October 20, 2005

Corona Med. Imaging, P.C. v State Farm Ins. Cos. (2005 NY Slip Op 51685(U))

Headnote

The relevant facts considered by the court were that plaintiff, a healthcare provider, submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that defendant insurance company failed to pay or deny the claim within the prescribed period. The main issue decided was whether defendant was precluded from raising certain defenses due to the untimely denial of the claim, and whether the defense of insurance fraud scheme could be asserted. The holding of the case was that plaintiff was not entitled to summary judgment because defendant raised a triable issue of fact as to whether there was a lack of coverage, and the court erred in granting plaintiff's motion for summary judgment.

Reported in New York Official Reports at Corona Med. Imaging, P.C. v State Farm Ins. Cos. (2005 NY Slip Op 51685(U))

Corona Med. Imaging, P.C. v State Farm Ins. Cos. (2005 NY Slip Op 51685(U)) [*1]

Corona Med. Imaging, P.C. v State Farm Ins. Cos.

2005 NY Slip Op 51685(U) [9 Misc 3d 135(A)]

Decided on October 20, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 October 20, 2005

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: RUDOLPH, P.J., ANGIOLILLO and McCABE, JJ.
2004-1770 N C

CORONA MEDICAL IMAGING, P.C. a/a/o DOMINGO ESPINAL, Respondent,
against
STATE FARM INSURANCE COMPANIES, Appellant.

Appeal from an order of the District Court of Nassau County, First District (Francis D. Ricigliano, J.), entered October 1, 2004. The order, insofar as appealed from, granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment.

Order unanimously modified by denying plaintiff’s motion for summary judgment; as so modified, affirmed with $10 costs.

In this action to recover first-party no-fault benefits for medical services rendered to its assignor, plaintiff health care provider established its prima facie entitlement to summary judgment by proof that it submitted a claim, 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]; 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 herein failed to pay or deny the claim 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]). Defendant was not, however, 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]). Contrary to the finding of the [*2]court below, the affidavit of defendant’s special investigator, which, inter alia, revealed numerous discrepancies in the examinations under oath of plaintiff’s assignor and defendant’s insured as to the circumstances surrounding the accident, was sufficient to demonstrate that said 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, since defendant raised a triable issue of fact as to whether there was a lack of coverage (see Zuckerman v City of New York, 49 NY2d 557 [1980]), the court below erred in granting plaintiff’s motion for summary judgment.
Decision Date: October 20, 2005