April 30, 2014
J.C. Healing Touch Rehab, P.C. v Eveready Ins. Co. (2014 NY Slip Op 50774(U))
https://www.beynensonlaw.com/case-law/j-c-healing-touch-rehab-p-c-v-eveready-ins-co-2014-ny-slip-op50774u/
- Decided
- April 30, 2014
- Citation
- 2014 NY Slip Op 50774(U) · 43 Misc 3d 138(A)
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Issues
- Verification requests
- Legal questions
- Outstanding verification and premature actions (see the maps)
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 J.C. Healing Touch Rehab, P.C. v Eveready Ins. Co. (2014 NY Slip Op 50774(U))
| J.C. Healing Touch Rehab, P.C. v Eveready Ins. Co. |
| 2014 NY Slip Op 50774(U) [43 Misc 3d 138(A)] |
| Decided on April 30, 2014 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports.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, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-378 K C
against
Eveready Ins. Co., Appellant.
Appeal from an order of the Civil Court of the City of New York, Kings County (Pamela L. Fisher, J.), entered October 31, 2011. The order, insofar as appealed from, upon denying plaintiff’s motion for summary judgment, made, in effect, CPLR 3212 (g) findings in plaintiff’s favor, and denied defendant’s cross motion for summary judgment dismissing the complaint.
[*1]ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.
In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment, and defendant cross-moved for summary judgment dismissing the complaint on the ground that it had timely and properly denied the claims at issue based on a lack of medical necessity. Insofar as is relevant to this appeal, the Civil Court, upon denying plaintiff’s motion, made, in effect, CPLR 3212 (g) findings in plaintiff’s favor, denied defendant’s cross motion, and held that the only remaining issue for trial was whether the verification requested by defendant was outstanding.
For the reasons stated in EMC Health Prods., Inc. as Assignee of Brian Byers v Geico Ins. Co. (___ Misc 3d ___, 2014 NY Slip Op _____ [Appeal No. 2012-1208 K C], decided herewith), we find that defendant failed to articulate a sufficient basis to strike the Civil Court’s implicit CPLR 3212 (g) findings in plaintiff’s favor. Moreover, upon a review of the record, we find that the Civil Court correctly found that there is a triable issue of fact as to whether the verification requested by defendant was outstanding (see Westchester Med. Ctr. v A Cent. Ins. Co., 114 AD3d 937 [2014] Wyckoff Hgts. Med. Ctr. v Government Empls. Ins. Co., 114 AD3d 855 [2014]).
Accordingly, the order, insofar as appealed from, is affirmed.
Pesce, P.J., Aliotta and Solomon, JJ., concur.
Decision Date: April 30, 2014
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.
Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?
This decision: Fact issues remain on whether the verification defense applies (rules on the question, but another ground decided the case)
Affirmed that a triable issue of fact existed as to whether the verification the insurer requested remained outstanding, leaving that as the only trial issue after the insurer's medical-necessity cross motion and challenge to the CPLR 3212 (g) findings failed.
Of the 385 decisions on this question in the Second Department courts and the Court of Appeals, 114 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 01319) FollowedThe insurer raised a factual issue as to whether it mailed a proper denial 22 days after receiving requested verification.
- Wyckoff Hgts. Med. Ctr. v Government Empls. Ins. Co. (2014 NY Slip Op 01166) FollowedAn insurer's denial need not include a peer review report or other medical evidence when issued under 11 NYCRR 65-3.8.
Similar decisions
- SS Med. Care, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51305(U))The provider's action was premature because the insurer proved timely verification requests and nonreceipt of the requested information.
- City Chiropractic, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51802(U))The provider's action was premature because it did not show that all requested verification had been supplied before suit.
- J.C. Healing Touch Rehab, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 50033(U))The provider's verification-mailing proof raised a factual issue on prematurity, but its own summary judgment proof was deficient.
- J.C. Healing Touch Rehab, P.C. v Nationwide Ins. (2013 NY Slip Op 52011(U))The insurer's EUO scheduling letters were timely mailed and tolled the 30-day claim determination period.
- J.C. Healing Touch Rehab, P.C. v Amica Mut. Ins. Co. (2014 NY Slip Op 50969(U))The provider failed to establish either an untimely denial or a timely denial that was legally insufficient.