March 8, 2004

Hospital for Joint Diseases v Allstate Ins. Co. (2004 NY Slip Op 01546)

https://www.beynensonlaw.com/case-law/hospital-for-joint-diseases-v-allstate-ins-co-2004-ny-slip-op-01546/

Court: Appellate Division, Second Department
Decided: March 8, 2004
Citation: 2004 NY Slip Op 01546 · 5 AD3d 441
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Distinguished in 1, contrasted (cf., but see) in 1 and followed in 5 later decisions (see Cited by)
Issues: Timeliness and preclusion

Cite as

Hospital for Joint Diseases v Allstate Ins. Co., 5 AD3d 441 (2d Dept 2004)

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.

Resubmission of a previously denied no-fault claim does not restart the insurer's 30-day period to deny it. The hospital sued solely on the insurer's failure to pay or deny resubmitted bills within 30 days under Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3). The insurer established that it had timely denied identical claims previously submitted by the hospital. The Appellate Division, Second Department, affirmed denial of the hospital's summary judgment motion and grant of the insurer's cross motion dismissing the complaint. The hospital could challenge the original denials by suit or arbitration under Insurance Law § 5106 (b); the court did not reach the remaining contentions.

Reported in New York Official Reports at Hospital for Joint Diseases v Allstate Ins. Co. (2004 NY Slip Op 01546)

Hospital for Joint Diseases v Allstate Ins. Co.

2004 NY Slip Op 01546 [5 AD3d 441]

March 8, 2004

Appellate Division, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, May 26, 2004

Hospital for Joint Diseases, as Assignee of Irene Allen, Appellant,
v
Allstate Insurance Company, Respondent.

—

In an action to recover unpaid benefits due under the no-fault provisions of the Insurance Law, the plaintiff appeals from an order of the Supreme Court, Nassau County (Cozzens, J.), dated January 31, 2003, which denied its motion for summary judgment and granted the defendant’s cross motion for summary judgment dismissing the complaint.

Ordered that the order is affirmed, with costs.

The plaintiff Hospital for Joint Diseases, as assignee of its patient, alleged in its complaint that the defendant no-fault insurer was liable for two no-fault claims which were mailed on March 6, 2002, because it neither paid nor denied the claims within 30 days of receipt, as required by Insurance Law § 5106 (a) and the corresponding regulation of the Insurance Department, 11 NYCRR 65.15 (g) (3). Thereafter, the plaintiff made the same argument in a motion for summary judgment.

The defendant cross-moved for summary judgment dismissing the complaint, submitting evidence that before the medical services at issue were rendered, it had notified the plaintiff’s assignor that it had terminated her no-fault benefits based upon an independent medical examination, and that the plaintiff had previously submitted claims for these same billings which the defendant timely denied. The Supreme Court denied the plaintiff’s motion, granted the defendant’s cross motion, and dismissed the complaint. The plaintiff appeals.

We affirm. Under the no-fault law, a claimant whose claim for benefits has been denied is entitled to “seek immediate redress, and to recover both the amount of any overdue claim and reasonable attorney’s fees in securing payment” (Roggio v Nationwide Mut. Ins. Co., 66 NY2d 260, 262 [1985]). A claimant may either file suit seeking payment of the claim, or, pursuant to Insurance Law § 5106 (b), submit the dispute to arbitration, pursuant to simplified procedures promulgated by the Insurance Department. In this case, the plaintiff did neither, opting instead to repeatedly resubmit the denied claims, apparently in the hope that eventually the defendant would fail to issue a denial within 30 days of receipt. We hold, however, that the 30-day period in which to deny a claim for no-fault benefits does not run anew as the result of the re-submission of a previously-denied claim.

Since the plaintiff’s complaint was predicated solely upon the defendant’s failure to pay or deny the claims sent March 6, 2002, within 30 days of receipt, and the defendant established that it previously issued timely denials for identical claims submitted by the plaintiff, the defendant was properly granted summary judgment dismissing the complaint.

In light of the foregoing, we do not reach the parties’ remaining contentions. Smith, J.P., Goldstein, Luciano and Adams, JJ., concur.

Cited by (12)

A label shows how the later decision treated this one.

Willis Acupuncture, PC v Government Employees Ins. Co. (2004 NY Slip Op 51702(U)) DistinguishedAn earlier blanket medical-necessity disclaimer does not excuse an insurer from timely denying each provider claim.
Mount Sinai Hosp. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 05779) Contrasted (cf., but see)The insurer's denial of a defective UB-04 submission did not excuse its failure to respond to the hospital's later NF-5 claim.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2004 NY Slip Op 08669) FollowedAn untimely denial does not preclude an exhaustion defense or establish entitlement to judgment on a previously denied duplicate claim.
New York & Presbyt. Hosp. v AIU Ins. Co. (2005 NY Slip Op 06014) FollowedA resubmitted no-fault claim previously and timely denied is not subject to a new 30-day payment-or-denial period.
T&G Med. Supplies, Inc. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 50636(U)) FollowedThe supplier lacked standing because its assignor neither received the supplies nor incurred an obligation to pay for them.
Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 50347(U)) FollowedResubmission of an identical claim does not restart the insurer's 30-day period to pay or deny it.
A.C. Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2021 NY Slip Op 50841(U)) FollowedThe provider could not retroactively end a verification toll by dropping the services at issue after commencing its action.
A & S Med. P.C. v Allstate Ins. Co. (2005 NY Slip Op 00505)An insurer must timely respond to a provider's first assigned claim despite an earlier blanket denial sent to the insured.
Travelers Indem. Co. v Parisien (2020 NY Slip Op 51561(U))The insurers' declaratory judgment action was dismissed because adequate statutory remedies existed and reimbursement claims were already in litigation.
American Ind. Ins. v Gerard Ave. Med. P.C. (2005 NY Slip Op 52302(U))The out-of-state insurer failed to supply facts establishing that the arbitrator lacked power to award no-fault benefits.

Show all 12 citing decisions

Similar decisions

Hospital for Joint Diseases v Countrywide Ins. Co. (2004 NY Slip Op 06513)The insurer raised factual issues over when the providers mailed their claims and whether earlier denials properly disposed of them.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 05602)The insurer proved a timely denial but failed to establish that the provider's treatment was unrelated to the accident.
NYU-Hospital for Joint Diseases v Allstate Ins. Co. (2014 NY Slip Op 08613)The hospital failed to establish entitlement to summary judgment because its own papers included a timely and sufficient denial.
Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 05413)The hospitals' first and fifth claims were dismissed because policy limits were exhausted and requested verification remained outstanding.
New York Hosp. Med. Ctr. of Queens v Allstate Ins. Co. (2014 NY Slip Op 00640)The providers established receipt of their claim and nonpayment or improper denial within 30 days, warranting summary judgment.