March 5, 2007

DSL Med. Practice, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50398(U))

https://www.beynensonlaw.com/case-law/dsl-med-practice-p-c-v-american-tr-ins-co-2007-ny-slip-op-50398u/

Court: Appellate Term, Second Department
Decided: March 5, 2007
Citation: 2007 NY Slip Op 50398(U) · 14 Misc 3d 145(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Verification requests Timeliness and preclusion
Legal questions: Proof of mailing · Outstanding verification and premature actions (see the maps)

Cite as

DSL Med. Practice, P.C. v American Tr. Ins. Co., 14 Misc 3d 145(A), 2007 NY Slip Op 50398(U) (App Term, 2d Dept, 2d & 11th Jud Dists 2007)

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 provider's four claims were premature because timely verification requests for the assignor's Social Security number remained unanswered. The insurer's affidavits established knowledge of the preparation and issuance of the requests and detailed an office mailing procedure sufficient to presume mailing of initial and follow-up letters. Following Olympic Chiropractic, P.C. v American Tr. Ins. Co., the Appellate Term, Second Department, recognized the Social Security number as a proper verification subject. It affirmed the order, insofar as appealed from, denying the provider summary judgment and granting the insurer partial summary judgment dismissing those four claims. Summary judgment was also denied on the remaining claim because a factual issue existed as to payment through a prior claim.

Reported in New York Official Reports at DSL Med. Practice, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50398(U))

[*1]

DSL Med. Practice, P.C. v American Tr. Ins. Co.

2007 NY Slip Op 50398(U) [14 Misc 3d 145(A)]

Decided on March 5, 2007

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This opinion is uncorrected and will not be published in the printed Official Reports.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 March 5, 2007

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., WESTON PATTERSON and GOLIA, JJ
2005-1850 K C.

DSL Medical Practice, P.C. a/a/o Marcos Marinez, Appellant,
against
American Transit Insurance Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Eileen Nadelson, J.), entered September 26, 2005. The order, insofar as appealed from, denied plaintiff’s motion for summary judgment and granted defendant partial summary judgment on its cross motion.

Order, insofar as appealed from, affirmed without costs.

In this action to recover first-party no-fault benefits for medical services provided its assignor, defendant established that in response to plaintiff’s claims for $627.50, $540.80, $612.39, and $338, it issued timely initial and follow-up verification requests, for assignor’s social security number, all of which remain unsatisfied. Defendant’s affidavits set forth the basis of the affiants’ knowledge of the preparation and issuance of the verification request letters and a sufficiently detailed description of standard office mailing procedure so as to give rise to the presumption of mailing (see New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 574 [2006]). As an assignor’s social security number is a proper subject of verification (Olympic Chiropractic, P.C. v American Tr. Ins. Co., 14 Misc 3d 129[A], 2007 NY Slip Op 50011[U] [App Term, 2d & 11th Jud Dists]; see generally Cassano v Carb, 436 F3d 74 [2d Cir 2006]), the court below properly denied plaintiff’s motion for summary judgment, granted defendant’s cross motion for summary judgment as to those claims under which it cross-moved for relief, and dismissed those claims as premature (Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492, 493 [2005]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [2004]; A.B. Med. Servs. PLLC v Utica Mut. Ins. Co., 10 Misc 3d 50, 54 [App Term, 2d & 11th Jud Dists 2005]). With respect to the remaining [*2]claim, for $311.53, a triable issue exists as to whether defendant paid for said treatment as part of a prior claim submitted by plaintiff.

Pesce, P.J., Weston Patterson and Golia, JJ., concur.
Decision Date: March 5, 2007

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.

Proof of mailing

Open the full map

Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?

This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice

Held the insurer's affidavits, stating the affiants' knowledge of preparing and issuing the verification letters and detailing standard office mailing procedure, gave rise to the presumption of mailing.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (this one included) are in the same category.

Outstanding verification and premature actions

Open the full map

Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?

This decision: Timely requests went unanswered; the claim is not overdue and the action is premature

Held the claims premature because timely initial and follow-up requests for the assignor's social security number, a proper verification subject, remained unanswered.

Premature: verification outstandingNonresponse denial upheldTriable issueInsurer's showing failsProvider compliedThis decisionCites it or cited by itCited or followed

Of the 385 decisions on this question in the Second Department courts and the Court of Appeals, 153 (this one included) are in the same category.

Cited in this decision

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

Olympic Chiropractic, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50011(U)) FollowedA timely but factually insufficient IME denial does not preserve a medical-necessity defense.
New York & Presbyt. Hosp. v Progressive Cas. Ins. Co. (2004 NY Slip Op 01750) FollowedThe insurer proved policy exhaustion on one hospital claim and absence of coverage on another, requiring dismissal of both.
A.B. Med. Servs. PLLC v Utica Mut. Ins. Co. (2005 NY Slip Op 25456) FollowedThe providers obtained partial summary judgment because defective EUO requests and incomplete IME follow-up failed to toll denial time.

Similar decisions

D.S. Chiropractic, P.C. v Country-Wide Ins. Co. (2009 NY Slip Op 51579(U))The insurer's verification follow-ups mailed on the 30th calendar day were ineffective, defeating its argument that the action was premature.
Island Chiropractic Testing, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51795(U))The provider's verification responses presented a factual dispute that precluded summary judgment for either party.
Compas Med., P.C. v American Tr. Ins. Co. (2015 NY Slip Op 51240(U))Conflicting proof of claim receipt and verification responses precluded summary judgment for either party.
A.M. Med. Servs., P.C. v New York Cent. Mut. Ins. (2006 NY Slip Op 51662(U))The insurer proved mailing of one medical necessity denial but failed to prove verification mailing for four other claims.
Northshore Chiropractic Diagnostics, P.C. v A. Cent. Ins. Co. (2014 NY Slip Op 51825(U))The insurer's verification requests were timely, but a factual issue remained as to whether the provider adequately responded.