May 23, 2005

A.B. Med. Servs. PLLC v State-Wide Ins. Co. (2005 NYSlipOp 50785(U))

https://www.beynensonlaw.com/case-law/a-b-med-servs-pllc-v-state-wide-ins-co-2005-nyslipop-50785u/

Court: Appellate Term, Second Department
Decided: May 23, 2005
Citation: 2005 NY Slip Op 50785(U)
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Followed in 2 later decisions (see Cited by)
Issues: Staged accidents, lack of coverage Discovery and procedure Timeliness and preclusion
Legal questions: No covered accident (founded belief) · Claimant's prima facie case on motions (see the maps)

Cite as

A.B. Med. Servs. PLLC v State-Wide Ins. Co., 2005 NY Slip Op 50785(U) (App Term, 2d Dept, 2d & 11th Jud Dists 2005)

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.

The insurer's attorney affirmation and unsworn reports failed to raise a triable staged-collision issue without an excuse for inadmissibility. The providers separately identified their claims within one cause of action, making dismissal under CPLR 3014 unwarranted absent prejudice. The insurer's late denial under 11 NYCRR 65-3.8 (c) precluded provider-fraud defenses, but not staged-collision coverage objections. The Appellate Term, Second Department, reversed, reinstated the complaint, granted the providers summary judgment, and remanded for interest and attorney fees under Insurance Law § 5106 (a). Citing anti-fraud policy, it stayed judgment entry for 45 days and permitted renewal with proper papers under CPLR 2221. A dissent would have found the insurer's submissions sufficient to raise a factual issue.

Reported in New York Official Reports at A.B. Med. Servs. PLLC v State-Wide Ins. Co. (2005 NYSlipOp 50785(U))

[*1]

A.B. Med. Servs. PLLC v State-Wide Ins. Co.

2005 NYSlipOp 50785(U)

Decided on May 23, 2005

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This opinion is uncorrected and will not be published in the printed Official Reports.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 May 23, 2005

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: PATTERSON, J.P., GOLIA and RIOS, JJ.
2004-667 K C

A.B. MEDICAL SERVICES PLLC D.A.V. CHIROPRACTIC P.C. LVOV ACUPUNCTURE P.C. a/a/o Marie Rettelye Pierre, Appellants,
against
STATE-WIDE INSURANCE COMPANY, Respondent.

Appeal by plaintiffs from an order of the Civil Court, Kings County (S. Krauss, J.), entered on April 8, 2004, which denied their motion for summary judgment and dismissed the complaint with leave to replead.

Order reversed without costs, complaint reinstated, plaintiffs’ motion for summary judgment granted and matter remanded to the court below for a calculation of statutory interest and an assessment of attorney’s fees; entry of judgment stayed for 45 days from the date of the order entered hereon, with leave to defendant to renew upon submission of proper papers within said period.

In this action to recover first-party no-fault benefits for medical services rendered to their assignor, plaintiffs established a prima facie entitlement to summary judgment by proof that they submitted their claims, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue (see Insurance Law
§ 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). While the claims of the three plaintiffs were pleaded under one cause of action in the [*2]complaint, the specific claims and amounts sought to be recovered by the individual plaintiffs were stated separately as to each of the plaintiffs. Under the circumstances, and in the absence of any showing of prejudice to defendant, we find there was no basis to deny the plaintiffs’ motion for summary judgment and to dismiss the complaint with leave to replead (see CPLR 3014).

Defendant’s denial of plaintiffs’ claims, in essence, asserted misrepresentation and/or fraud by plaintiffs and the plaintiffs’ assignor. Since the defendant failed to pay or deny the claim within the 30-day statutory period (11 NYCRR 65-3.8 [c]), it is precluded from raising most defenses (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]), including its defense of provider fraud (id. at 285; Melbourne Med., P.C. v Utica Mut. Ins. Co., 4 Misc 3d 92 [App Term, 2d & 11th Jud Dists 2004]).

Defendant, however, is not precluded from asserting the defense that the collision was in 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]). In opposition to plaintiffs’ motion for summary judgment, and in support of its defense of fraud, defendant submitted the affirmation of its attorney who lacked personal knowledge of the investigation (Melbourne Med., P.C. v Utica Mut. Ins. Co., 4 Misc 3d 92, supra), and unsworn investigative reports which did not constitute competent proof in admissible form (S & M Supply v State Farm Mut. Auto. Ins. Co., 4 Misc 3d 130[A], 2004 NY Slip Op 50693[U] [App Term, 9th & 10th Jud Dists]). While hearsay evidence may be admissible in opposing a motion for summary judgment, there must be an acceptable excuse for failure to tender the proof in admissible form (see Friends of Animals v Associated Fur Mfrs., 46 NY2d 1065, 1068 [1979]; Allstate Ins. Co. v Keil, 268 AD2d 545 [2000]), which defendant has failed to proffer. Accordingly, plaintiffs’ motion for summary judgment should have been granted.

Inasmuch as the issues raised herein involve an alleged staged collision in furtherance of an insurance fraud scheme, and in consideration of the strong public policy to stem the perpetration of no-fault insurance fraud underlying the revisions to the insurance regulations (see Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854, 861-862 [2003]), defendant is granted leave to renew upon
submission of proper papers in opposition to plaintiffs’ motion for summary judgment (see CPLR 2221), to demonstrate that the defense 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, the complaint is reinstated, plaintiffs’ motion for summary judgment granted, and matter remanded to the court below for a calculation of statutory interest and an assessment of attorney’s fees; entry of judgment is stayed for 45 days from the date of the order entered hereon, with leave to defendant to renew upon submission of proper papers within said period.

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

Golia, J., dissents in a separate memorandum.

Golia, J., dissents and votes to modify the order and deny plaintiffs’ motion for summary judgment in the following memorandum:

Contrary to the holding of the majority, I find that the papers submitted by the defendant in opposition to the plaintiffs’ motion for summary judgment were sufficient to raise an issue of fact as to whether the defense of fraud 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]).

For the reasons stated in my dissent in Ocean Diagnostic Imaging v Lancer Ins. Co. (6 Misc 3d 62 [App Term, 2d & 11th Jud Dists 2004]), I find that the unsworn reports when submitted in opposition to a motion for summary judgment and accompanied by an affidavit or affirmation of an attorney which makes reference to such report, are sufficient for the purpose of raising a triable issue of fact. This Court must, when deciding a motion for summary judgment, interpret the evidence in the light most favorable to the non-movant (see Weiss v Garfield, 21 AD2d 156 [1964]). This is especially true where there is an allegation of fraud.

Accordingly, I would modify the order of the lower court and would deny the plaintiffs’ motion for summary judgment.
Decision Date: May 23, 2005

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.

No covered accident (founded belief)

Open the full map

Did the insurer show the claimed injuries did not arise from a covered accident (staged, intentional, or unrelated)?

This decision: Insurer's proof did not raise an issue or failed at trial; provider prevails on it

Held the insurer's staged-collision defense unsupported because its attorney's affirmation lacked personal knowledge and the investigative reports were unsworn without excuse, so the providers won summary judgment, with leave to renew.

Defense establishedTriable issueInsurer's motion failsDefense not shownThis decisionCites it or cited by itCited or followed

Of the 234 decisions on this question in the Second Department courts and the Court of Appeals, 80 (this one included) are in the same category.

Claimant's prima facie case on motions

Open the full map

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 established prima facie entitlement by proof that they submitted claims stating the fact and amount of loss and that payment was overdue, and that pleading their claims in one cause of action was no bar.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followed

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

A label shows how this decision treated the case it cites.

Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359) FollowedThe hospitals established entitlement to summary judgment by proving that statutory billing forms were mailed and received and payment was overdue.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U)) FollowedA provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
Melbourne Med., P.C. v Utica Mut. Ins. Co. (2004 NY Slip Op 24221) FollowedEUO requests do not toll the claim determination period when the governing no-fault regulations do not authorize EUO verification.
S & M Supply Inc. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 50693(U)) FollowedThe insurer's EUO defense was precluded by untimely denials, and its accident-fraud evidence was inadmissible.
Ocean Diagnostic Imaging, P.C. v Lancer Ins. Co. (2004 NY Slip Op 24501)The insurer's submissions failed to raise a factual issue whether the claimed injuries arose from the accident.

Cited by

A label shows how the later decision treated this one.

Careplus Med. Supply Inc. v State-Wide Ins. Co. (2005 NY Slip Op 25545) FollowedThe insurer's completed denial form established receipt of the provider's claims and showed that the denial was untimely.
Ultra Diagnostics Imaging v Liberty Mut. Ins. Co. (2005 NY Slip Op 25402) FollowedThe insurer's wage-verification fraud allegations failed to establish a lack-of-coverage defense exempt from untimely-denial preclusion.
V.S. Med. Servs., P.C. v Allstate Ins. Co. (2006 NY Slip Op 26000)An insurer asserting a staged collision at trial need only rebut presumed coverage; the provider retains the burden of persuasion.
RDK Med. P.C. v General Assur. Co. (2005 NY Slip Op 51281(U))The master arbitration award lacked competent evidence that the billed services were not rendered and was vacated.
Bedford Park Med. Practice P.C. v American Tr. Ins. Co. (2005 NY Slip Op 51282(U))The insurer's IME report raised a medical-necessity issue but did not establish entitlement to summary judgment dismissing the provider's claims.
B.Y., M.D., P.C. v American Tr. Ins. Co. (2010 NY Slip Op 51902(U))The insurer's proof raised a factual question about employment at the time of the accident for the Workers' Compensation Board to resolve first.

Similar decisions

A.B. Med. Servs. PLLC v GMAC Ins. (2005 NYSlipOp 50602(U))Transportation benefits claimed under the revised no-fault regulations are reimbursable but cannot be assigned to a transportation provider.
A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51033(U))The insurer's EUO evidence did not establish a founded belief that the claimed injuries arose from a noncovered event.
A.B. Med. Servs. PLLC v Allstate Ins. Co. (2006 NY Slip Op 50474(U))The insurer failed to establish an EUO-authorizing endorsement or admissible support for its fraud defense.
Ocean Diagnostic Imaging, P.C. v Utica Mut. Ins. Co. (2005 NY Slip Op 51747(U))The insurer's untimely EUO request did not toll its denial deadline, and its staged-accident defense lacked admissible proof.
A.B. Med. Servs. PLLC v Utica Mut. Ins. Co. (2006 NY Slip Op 51334(U))The insurer's incomplete denial and inadmissible fraud proof failed to defeat the health care providers' summary judgment motion.