June 2, 2006

Damadian MRI in Canarsie, P.C. v General Assur. Co. (2006 NY Slip Op 51048(U))

https://www.beynensonlaw.com/case-law/damadian-mri-in-canarsie-p-c-v-general-assur-co-2006-ny-slip-op-51048u/

Court: Appellate Term, Second Department
Decided: June 2, 2006
Citation: 2006 NY Slip Op 51048(U) · 12 Misc 3d 130(A)
Posture: Trial
Outcome: Provider prevailed
Issues: Assignments and standing Verification requests Provider's prima facie case
Legal questions: Claimant's prima facie case at trial (see the maps)

Cite as

Damadian MRI in Canarsie, P.C. v General Assur. Co., 12 Misc 3d 130(A), 2006 NY Slip Op 51048(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2006)

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 waived defenses concerning assignment forms by failing to object timely to their completeness or seek verification. The Appellate Term, Second Department, affirmed a judgment for the provider after a nonjury trial. The trial court had rejected the insurer's medical-necessity defense, but the appeal challenged admission of the assignment forms and argued that their exclusion would defeat the provider's prima facie case. The appellate court explained that claim submission showing the fact and amount of loss, together with overdue payment, established the provider's prima facie entitlement under Insurance Law § 5106 (a). Because the insurer did not timely object or request verification under 11 NYCRR 65-3.5, its assignment-based defenses were waived.

Reported in New York Official Reports at Damadian MRI in Canarsie, P.C. v General Assur. Co. (2006 NY Slip Op 51048(U))

[*1]

Damadian MRI in Canarsie, P.C. v General Assur. Co.

2006 NY Slip Op 51048(U) [12 Misc 3d 130(A)]

Decided on June 2, 2006

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This opinion is uncorrected and will not be published in the printed Official Reports.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 June 2, 2006

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : RUDOLPH, P.J., McCABE and TANENBAUM, JJ
2005-1385 S C.

Damadian MRI in Canarsie, P.C., a/a/o Tyrone Harley, Respondent,

against

General Assurance Company, Appellant.

Appeal from a judgment of the District Court of Suffolk County, Second District (Patrick J. Barton, J.), entered April 15, 2005. The judgment, after a nonjury trial, awarded plaintiff the sum of $3,961.37.

Judgment affirmed without costs.

Plaintiff commenced the instant action to recover assigned first-party no-fault benefits. After trial, the court found in favor of plaintiff and held that defendant failed to establish its defense that the services rendered were not medically necessary. On appeal, defendant argues that the assignment of benefits forms were improperly admitted into evidence and, as a result, the judgment should be reversed because without the assignment of benefits forms, plaintiff failed to make out a prima facie case.

It is well settled that a health care provider establishes its prima facie entitlement to judgment as a matter of law 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]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). Since defendant failed to timely object to the completeness of the assignment of benefits forms or seek verification of same as required by 11 NYCRR 65-3.5, defendant waived any defenses based thereon (see Hospital for Joint Diseases v Allstate Ins. Co., 21 AD3d 348 [2005]; Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d 564 [2005]; New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co., 8 AD3d 640 [2004]). Accordingly, the judgment is affirmed.

Rudolph, P.J., McCabe and Tanenbaum, JJ., concur.
Decision Date: June 2, 2006

Legal questions

A question 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.

Claimant's prima facie case at trial

Open the full map

What must a no-fault claimant prove at trial to make out its prima facie case for overdue benefits?

This decision: Claimant's trial proof held to make out its prima facie case

Rejected the insurer's argument that, without the assignment forms, the claimant failed to make out its prima facie case at trial, holding that the insurer waived assignment defenses by not objecting or seeking verification in time.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decision

Of the 93 decisions on this question in the Second Department courts and the Court of Appeals, 40 (this one included) are in the same category.

Cited in this decision

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.
Hospital for Joint Diseases v Allstate Ins. Co. (2005 NY Slip Op 06192)An insurer waived assignment objections by failing to timely object to hospital forms or seek verification of the assignments.
Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co. (2005 NY Slip Op 02235)The insurer failed to prove mailing of its denial, and the denial was incomplete even if timely.
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.

Similar decisions

Damadian Mri In Garden City v Windsor Group Ins. (2004 NY Slip Op 50262(U))The provider failed to establish entitlement to summary judgment because its assignment named an assignee whose identity remained uncertain.
Urban Radiology, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50850(U))The insurer waived its assignment defense by failing to timely object to incomplete claim forms or seek verification of a valid assignment.
Damadian Mri In Garden City v Liberty Mut. Ins. Co. (2003 NY Slip Op 51702(U))An insurer that fails to deny a no-fault claim within 30 days of receipt is precluded from asserting lack of medical necessity.
Diagnostic Rehab. Med. Serv. P.C. v Travelers Indem. Co. (2004 NY Slip Op 24505)The insurer waived the assignment defect by neither seeking additional verification nor identifying the deficiency in its denial.
Comprehensive MRI of N.Y., P.C. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50128(U))Conflicting medical expert opinions raised a triable issue of fact concerning the medical necessity of the provider's services.