulin v Needham, 28 AD3d 531 [2006]).
The parties’ remaining contentions, including those raised by the amici curiae, need not be reached in light of our determination. Chambers, J.P., LaSalle, Barros and Christopher, JJ., concur.
Reported in New York Official Reports at City Anesthesia Healthcare, P.C. v Erie Ins. Co. of N.Y. (2021 NY Slip Op 50135(U))
| City Anesthesia Healthcare, P.C. v Erie Ins. Co. of N.Y. |
| 2021 NY Slip Op 50135(U) [70 Misc 3d 141(A)] |
| Decided on February 19, 2021 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on February 19, 2021
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : THOMAS P. ALIOTTA, P.J., MICHELLE WESTON, DAVID ELLIOT, JJ
2019-1427 K C
against
Erie Insurance Co. of NY, Appellant.
Robyn M. Brilliant, P.C. (Robyn M. Brilliant and Barry Montrose of counsel), for appellant. Zara Javakov, P.C. (Zara Javakov and Victoria Tarasova of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Rachel Freier, J.), entered March 8, 2019. The order, insofar as appealed from, denied defendant’s motion for summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and defendant’s motion for summary judgment dismissing the complaint is granted.
In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from so much of an order of the Civil Court entered March 8, 2019 as denied defendant’s motion for summary judgment dismissing the complaint.
Contrary to the determination of the Civil Court, defendant demonstrated that, before it had received the claim at issue, it properly scheduled independent medical examinations (IMEs) of plaintiff’s assignor, and that the assignor failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Defendant also demonstrated that it timely denied the claim (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), based upon the assignor’s failure to appear for the IMEs. An assignor’s appearance at an IME “is a condition precedent to the insurer’s liability on the policy” (Stephen Fogel Psychological, P.C., 35 AD3d at 722). Plaintiff’s contention that the pre-claim IME scheduling letter was required to be mailed within 30 days of defendant’s receipt of the NF-2 lacks merit (see 11 NYCRR 65-3.5 [a], [d]; Appendix 13).
Accordingly, the order, insofar as appealed from, is reversed, and defendant’s motion for summary judgment dismissing the complaint is granted.
ALIOTTA, P.J., WESTON and ELLIOT, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: February 19, 2021
Reported in New York Official Reports at PDG Psychological, P.C. v State Farm Mut. Ins. Co. (2021 NY Slip Op 50134(U))
| PDG Psychological, P.C. v State Farm Mut. Ins. Co. |
| 2021 NY Slip Op 50134(U) [70 Misc 3d 141(A)] |
| Decided on February 19, 2021 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on February 19, 2021
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : THOMAS P. ALIOTTA, P.J., MICHELLE WESTON, DAVID ELLIOT, JJ
2019-1370 Q C
against
State Farm Mutual Insurance Co., Respondent.
Law Office of David O’Connor, P.C. (David O’Connor of counsel), for appellant. Rivkin Radler, LLP (Stuart M. Bodoff and Cheryl F. Korman of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Queens County (Larry Love, J.), entered October 16, 2018. The order, insofar as appealed from, granted the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches is denied, and the matter is remitted to the Civil Court for a determination of the remaining branch of defendant’s motion.
Insofar as is relevant to this appeal in this action by a provider to recover assigned first-party no-fault benefits, defendant moved to, among other things, dismiss the complaint on the ground of laches, based on plaintiff’s delay in prosecuting the action. The Civil Court granted this branch of defendant’s motion.
For the reasons stated in V.S. Med. Servs., P.C. v State Farm Mut. Ins. Co. (67 Misc 3d 142[A], 2020 NY Slip Op 50734[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2020]), the order, insofar as appealed from, is reversed, the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches is denied, and the matter is remitted to the Civil Court for a determination of the branch of defendant’s motion seeking to dismiss so much of the complaint as sought statutory no-fault interest (see Rockaway Med. & Diagnostic, P.C. v State Farm Mut. Ins. Co., 66 Misc 3d 147[A], 2020 NY Slip Op 50238[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2020]).
ALIOTTA, P.J., WESTON and ELLIOT, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: February 19, 2021
Reported in New York Official Reports at Vitality Chiropractic, P.C. v Metropolitan Auto Home & Life Ins. (2021 NY Slip Op 50133(U))
| Vitality Chiropractic, P.C. v Metropolitan Auto Home & Life Ins. |
| 2021 NY Slip Op 50133(U) [70 Misc 3d 141(A)] |
| Decided on February 19, 2021 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on February 19, 2021
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : THOMAS P. ALIOTTA, P.J., MICHELLE WESTON, DAVID ELLIOT, JJ
2019-1296 Q C
against
Metropolitan Auto Home and Life Insurance, Respondent.
Law Office of David O’Connor, LLC (David O’Connor of counsel), for appellant. Bruno, Gerbino & Soriano, LLP (Nathan M. Shapiro and Susan Eisner of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Queens County (John C.V. Katsanos, J.), entered January 11, 2019. The order, insofar as appealed from, granted the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches is denied, and the matter is remitted to the Civil Court for a determination of the remaining branch of defendant’s motion.
In this action by a provider to recover assigned first-party no-fault benefits, defendant moved to, among other things, dismiss the complaint on the ground of laches, based on plaintiff’s delay in prosecuting the action. Insofar as is relevant to this appeal, the Civil Court granted this branch of defendant’s motion and found that the branch of the motion seeking to toll statutory no-fault interest was moot.
For the reasons stated in V.S. Med. Servs., P.C. v State Farm Mut. Ins. Co. (67 Misc 3d 142[A], 2020 NY Slip Op 50734[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2020]), the order, insofar as appealed from, is reversed, the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches is denied, and the matter is remitted to the Civil Court for a determination of the remaining branch of defendant’s motion (see Rockaway Med. & Diagnostic, P.C. v State Farm Mut. Ins. Co., 66 Misc 3d 147[A], 2020 NY Slip Op 50238[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2020]).
ALIOTTA, P.J., WESTON and ELLIOT, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: February 19, 2021
Reported in New York Official Reports at DJS Med. Supplies, Inc. v Metropolitan Auto Home & Life Ins. (2021 NY Slip Op 50132(U))
| DJS Med. Supplies, Inc. v Metropolitan Auto Home & Life Ins. |
| 2021 NY Slip Op 50132(U) [70 Misc 3d 141(A)] |
| Decided on February 19, 2021 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Decided on February 19, 2021
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : THOMAS P. ALIOTTA, P.J., MICHELLE WESTON, DAVID ELLIOT, JJ
2019- 959 Q C
against
Metropolitan Auto Home and Life Insurance, Respondent.
Law Office of David O’Connor, P.C. (David B. O’Connor of counsel), for appellant. Bruno, Gerbino. Soriano & Aitken, LLP (Nathan Shapiro and Susan Eisner of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Queens County (John C.V. Katsanos, J.), entered January 11, 2019. The order, insofar as appealed from, granted the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches is denied, and the matter is remitted to the Civil Court for a determination of the remaining branch of defendant’s motion.
In this action by a provider to recover assigned first-party no-fault benefits, defendant moved to, among other things, dismiss the complaint on the ground of laches, based on plaintiff’s delay in prosecuting the action. Insofar as is relevant to this appeal, the Civil Court granted this branch of defendant’s motion and found that the branch of the motion seeking to toll statutory no-fault interest was moot.
For the reasons stated in V.S. Med. Servs., P.C. v State Farm Mut. Ins. Co. (67 Misc 3d 142[A], 2020 NY Slip Op 50734[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2020]), the order, insofar as appealed from, is reversed, the branch of defendant’s motion seeking to dismiss the complaint on the ground of laches is denied, and the matter is remitted to the Civil Court for a determination of the remaining branch of defendant’s motion (see Rockaway Med. & Diagnostic, P.C. v State Farm Mut. Ins. Co., 66 Misc 3d 147[A], 2020 NY Slip Op 50238[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2020]).
ALIOTTA, P.J., WESTON and ELLIOT, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: February 19, 2021
Reported in New York Official Reports at Matter of Country-Wide Ins. Co. v TC Acupuncture, P.C. (2021 NY Slip Op 01120)
| Matter of Country-Wide Ins. Co. v TC Acupuncture, P.C. |
| 2021 NY Slip Op 01120 [191 AD3d 557] |
| February 18, 2021 |
| Appellate Division, First Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| In the Matter of Country-Wide Insurance Company,
Respondent, v TC Acupuncture, P.C., as Assignee of Darrius Williams, Appellant. |
Gary Tsirelman, P.C., Brooklyn (Gary Tsirelman of counsel), for appellant.
Jaffe & Velazquez LLP, New York (Thomas Torto of counsel), for respondent.
Order, Supreme Court, New York County (Lynn R. Kotler, J.), entered June 8, 2018, which, in effect, granted reargument and adhered to the original determination, which granted the petition to vacate a master arbitrator’s award in favor of respondent, unanimously reversed, on the law, without costs, the petition denied, the master arbitrator’s award confirmed, and the matter remanded for a determination of respondent’s attorneys’ fees.
Although the motion court purported to deny respondent’s motion for reargument, it effectively granted the motion by addressing the merits. Accordingly, the order is appealable (CPLR 5701 [a] [2] [viii]; Castillo v Mount Sinai Hosp., 140 AD3d 619, 620 [1st Dept 2016], lv denied 28 NY3d 913 [2017]).
As respondent argued, the court overlooked existing authority confirming that CPLR 7511 (b) limits courts’ vacatur of arbitration awards to circumstances not present in this case (see Matter of New York State Correctional Officers & Police Benevolent Assn. v State of New York, 94 NY2d 321, 326 [1999] [“(E)ven in circumstances where an arbitrator makes errors of law or fact, courts will not assume the role of overseers to conform the award to their sense of justice”]).
The order that vacated the arbitration award cited no basis for vacatur under CPLR 7511 (b), finding only that the arbitrator and master arbitrator applied the wrong burden of proof to plaintiff’s fraudulent incorporation defense. Although on reargument the motion court determined that this Court’s decision in Country-Wide Ins. Co. v TC Acupuncture, P.C. (140 AD3d 643 [1st Dept 2016]), decided June 28, 2016, could not apply to the petition decided on June 9, 2016, Country-Wide did not state a new proposition of law, but merely cited existing authority (id. at 643-644 [“Even assuming, without deciding, that the master arbitrator applied the wrong burden of proof, the award is not subject to vacatur on that ground”], citing New York State Correctional Officers, 94 NY2d at 326).
Respondent is entitled to its reasonable attorneys’ fees on appeal (11 NYCRR 65-4.10 [j] [4]; Matter of Country-Wide Ins. Co. v TC Acupuncture P.C., 179 AD3d 414, 415 [1st Dept 2020]). We therefore remand the matter to Supreme Court for the calculation of those fees. Concur—Renwick, J.P., Kern, Singh, Shulman, JJ.
Reported in New York Official Reports at Total Chiropratic P.C. v Mercury Cas. Ins. Co. (2021 NY Slip Op 50142(U))
Total Chiropratic P.C.,
a/a/o Santia Louis, Plaintiff(s),
against Mercury Casualty Insurance Co., Defendant(s). |
CV-734629-18
Plaintiff’s Firm
Richard Rozhik
The Rybak Firm, PLLC
1810 Voorhies Avenue, Suite 7
Brooklyn, New York 11235
Telephone: (718)
975 – 2035
Facsimile: (718) 975 – 2037
rrozhik@rybakfirm.com
Defendant’s Firm
Sabiha Farkas, Esq.
Law Office of Patrick Neglia
200 Broadhollow Road, Suite
207
Melville, New York 11747
(T) (866) 543-0404 x60405
(F) (877)
389-1097
sfarkas@mercuryinsurance.com
Patria Frias-Colón, J.
Upon the foregoing cited papers and after oral arguments on January 8, 2021, pursuant to [*2]CPLR §3212(g), the Decision and Order on Defendant’s Motion for Summary Judgment and Plaintiff’s Cross-Motion for Summary Judgment, is as follows:
PROCEDURAL POSTURE:
In this No-Fault proceeding, Mercury Casualty Insurance Company (“Defendant/Insurer”), appearing through its attorney, pursuant to CPLR §3212(a) moves for Summary Judgment and dismissal of the complaint as barred by the doctrines of collateral estoppel and res judicata. In the alternative, Defendant moves for partial Summary Judgment seeking a prima facie finding that it timely and properly denied the bills in dispute. Total Chiropractic, P.C. (“Plaintiff/Provider”), appearing through its attorney, opposes Defendant’s motion. Pursuant to CPLR §3212(a), Plaintiff cross-moves for an Order granting Summary Judgment seeking a prima facie finding that it timely and properly mailed said bills totaling $2,100.00. Plaintiff further submits that the Declaratory Judgment issued against it, was entered on default, the issues have not been litigated therefore collateral estoppel and res judicata do not apply.[FN1] Based on the foregoing, Defendant’s motion is GRANTED and Plaintiff’s cross-motion is DENIED.
FACTUAL BACKGROUND:
Plaintiff commenced the instant No-Fault action seeking payment for medical services it rendered to Assignor Santia Louis as a result of alleged injuries related to a July 10, 2015 motor vehicle accident under claim number 2015004500398710.
Defendant commenced the Declaratory Judgment action against Plaintiff on October 6, 2016, in Supreme Court of the State of New York in Orange County, under Index Number EF 004083-2016 seeking an Order that Plaintiff not be entitled to payment for the claims submitted to Defendant. Specifically, Defendant alleged that the Assignor made material misrepresentations about her actual place of residence, which began with the procurement of the policy and continued until the date of motor vehicle accident. The Assignor’s misrepresentation reduced the amount of her policy premiums.[FN2]
Defendant was granted its application for a Declaratory Judgment on December 5, 2016, where Orange County Supreme Court Justice Vazquez-Doles concluded “…the [Defendant] has no duty to provide any first party benefits coverage to [Assignor], and other interested parties [*3]listed as defendants,” and that Defendant “is entitled to monetary relief against [Assignor]”[FN3] . Plaintiff failed to file an answer or a motion to renew or re-argue or appeal the Orange County Declaratory Judgment action. On December 13, 2016, Defendant served the Plaintiff the Orange County Declaratory Judgment.[FN4]
Plaintiff commenced the instant No-Fault action on August 2, 2018 and issue was joined on September 19, 2018.[FN5]
POSITION OF THE PARTIES:
Defendant avers its Motion for Summary Judgment should be granted in its entirety and Plaintiff’s complaint should be dismissed with prejudice. Defendant relies on the above-referenced Orange County Declaratory Judgement in support of its collateral estoppel and res judicata position since said Declaratory Judgment ordered that Mercury “has no duty to provide any first party benefits coverage to Defendant Santia Louis, and other interested parties listed as Defendants, arising out of the same July 10, 2015 motor vehicle accident as in the instant matter, given the Defendant’s misrepresentation of her place of residence was “material” as defined in Insurance Law §3105(b).” The Defendant also relies on the October 23, 2017 Decision and Order issued by Kings County Civil Court Judge Richard Montelione dismissing with prejudice a related matter bearing the caption Total Chiropractic, P.C. a/a/o Santia Louis, et. al., Index Number 073058/15, that also relied on the same Orange County Declaratory Judgment.
Plaintiff avers that said Declaratory Judgment has no preclusive effect in this case because it applies only to the Assignor and not the service provider Plaintiff in this matter. Plaintiff points to Jamaica Wellness Med., P.C. v. Mercury Cas. Co. where the Appellate Term opined the “Supreme Court order in the declaratory judgment action merely awarded a default judgment to Mercury against [Plaintiff]’s assignor, but did not declare the rights of Mercury as against [Plaintiff], the Supreme Court order cannot be considered a conclusive final determination of [Plaintiff]’s rights and, thus, can have no preclusive effect on the no-fault action at bar.”[FN6]
Plaintiff also argues that Defendant failed to establish it timely and properly denied Plaintiff’s claim and is now precluded from raising the defense of the Assignor’s material misrepresentations to procure the underlying insurance policy. Plaintiff relies on the Appellate Division holding in Westchester Med. Ctr. v. GMAC Ins. Co. Online, Inc, which found that “although the defendants contend that they submitted evidence showing that the plaintiff’s assignor misrepresented his state of residence in connection with the issuance of the subject insurance policy, the defendants are precluded from asserting that defense, as a result of their [*4]untimely denial of the claim.”[FN7] See also Gutierrez v. United Servs. Auto. Assn., holding that “Plaintiff correctly argues that defendant failed to demonstrate that it is not precluded from asserting its proffered defense—that the insurance policy at issue was fraudulently procured—as it failed to establish that it had timely denied plaintiff’s claim on that ground.”[FN8] Any so-called global or blanket denial of claim form that does not specifically address Plaintiff’s claim is insufficient to avoid the preclusion of the defense.[FN9]
ANALYSIS:
In deciding a motion for Summary Judgment, the Court’s role is solely to determine if any triable issues exist, not to determine the merits of any such issues. Sillman v. Twentierth Centry-Fox Film Corp., 3 NY.2d 395 (1957). Summary Judgment may only be granted if no genuine triable issue of fact is presented. See Gomes v. Courtesy Bus Co., 251 AD2d 625 (2nd Dep’t 1998).
The movant must establish the cause of action “sufficiently to warrant the court as a matter of law in directing judgment” in the movant’s favor and must do so by evidentiary proof in admissible form. See CPLR §3212(b); Friends of Animals, Inc. v. Associated Fur Mfrs., 46 NY2d 1065 (1979). “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.” Winegrad v. New York University Medical Center, 64 NY2d 851, 853 (1986).
Once such entitlement has been demonstrated by the movant, then the burden shifts to the party opposing the motion to demonstrate by admissible evidence that existence of a factual issue requiring a trial of the action or tender an acceptable excuse for his failure to do so. Zuckerman v. City of New York, 49 NY2d 557, 560 (1980). However, the Court of Appeals has made clear that bare allegations or conclusory assertions are insufficient to create genuine, bona fide issues of fact necessary to defeat such a motion. Rotuba Extruders, Inc. v. Ceppos, 46 NY2d 223, 231 (1978).
Under New York state law, Default Judgments that have not been vacated, are final orders and can preclude Plaintiff’s claims for payment. See Lazides v P & G Enters., 58 AD3d 607, 871 NYS2d 357 [2nd Dept 2009], revg 2007 WL 6861118 [Sup Ct, Kings County 2007]. The courts have reasoned that to hold otherwise would destroy or impair the rights or interests established by Default Judgments. See Schuylkill Fuel Corp. v Nieberg Realty Corp., 250 NY 304, 306-307, 165 NE 456 [1929]; Great Health Care Chiropractic, P.C. v Progressive Ins. Co., 48 Misc 3d 134[A], 18 NYS3d 579, 2015 NY Slip Op 51077[U] [App Term, 2nd Dept, 2d, 11th & 13th Jud. Dists. 2015] An order specifying the court’s Declaratory Judgment is a conclusive [*5]final determination, notwithstanding that it was entered on default. See Metro Health Prods., Inc. v Nationwide Ins., 48 Misc 3d 85, 16 NYS3d 366 [App. Term, 2nd Dept, 2d, 11th & 13th Jud. Dists., 2015].
New York State Insurance Law and Regulations 11 NYCRR §65 (“Regulations”) provide that an insurer must pay or deny a claim for No-Fault benefits within thirty days from the receipt of the claim. See Insurance Law§5106 and Regulations §65-3. Defendant must produce legally sufficient evidence that a denial form was generated and mailed within 30-days of the receipt of the claim for No-Fault benefits, or the time was tolled by issuing a proper verification request. Jul Pol Corp. v State Farm Fire and Casualty Company, 2003 NY Slip 51153 (U) (App. Term, 2nd and 11th Jud. Distrs., July 9, 2003).
The threshold issue hereis whether a default judgment that was not vacated has preclusive effects to permit the Plaintiff to collect payment for a claim submitted as first party benefits under New York’s No-Fault Insurance law. If established, this Court does not have to consider the issue of whether Plaintiff met its prima facie burden warranting payment for medical services or whether the Defendant established the bills in dispute were appropriately denied.
The Court finds that the Orange County Declaratory Judgment is a final Order that names both the Assignor and the Plaintiff and clearly delineates the rights and obligations of the parties.[FN10] The Declaratory Judgment clearly recites the relief requested by the Defendant and decrees the Defendant “has no duty to provide any first party benefits coverage to [Assignor], and other interested parties listed as defendants.”[FN11] The Plaintiff and Assignors are named Defendants on the Orange County Declaratory Judgment.[FN12] In its affidavits, Plaintiff failed to produce any evidence to raise a triable issue of fact regarding whether it is covered as a Defendant in the Orange County Declaratory Judgment.
The Court is not persuaded by Plaintiff’s reliance on Jamaica Wellness Med P.C. v. Mercury Cas. Co., 2018 NY Slip Op 51128 (U), as its inapplicable to the instant matter. The default judgment granted in the Jamaica Wellness Medical case was only against the Assignor, as the Plaintiff provider had appeared in the action and served an Answer. The Appellate Term specifically notes that “upon review of the record, we find that, as the March 23, 2016 Supreme Court order in the declaratory judgment action merely awarded a default judgment action to Mercury against Jamaica’s assignor, but did not declare the rights of Mercury as against Jamaica.”[FN13] Therefore the facts here are distinguishable given that Mercury’s Declaratory Judgment Order entered on default was specifically against both Assignor Santia Louis and Plaintiff provider Total Chiropractic P.C., who were both named in the Orange County Declaratory Judgment action and the case herein, and both failed to respond to the Orange County Declaratory Judgment action.
Finally, the Appellate Division, 2nd Department held that when an accident victim assigns his or her No-Fault claim to a medical provider, pursuant to 11 NYCRR 65-3.11, the medical provider as the “assignee ‘stands in the shoes’ of an assignor and thus acquires no greater rights than its assignor.” Long Island Radiology v. Allstate Ins. Co., 36 AD3d 763, 830 N.Y.S.2d 192 (2nd Dept. 2007). If a certain defense may be raised by the Defendants against the injured party, it is available as against the provider who accepts the assignments of no-fault benefits. As such, a finding of material misrepresentation of an assignor would be imputed onto the health care provider who takes an assignment of benefits and assumes this risk when accepting the assignment.
CONCLUSION:
Accordingly, the Orange County Declaratory Judgment declared the rights and obligations of both the Plaintiff and the Assignor which found there is no coverage based on the Assignor’s material misrepresentations about her residence. The Court need not consider whether either party established their respective prima facie cases.
The Defendant’s motion is GRANTED and the Plaintiff’s motion is DENIED as moot. The complaint is dismissed with prejudice.
This constitutes the Decision and Order of the Court.
Date: February 8, 2021
Brooklyn, New York
Hon. Patria
Frias-Colón
Civil Court, Kings County
Footnotes
Footnote 1:On January 11, 2017 Defendant held an inquest against the Assignor wherein Defendant was awarded judgment in the amount of $81,021.15 for damages plus $5,745.50 in court costs and attorney fees. See the Trial Decision in Defendant’s Exhibit G.
Footnote 2:See Defendant’s Exhibit C, Summons and Verified Complaint, Index Number EF 004083-2016 and Exhibit E, Transcript of Santia Louis Examination Under Oath (EUO) dated November 4, 2015.
Footnote 3:See Defendant’s Motion Exhibit A, Judgment, Notice of Entry, and Affidavit of Service.
Footnote 4:Id.
Footnote 5:See Plaintiff’s Exhibit 2 and 3.
Footnote 6:60 Misc 3d 139(A) (App. Term, 2d Dep’t, 2018).
Footnote 7:80 AD3d 603, 604 (2d Dep’t, 2011).
Footnote 8:47 Misc 3d 152(A) (App. Term, 2d Dep’t, 2015).
Footnote 9:See St. Barnabas Hosp. v. Allstate Ins. Co., 66 AD3d 996 (2d Dep’t, 2009); A & S Med. P.C. v. Allstate Ins. Co., 15 AD3d 170 (1st Dep’t, 2005), affirming 196 Misc 2d 322 (App. Term, 1st Dep’t, 2003).
Footnote 10:See Defendant Motion Exhibit A, Judgment, Notice of Entry, and Affidavit of Service.
Footnote 11:Id.
Footnote 12:Id.
Footnote 13:Jamaica Wellness Med P.C. v. Mercury Cas. Co., 2018 NY Slip Op 51128 (U)
Reported in New York Official Reports at Allay Med. Servs., P.C. v Nationwide Ins. (2021 NY Slip Op 50087(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
Nationwide Ins., Appellant.
Hollander Legal Group , P.C. (Allan S. Hollander of counsel), for appellant. The Rybak Firm, PLLC (Damin J. Toell and Karina Barska of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Odessa Kennedy, J.), entered May 31, 2019. The order, insofar as appealed from as limited by the brief, denied defendant’s motion for, in effect, summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and defendant’s motion for, in effect, summary judgment dismissing the complaint is granted.
Plaintiff Allay Medical Services, P.C. (Allay) commenced this action on June 1, 2016 to recover assigned first-party no-fault benefits for injuries sustained by “Miller, Nichole” in an accident on October 31, 2015, the complaint stating that claim number 363323-GC had been assigned to the matter. Defendant Nationwide Ins. (Nationwide) served an answer and, thereafter, moved to dismiss the complaint pursuant to CPLR 3211 (a) (5), contending that plaintiff’s action was barred, insofar as is relevant, under the doctrine of res judicata, by an order and judgment in a Supreme Court declaratory judgment action. The Supreme Court order and judgment, entered April 25, 2016 upon the default of Allay in opposing a motion by Nationwide, declared that Nationwide was “under no obligation to pay any of the claims identified in Exhibit 1 to the Complaint.” Among other things, Exhibit 1 identified claim number 363323-GC and an accident on October 31, 2015, and listed the eligible injured person as having the initials N.M. Plaintiff opposed defendant’s motion in the Civil Court. As limited by its brief, defendant appeals from so much of an order of the Civil Court entered May 31, 2019 as denied the motion.
For the reasons stated in Allay Med. Servs., as Assignee of Diop, Gregoria v Nationwide Ins. (— Misc 3d &mdash, 2021 NY Slip Op _____ [appeal No. 2019-1180 K C], decided herewith), the order, insofar as appealed from, is reversed, and defendant’s motion for, in effect, summary judgment dismissing the complaint is granted.
WESTON, J.P., ELLIOT and TOUSSAINT, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: February 5, 2021
Reported in New York Official Reports at Allay Med. Servs., P.C. v Nationwide Ins. (2021 NY Slip Op 50086(U))
SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
against
Nationwide Ins., Appellant.
Hollander Legal Group , P.C. (Allan S. Holllander of counsel), for appellant. The Rybak Firm, PLLC (Damin J. Toell and Karina Barska of counsel), for respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Odessa Kennedy, J.), dated May 31, 2019. The order, insofar as appealed from as limited by the brief, denied defendant’s motion for, in effect, summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and defendant’s motion for, in effect, summary judgment dismissing the complaint is granted.
Plaintiff Allay Medical Services, P.C. (Allay) commenced this action on June 1, 2016 to recover assigned first-party no-fault benefits for injuries sustained by “Diop, Gregoria” in an accident on July 3, 2015, the complaint stating that claim number 859968 had been assigned to the matter. Defendant Nationwide Ins. (Nationwide) served an answer and, thereafter, moved to dismiss the complaint pursuant to CPLR 3211 (a) (5), contending that plaintiff’s action was barred, insofar as is relevant, under the doctrine of res judicata, by an order and judgment in a Supreme Court declaratory judgment action. The Supreme Court order and judgment, entered April 25, 2016 upon the default of Allay in opposing a motion by Nationwide, declared that Nationwide was “under no obligation to pay any of the claims identified in Exhibit 1 to the Complaint.” Among other things, Exhibit 1 identified claim number 859968 and an accident on July 3, 2015, and listed the eligible injured person as having the initials G.D. Plaintiff opposed defendant’s motion in the Civil Court. As limited by the brief, defendant appeals from so much of an order of the Civil Court entered May 31, 2019 as denied the motion.
Initially, we note that, although defendant’s motion was denominated as one to dismiss the complaint pursuant to CPLR 3211 (a) (5), the motion was made after issue was joined (see generally CPLR 3211 [e]). “Whether or not issue has been joined, the court, after adequate notice to the parties, may treat the motion as a motion for summary judgment” (CPLR 3211 [c]). While the Civil Court never notified the parties that it was treating the motion as one for [*2]summary judgment, an exception to the notice requirement is applicable, as defendant’s motion exclusively involved “a purely legal question rather than any issues of fact” (Mihlovan v Grozavu, 72 NY2d 506, 508 [1988]; see Four Seasons Hotels v Vinnik, 127 AD2d 310, 320 [1987]; Renelique v State-Wide Ins. Co., 50 Misc 3d 137[A], 2016 NY Slip Op 50095[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016]). Consequently, it was proper for the Civil Court to treat defendant’s motion to dismiss as one for summary judgment “without first giving notice of its intention to do so” (Four Seasons Hotels, 127 AD2d at 320).
“Under the doctrine of res judicata, a final adjudication of a claim on the merits precludes relitigation of that claim and all claims arising out of the same transaction or series of transactions by a party or those in privity with a party” (Ciraldo v JP Morgan Chase Bank, N.A., 140 AD3d 912, 913 [2016]; see Matter of Hunter, 4 NY3d 260, 269 [2005]; Schuylkill Fuel Corp. v Nieberg Realty Corp., 250 NY 304, 306-307 [1929]).
As defendant’s moving papers sufficiently established that the claim number and the date of the subject accident in the action at bar are identical to those in the prior action where there has been a final adjudication of the claim on the merits (see Ciraldo, 140 AD3d at 913), plaintiff’s present action in the Civil Court was precluded under the doctrine of res judicata. Consequently, in light of the Supreme Court’s order and judgment, the Civil Court should have granted defendant’s motion (see EBM Med. Health Care, P.C. v Republic W. Ins., 38 Misc 3d 1 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]), as any judgment in favor of plaintiff in this action would destroy or impair rights or interests established by the judgment and order in the declaratory judgment action (see Schuylkill Fuel Corp., 250 NY at 306-307; Flushing Traditional Acupuncture, P.C. v Kemper Ins. Co., 42 Misc 3d 133[A], 2014 NY Slip Op 50052[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]; EBM Med. Health Care, P.C., 38 Misc 3d at 2).
Accordingly, the order, insofar as appealed from, is reversed, and defendant’s motion for, in effect, summary judgment dismissing the complaint is granted.
WESTON, J.P., ELLIOT and TOUSSAINT, JJ., concur.
ENTER:
Paul Kenny
Chief Clerk
Decision Date: February 5, 2021