September 30, 2005
Careplus Med. Medical Supply Inc. v Allstate Ins. Co. (2005 NY Slip Op 51598(U))
https://www.beynensonlaw.com/case-law/careplus-med-medical-supply-inc-v-allstate-ins-co-2005-ny-slip-op-51598u/
- Decided
- September 30, 2005
- Citation
- 2005 NY Slip Op 51598(U) · 9 Misc 3d 131(A)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
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 Careplus Med. Medical Supply Inc. v Allstate Ins. Co. (2005 NY Slip Op 51598(U))
| Careplus Med. Medical Supply Inc. v Allstate Ins. Co. |
| 2005 NY Slip Op 51598(U) [9 Misc 3d 131(A)] |
| Decided on September 30, 2005 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| As corrected in part through November 4, 2011; it will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS
PRESENT: PESCE, P.J., WESTON PATTERSON and BELEN, JJ.
2004-1372 K C
against
Allstate Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Kings County (Robin S. Garson, J.), entered August 18, 2004. The order, insofar as appealed from, granted plaintiff’s motion for summary judgment in regard to causes of action relating to assignors Romana Hernandez and Jaime Diaz.
Order, insofar as appealed from, unanimously reversed without costs and plaintiff’s motion for summary judgment denied in causes of action relating to Romana Hernandez and Jaime Diaz.
In this action to recover first-party no-fault benefits for medical supplies rendered to their assignors, plaintiff established a prima facie entitlement to summary judgment with regard to the causes of action relating to assignors Romana Hernandez and Jaime Diaz 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]). Inasmuch as defendant failed to pay or deny the claims within the 30-day prescribed period (11 NYCRR 65-3.8 [c]), it was precluded from raising most defenses (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]).
However, defendant was not precluded from asserting the defense that the various collisions were in furtherance of insurance fraud schemes, despite the untimely denials of the [*2]claims (see Matter of Metro Med. Diagnostics v Eagle Ins. Co., 293 AD2d 751 [2002]). The affidavit of defendant’s claims representative, that the insureds in both cases were involved in intentionally caused collisions, was sufficient to raise a triable issue of fact as to whether the claims of assignors Hernandez and Diaz were
[*3]
fraudulent (see A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co., 6 Misc 3d 130[A], 2005 NY Slip Op 50076[U] [App Term, 2d & 11th Jud Dists]).
Decision Date: September 30, 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.
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 claims representative's affidavit that the insureds were involved in intentionally caused collisions sufficient to raise a triable issue of fraud, so the provider's motion was denied on those claims.
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 provider established prima facie entitlement on the two assignors' claims by proof that it submitted claims stating the fact and amount of loss and that payment was overdue.
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)The 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))A provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
- A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2005 NY Slip Op 50076(U)) FollowedThe insurer's affidavit and EUO evidence raised a triable coverage issue despite untimely denials of certain claims.
Cited by
- 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.
Similar decisions
- Careplus Med. Supply, Inc. v Allstate Ins. Co. (2009 NY Slip Op 51398(U))The provider failed to establish a prima facie case because its billing manager's affidavit did not authenticate the supporting records.
- Careplus Med. Supply Inc. v Allstate Ins. Co. (2005 NYSlipOp 51525(U))The former medical-equipment fee schedule caps reimbursement at 150 percent of cost and does not use local prevailing rates.
- Careplus Med. Supply Inc. v Kemper Auto & Home Ins. Co. (2005 NYSlipOp 50958(U))The insurer's sworn accident reconstruction report raised a triable issue whether the claimed injuries arose from an insured incident.
- Amaze Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 50211(U))The provider established entitlement to summary judgment by proving submission of complete claims that were not paid or denied within 30 days.
- Careplus Med. Supply, Inc v Allstate Indem. Co. (2005 NY Slip Op 51527(U))The insurer improperly reduced equipment claims to local prevailing rates under a fee schedule allowing 150 percent of cost.