December 7, 2012

Huntington Hosp. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52274(U))

https://www.beynensonlaw.com/case-law/huntington-hosp-v-new-york-cent-mut-fire-ins-co-2012-ny-slip-op52274u/

Court: Appellate Term, Second Department
Decided: December 7, 2012
Citation: 2012 NY Slip Op 52274(U) · 37 Misc 3d 141(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Verification requests
Legal questions: Outstanding verification and premature actions · Proof of mailing (see the maps)

Cite as

Huntington Hosp. v New York Cent. Mut. Fire Ins. Co., 37 Misc 3d 141(A), 2012 NY Slip Op 52274(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2012)

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 action was premature because unanswered verification requests tolled payment time, and a general denial did not address its bill. The insurer's litigation examiner established timely mailing of initial and follow-up verification requests and nonreceipt of the requested verification. The provider did not rebut that showing under 11 NYCRR 65-3.8 (a). Its opposing denial form omitted the bill's amount and date, the service provider, and the services rendered; it identified an applicant other than the provider and expressly stated that the applicant was not an assignee. The provider therefore failed to prove a denial of the particular bill. The Appellate Term, Second Department, reversed the order and granted the insurer summary judgment dismissing the complaint.

Reported in New York Official Reports at Huntington Hosp. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52274(U))

[*1]

Huntington Hosp. v New York Cent. Mut. Fire Ins. Co.

2012 NY Slip Op 52274(U) [37 Misc 3d 141(A)]

Decided on December 7, 2012

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This opinion is uncorrected and will not be published in the printed Official Reports.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 December 7, 2012

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS

PRESENT: : LaSALLE, J.P., MOLIA and IANNACCI, JJ
2011-2439 N C.

Huntington Hospital as Assignee of CANDICE VERDON, Respondent, —
against
New York Central Mutual Fire Ins. Co., Appellant.

Appeal from an order of the District Court of Nassau County, First District (Michael A. Ciaffa, J.), entered August 2, 2011. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, without costs, and defendant’s motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the District Court which denied defendant’s motion for summary judgment dismissing the complaint.

In support of its motion, defendant submitted an affidavit by its litigation examiner which established that defendant had timely mailed a request and follow-up request for verification (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]), and that the requested verification had not been provided. Since plaintiff has not rebutted defendant’s prima facie [*2]showing that defendant’s initial request and follow-up request for verification were timely mailed and that plaintiff failed to respond to the requests, defendant established that its time to pay or deny the claim had been tolled. Consequently, defendant’s motion for summary judgment dismissing the complaint, on the ground that the action was premature, should have been granted (see Insurance Department Regulations [11 NYCRR] § 65-3.8 [a]; Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 [2005]; Mary Immaculate Hosp. v New York Cent. Mut. Fire Ins. Co., 21 Misc 3d 130[A], 2008 NY Slip Op 52046[U] [App Term, 9th & 10th Jud Dists 2008]).

Contrary to plaintiff’s argument, plaintiff did not prove that defendant had issued a denial in response to the bill at issue. The denial attached to plaintiff’s opposition was a general denial, not a specific denial, as it did not set forth an amount of the bill, or the date of the bill, or who had rendered services, or what those services were. Moreover, the denial lists Candice Vernon as the applicant for benefits, not plaintiff, and explicitly states that the applicant is not an assignee.

Accordingly, the order is reversed, and defendant’s motion for summary judgment dismissing the complaint is granted.

LaSalle, J.P., Molia and Iannacci, JJ., concur.
Decision Date: December 07, 2012

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.

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 action premature because the insurer showed timely initial and follow-up verification requests that went unanswered, tolling its time to pay or deny; the general denial the provider submitted did not address the bill at issue.

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.

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 (rules on the question, but another ground decided the case)

Held the litigation examiner's affidavit established timely mailing of the initial and follow-up verification requests, and the provider did not rebut that showing.

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.

Cited in this decision

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

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 09484) FollowedAn insurer need not pay or deny a no-fault claim until it receives all relevant verification requested.
Mary Immaculate Hosp. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 52046(U)) FollowedThe provider recovered on the first claim, but the second was premature because requested assignment verification remained unanswered.

Cited by

A label shows how the later decision treated this one.

Bay Ls Med. Supplies, Inc. v Mvaic (2014 NY Slip Op 50417(U)) FollowedMVAIC's IME nonappearance defense was precluded because its scheduling letters were mailed more than 30 days after receipt of the claim.

Similar decisions

Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 50347(U))Resubmission of an identical claim does not restart the insurer's 30-day period to pay or deny it.
Nyack Hosp. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 52184(U))An insurer must accept a completed hospital facility form in place of an application for motor vehicle no-fault benefits.
Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 50033(U))The insurer established that unanswered, timely verification requests tolled its time to pay or deny the hospital's claim.
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.
NYU Hosp. for Joint Diseases v Country Wide Ins. Co. (2011 NY Slip Op 04219)The insurer's denial was fatally defective because it omitted required information and named the assignor as the benefits applicant.