November 14, 2006

Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2006 NY Slip Op 08214)

https://www.beynensonlaw.com/case-law/hospital-for-joint-diseases-v-travelers-prop-cas-ins-co-2006-ny-slip-op-08214/

Court: Appellate Division, Second Department
Decided: November 14, 2006
Citation: 2006 NY Slip Op 08214 · 34 AD3d 532
Posture: Summary judgment
Outcome: Provider prevailed
Later history: Affirmed by Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067)
Later treatment: Distinguished in 1 and contrasted (cf., but see) in 1 later decisions (see Cited by)
Issues: Provider's prima facie case Assignments and standing
Legal questions: Challenging the assignment of benefits · Claimant's prima facie case on motions (see the maps)

Cite as

Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 34 AD3d 532 (2d Dept 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.

An insurer waives claim-form and assignment defenses by failing to timely object to form adequacy or seek assignment verification. The Appellate Division, Second Department, affirmed summary judgment for the hospital on the third cause of action and denial of the insurers' cross motion to dismiss that cause of action. The hospital established entitlement through its bill, a signed certified-mail return receipt, and its third-party biller's affidavit confirming billing and the absence of payment or a denial. The insurers raised no triable issue and failed to establish entitlement on their cross motion. Their failure to timely challenge the forms or request assignment verification waived those defenses.

Reported in New York Official Reports at Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2006 NY Slip Op 08214)

Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co.

2006 NY Slip Op 08214 [34 AD3d 532]

November 14, 2006

Appellate Division, Second Department

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

As corrected through Wednesday, January 17, 2007

Hospital for Joint Diseases, Plaintiff, and New York and Presbyterian Hospital, Respondent,
v
Travelers Property Casualty Insurance Company et al., Appellant.

—[*1]

In an action to recover no-fault medical payments, the defendants appeal from an order of the Supreme Court, Nassau County (Joseph, J.), dated October 31, 2005, which granted the motion of the plaintiff New York and Presbyterian Hospital for summary judgment on the third cause of action and denied the defendants’ cross motion for summary judgment dismissing that cause of action.

Ordered that the order is affirmed, with costs.

In support of its motion for summary judgment on the third cause of action, the plaintiff New York and Presbyterian Hospital, as assignee of William Browne, made a prima facie showing of entitlement to judgment as a matter of law by submitting a hospital bill with a signed certified mail return receipt and by submitting the affidavit of its third-party biller, who attested that he billed the defendants for the subject medical treatment and that the defendants failed to pay the claim or issue a denial of claim form (see New York & Presbyt. Hosp. v Allstate Ins. Co., 30 AD3d 492, 493 [2006]). In opposition to the motion the defendants failed to raise a triable issue of fact, and in support of their cross motion for summary judgment dismissing the third cause of action the defendants failed to demonstrate their prima facie entitlement to judgment as a matter of law. The defendants’ failure to timely object to the adequacy of the claim forms or seek verification of the assignment constituted a waiver of any defenses based thereon (see Nyack Hosp. v Encompass Ins. [*2]Co., 23 AD3d 535 [2005], lv denied 7 NY3d 741 [2006]; 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 AIU Ins. Co., 8 AD3d 456 [2004]).

Accordingly, the Supreme Court properly granted the motion and denied the cross motion. Schmidt, J.P., Adams, Skelos and Covello, JJ., concur.

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.

Challenging the assignment of benefits

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Could the insurer contest the validity of the provider’s assignment of benefits, or had it waived that defense?

This decision: Insurer barred from contesting the assignment because it did not timely object, verify, deny or plead on that ground

Held the insurers could not defeat the hospital's summary judgment motion because their failure to timely object to the claim forms or seek verification of the assignment waived any defenses based on them.

Defense waivedAssignment sufficientAssignment defense upheldIssue of factThis decisionCites it or cited by itCited or followed

Of the 96 decisions on this question in the Second Department courts and the Court of Appeals, 48 (this one included) are in the same category.

Claimant's prima facie case on motions

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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 hospital made a prima facie showing by submitting the bill with a signed certified mail return receipt and its biller's affidavit that the insurer neither paid nor denied the claim.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followedDistinguished or limited

Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (this one included) are in the same category.

Cited in this decision

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

Nyack Hosp. v Encompass Ins. Co. (2005 NY Slip Op 08962) FollowedAn insurer's letters delaying payment pending its investigation do not toll the 30-day period for paying or denying a no-fault claim.
Hospital for Joint Diseases v Allstate Ins. Co. (2005 NY Slip Op 06192) FollowedAn 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) FollowedThe insurer failed to prove mailing of its denial, and the denial was incomplete even if timely.
New York Hosp. Med. Ctr. of Queens v AIU Ins. Co. (2004 NY Slip Op 05217) FollowedThe insurer waived objections to missing signatures by failing to challenge the hospital forms' completeness within 10 days of receipt.

Cited by

A label shows how the later decision treated this one.

Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067) AffirmedAn insurer that fails to timely seek verification of an assignment cannot later contest its validity when the underlying claim is covered.
NYU Hosp. for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 22379) DistinguishedA hospital seeking no-fault benefits must prove the fact and amount of loss; prescribed hospital claim forms are not inherently more reliable.
A.B. Med. Servs., PLLC v GEICO Cas. Ins. Co. (2007 NY Slip Op 03635) Contrasted (cf., but see)An insurer need not include a medical rationale in a denial form based on a medical examination or peer review report.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430)A provider need not prove a claim's merits for summary judgment where the insurer failed to timely and properly deny the claim.
New York Univ. Hosp. Rusk Inst. v Government Empls. Ins. Co. (2007 NY Slip Op 03671)An insurer need not set forth a medical rationale in a denial form when the denial rests on a medical examination or peer review report.
Westchester Med. Ctr. v Countrywide Ins. Co. (2007 NY Slip Op 09024)The insurer failed to prove mailing of verification requests and waived defenses based on incomplete assignment forms.
Westchester Med. Ctr. v Safeco Ins. Co. of Am. (2007 NY Slip Op 04484)The insurer waived claim-form and assignment defenses by failing to object timely to the forms or seek assignment verification.
New York & Presbyt. Hosp. v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 01537)The hospital established receipt of its no-fault billing and the insurer's failure to respond within the required 30-day period.
New York Hosp. Med. Ctr. of Queens v Country Wide Ins. Co. (2011 NY Slip Op 01628)The hospital satisfied verification requests by supplying the precise version of the NF-5 and assignment forms the insurer requested.

Similar decisions

Hospital for Joint Diseases v New York City Tr. Auth. (2005 NY Slip Op 01679)The self-insurer's evidence raised a triable issue about timely denial but did not establish entitlement to summary judgment.
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 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.
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.
Nyack Hosp. v Allstate Ins. Co. (2014 NY Slip Op 00641)The insurer waived objections to deficient claim forms by failing to contest their adequacy timely at the claims stage.