July 2, 2007

Inwood Hill Med. P.C. v Utica Mut. Ins. Co. (2007 NY Slip Op 51309(U))

https://www.beynensonlaw.com/case-law/inwood-hill-med-p-c-v-utica-mut-ins-co-2007-ny-slip-op-51309u/

Court: Appellate Term, First Department
Decided: July 2, 2007
Citation: 2007 NY Slip Op 51309(U) · 16 Misc 3d 130(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Timeliness and preclusion Staged accidents, lack of coverage
Legal questions: No covered accident (founded belief) (see the maps)

Cite as

Inwood Hill Med. P.C. v Utica Mut. Ins. Co., 16 Misc 3d 130(A), 2007 NY Slip Op 51309(U) (App Term, 1st Dept 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 insurer's late denials precluded its statutory, policy-condition, exclusion, and fraudulent-billing defenses. The providers established prima facie entitlement to summary judgment, and the insurer undisputedly failed to deny their claims within 30 days under 11 NYCRR 65-3.8 (c). Although a lack-of-coverage defense survived untimely denial under Central Gen. Hosp. v Chubb Group of Ins. Cos., the insurer's documents did not raise a factual issue as to whether the injuries arose from an insured incident or the collision was intentional and part of an insurance fraud scheme. The Appellate Term, First Department, reversed the order denying the providers' motion and granted them summary judgment.

Reported in New York Official Reports at Inwood Hill Med. P.C. v Utica Mut. Ins. Co. (2007 NY Slip Op 51309(U))

[*1]

Inwood Hill Med. P.C. v Utica Mut. Ins. Co.

2007 NY Slip Op 51309(U) [16 Misc 3d 130(A)]

Decided on July 2, 2007

Appellate Term, First 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This opinion is uncorrected and will not be published in the printed Official Reports.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 July 2, 2007

APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT

PRESENT: McCOOE, J.P., SCHOENFELD, HEITLER, JJ
570095/07.

Inwood Hill Medical P.C., Westchester Neurodiagnostic PC, and New Psychology P.C. a/a/o Angelita Rosario, individually and as mother of Jonathan Ramirez and Jessica Ramirez, Plaintiffs-Appellants, – –
against
Utica Mutual Insurance Company, Defendant-Respondent.

Plaintiffs appeal from an order of the Civil Court of the City of New York, New York County (Eileen A. Rakower, J.), dated August 15, 2005, which denied their motion for summary judgment.

Per Curiam.

Order (Eileen A. Rakower, J.), dated August 15, 2005, reversed, with $10 costs, and plaintiffs’ motion for summary judgment granted in the principal amount of $21,913.39.

In opposition to plaintiffs’ prima facie showing of entitlement to summary judgment, defendant failed to raise any triable issues of fact. Inasmuch as it is undisputed that defendant did not timely deny the subject claims within 30 days of receipt thereof (see 11 NYCRR 65-3.8 [c]), it is precluded from asserting any statutory defenses (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]), defenses predicated upon breach of conditions precedent or policy exclusion (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]), or a defense of provider fraud based on fraudulent billing practices (see Valley Psychological, P.C. v Liberty Mut. Ins. Co., 30 AD3d 718, 719 [2006]).

While an untimely denial does not preclude a defense based on lack of coverage, defendant’s documentary submissions were insufficient to raise issues of fact as to whether the alleged injuries arose out of an insured incident (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d at 199) or whether the accident was an intentional collision in furtherance of an insurance fraud scheme (see Matter of Metro Med. Diagnostics v Eagle Ins., 293 AD2d 751 [2002]).

We have considered defendant’s remaining arguments and find them unavailing.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concurI concurI concur
Decision Date: July 2, 2007

Legal questions

A question 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.

No covered accident (founded belief)

Open the full map

Did the insurer show the claimed injuries did not arise from a covered accident (staged, intentional, or unrelated)?

This decision: Insurer's proof did not raise an issue or failed at trial; provider prevails on it

Held the insurer's documentary submissions insufficient to raise an issue of fact whether the injuries arose from an insured incident or the accident was an intentional collision in an insurance fraud scheme, so the provider won summary judgment.

Defense establishedTriable issueInsurer's motion failsDefense not shownThis decision

Of the 29 decisions on this question in the First Department courts and the Court of Appeals, 7 (this one included) are in the same category.

Cited in this decision

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

Valley Psychological, P.C. v Liberty Mut. Ins. Co. (2006 NY Slip Op 04480) FollowedAn insurer's untimely denial precludes a fraud defense based on a psychologist's alleged failure to supervise treatment.

Similar decisions

Inwood Hill Med., P.C. v Utica Mut. Ins. Co. (2009 NY Slip Op 51129(U))The providers' medical biller failed to establish admissibility of the supporting documents, defeating their motion for summary judgment.
AT Med. P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50739(U))An untimely denial does not preclude a defense that the collision furthered an insurance fraud scheme.
Inwood Hill Med., P.C. v Metropolitan Prop. & Cas. Ins. Co. (2009 NY Slip Op 51264(U))The insurer was precluded from asserting a workers' compensation defense because it failed to establish timely mailing of its denial.
West Tremont Med. Diagnostics P.C. v Utica Mut. Ins. Co. (2009 NY Slip Op 51325(U))The insurer failed to establish a founded belief supporting its staged-accident defense, and its policy-exclusion defense was precluded.
Inwood Hill Med., P.C. v Progressive Cas. Ins. Co. (2009 NY Slip Op 51397(U))The insurer failed to prove the assignor's EUO and IME nonappearances, while the providers failed to authenticate their billing records.