June 3, 2005
GPM Chiropractic, P.C. v State Farm Mut. Ins. Co (2005 NYSlipOp 50861(U))
https://www.beynensonlaw.com/case-law/gpm-chiropractic-p-c-v-state-farm-mut-ins-co-2005-nyslipop-50861u/
- Decided
- June 3, 2005
- Citation
- 2005 NY Slip Op 50861(U)
- 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 GPM Chiropractic, P.C. v State Farm Mut. Ins. Co (2005 NYSlipOp 50861(U))
| GPM Chiropractic, P.C. v State Farm Mut. Ins. Co |
| 2005 NYSlipOp 50861(U) |
| Decided on June 3, 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS
PRESENT: June 3, 2005 SUPREME COURT OF THE STATE OF NEW YORK APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS PRESENT : PESCE, P.J., PATTERSON and BELEN, JJ.
2004-767 Q C
against
State Farm Mutual Insurance Co, Appellant.
Appeal by defendant from an order of the Civil Court, Queens County (A. Gazzara, J.), entered October 21, 2003, granting plaintiff’s cross motion for summary judgment.
Order unanimously reversed with $10 costs and plaintiff’s cross motion for summary judgment denied.
In this action to recover first-party no-fault benefits for medical services rendered to its assignor, plaintiff health care provider established a prima facie entitlement to summary judgment by proof that it submitted a claim, setting forth the fact and the amount of 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]). The burden then shifted to defendant to show a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).
It is uncontroverted that defendant did not deny plaintiff’s claim within the statutory period. Consequently, defendant is precluded from raising most defenses (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]; Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]), including any deficiency in the assignments (see New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co., 8 AD3d 640 [2004]; Presbyterian Hosp. in City of N.Y. v Aetna Cas. & Sur. Co., 233 AD2d 433 [1996]; A.B. Med. [*2]Servs. PLLC. v Nationwide Mut. Ins. Co., 6 Misc 3d 70 [App Term, 2d & 11th Jud Dists 2004]). Moreover, defendant’s requests for examinations under oath did not toll the 30-day claim determination period inasmuch as the applicable insurance regulations did not contain a provision entitling an insurer to an examination under oath (see King’s Med. Supply v Kemper Auto & Home Ins. Co., 3 Misc 3d 131[A], 2004 NY Slip Op 50401[U] [App Term, 2d & 11th Jud Dists]).
Nevertheless, defendant 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]). We find that the affidavit submitted by defendant’s special investigator was sufficient to demonstrate that defendant’s denial was based upon a “founded belief that the alleged injur[ies] do[ ] not arise out of an insured incident” (Central Gen. Hosp, 90 NY2d at 199). Consequently, a triable issue of fact exists as to whether there was a lack of coverage (see id.; Zuckerman v City of New York, 49 NY2d 557 [1980]). Accordingly, plaintiff’s cross motion for summary judgment is denied.
Decision Date: June 03, 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 special investigator's affidavit sufficient to show a founded belief that the collision furthered an insurance fraud scheme, raising a triable coverage issue that required denial of the provider's cross motion.
Of the 233 decisions on this question in the Second Department courts and the Court of Appeals, 102 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on 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 provider established its prima facie entitlement by proof that it submitted a claim stating the fact and amount of loss and that payment was overdue, shifting the burden to the insurer.
Of the 1,063 decisions on this question in the Second Department courts and the Court of Appeals, 511 (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.
- 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.
- A.B. Med. Servs. PLLC v Nationwide Mut. Ins. Co. (2004 NY Slip Op 24506)The providers' billing manager affidavit failed to establish submission of properly completed claim forms.
- King’S Med. Supply v Kemper Auto & Home Ins. Co. (2004 NY Slip Op 50401(U)) FollowedAn insurer cannot deny a claim for EUO nonappearance under the former regulation by invoking a policy's cooperation clause.
Cited by
- A.M. Med. Servs., P.C. v Nationwide Mut. Ins. Co. (2006 NY Slip Op 51425(U))The insurer's EUO transcripts supported a founded belief of fraud, raising a coverage issue that defeated both summary judgment motions.
- AA Acupuncture Serv., P.C. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 51066(U))An insurer's founded belief that a collision was staged raises a factual issue rather than establishing entitlement to summary judgment.
Similar decisions
- Gpm Chiropractic, P.C. v State Farm Mut. Ins. Co. (2005 NYSlipOp 50744(U))The insurer's investigator affidavit raised a triable coverage issue, but the assignor's EUO nonattendance did not warrant insurer summary judgment.
- New Century Chiropractic, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 52236(U))The insurer's investigator established a founded belief that the injuries did not arise from an insured incident, raising a coverage issue.
- A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51104(U))The insurer's investigator raised a triable fraud-related coverage issue despite EUO requests that did not toll the denial period.
- Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51275(U))The insurer's investigator affidavit failed to establish a founded belief that the claimed injuries did not arise from an insured incident.
- A.M. Med. Servs., P.C. v State Farm Mut. Ins. Co. (2007 NY Slip Op 52300(U))The insurer's investigator raised a triable issue as to whether the assignor's injuries arose from an insured incident.