November 19, 2004
A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51432(U))
https://www.beynensonlaw.com/case-law/a-b-med-servs-pllc-v-state-farm-mut-auto-ins-co-2004-ny-slip-op-51432u/
- Decided
- November 19, 2004
- Citation
- 2004 NY Slip Op 51432(U)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Later treatment
- Followed in 1 later decision (see Cited by)
Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.
Summary
Editorial summary by Beynenson Law, not part of the court’s decision.
Reported in New York Official Reports at A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51432(U))
| A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. |
| 2004 NY Slip Op 51432(U) |
| Decided on November 19, 2004 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS
PRESENT: McCABE, P.J., COVELLO and TANENBAUM, JJ.
2004-94 N C
against
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Respondent.
Appeal by plaintiffs from so much of an order of the District Court, Nassau County (S. Pardes, J.), entered November 17, 2003, as denied their motion for summary judgment.
Order insofar as appealed from unanimously affirmed with $10 costs.
In this action to recover first-party no-fault benefits for medical services rendered to their assignor, plaintiffs health care providers established a prima facie entitlement to summary judgment by proof that they submitted the statutory claim form, setting forth the fact and the amount of the loss sustained (see Insurance Law § 5106 [a]; New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co., 8 AD3d 640 [2004]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Damadian MRI in Elmhurst v Liberty Mut. Ins. Co., 2 Misc 3d 128 [A], 2003 NY Slip Op 51700 [U] [App Term, 9th & 10th Jud Dists]). Inasmuch as defendant failed to pay or deny the claim within the 30-day statutory period (11 NYCRR 65.15 [g] [3]), it is precluded from raising most defenses (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]).
However, defendant is not precluded from asserting the defense that the collision was in [*2]furtherance of an insurance fraud scheme, despite the untimely denial of the claim (see Matter of Metro Med. Diagnostics v Eagle Ins. Co., 293 AD2d 751 [2002]). The affidavit submitted by defendant’s special investigator was sufficient to demonstrate that defendant’s denial was based upon a “founded belief that the alleged injur[ies] do[] not arise out of an insured incident” (Central Gen. Hosp. v Chubb Group
of Ins. Cos., 90 NY2d 195, 199 [1997]). Accordingly, since defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage (see id.; Zuckerman v City of New York, 49 NY2d 557 [1980]), plaintiffs’ motion for summary judgment was properly denied.
Plaintiffs’ remaining contentions lack merit.
Decision Date: November 19, 2004
Legal questions (2)
Questions of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.
Did the insurer show the claimed injuries did not arise from a covered accident (staged, intentional, or unrelated)?
This decision: Founded belief shown; the question must be tried
Held the special investigator's affidavit showed a founded belief that the collision furthered an insurance fraud scheme, raising a triable coverage issue that defeated the providers' summary judgment motion.
Of the 234 decisions on this question in the Second Department courts and the Court of Appeals, 102 (this one included) are in the same category.
On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?
This decision: Claimant's proof held to make out its prima facie case (rules on the question, but another ground decided the case)
Held the providers made their prima facie showing by proof that they submitted the statutory claim form setting forth the fact and amount of loss, with the insurer having failed to pay or deny within 30 days.
Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (this one included) are in the same category.
Cited in this decision
- New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 05626)The insurer failed to establish mailing of assignment-verification requests and could not defeat the hospitals' summary judgment motion.
- Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359)The hospitals established entitlement to summary judgment by proving that statutory billing forms were mailed and received and payment was overdue.
- Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U))A provider need not submit additional medical-necessity evidence to obtain summary judgment when the insurer is precluded from that defense.
Cited by
A label shows how the later decision treated this one.
- A.B. Med. Servs., PLLC v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 25089) FollowedA provider retains the burden of proving coverage after an insurer produces admissible evidence of a founded belief that a collision was staged.
Similar decisions
- A.B. Med. Servs. PLLC v GMAC Ins. (2005 NYSlipOp 51079(U))The insurer's claims representative supplied facts supporting a founded belief that the alleged injuries did not arise from an insured incident.
- New Century Chiropractic, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 52236(U))The insurer's investigator established a founded belief that the injuries did not arise from an insured incident, raising a coverage issue.
- A.B. Med. Servs. Pllc v Lumbermens Mut. Cas. Co. (2004 NY Slip Op 50692(U))The providers failed to establish entitlement to summary judgment because their billing manager did not identify the provider represented.
- A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2005 NY Slip Op 25032)An insurer may assert a lack-of-coverage defense despite an untimely denial of no-fault claims.
- GPM Chiropractic, P.C. v State Farm Mut. Ins. Co (2005 NYSlipOp 50861(U))The insurer's investigator affidavit raised a triable staged-collision coverage issue despite an untimely denial.