October 15, 2013

Lenox Hill Radiology & Mia, P.C. v American Mfrs. Mut. Ins. Co. (2013 NY Slip Op 51750(U))

https://www.beynensonlaw.com/case-law/lenox-hill-radiology-mia-p-c-v-american-mfrs-mut-ins-co-2013-nyslip-op-51750u/

Court: Appellate Term, Second Department
Decided: October 15, 2013
Citation: 2013 NY Slip Op 51750(U) · 41 Misc 3d 131(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Timeliness and preclusion
Legal questions: Proof of mailing (see the maps)

Cite as

Lenox Hill Radiology & Mia, P.C. v American Mfrs. Mut. Ins. Co., 41 Misc 3d 131(A), 2013 NY Slip Op 51750(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013)

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 submitted its claims more than 45 days after the services and offered no explanation for the delay. The insurers' claims examiner established both timely mailing of the denial and the provider's late submission under 11 NYCRR 65-1.1. The denial adequately identified the ground and advised the provider that a reasonable justification would excuse lateness, as required by 11 NYCRR 65-3.3 (e). The provider supplied none. The Appellate Term, Second Department, reversed the order denying the insurers' motion and granted summary judgment dismissing the complaint for assigned no-fault benefits.

Reported in New York Official Reports at Lenox Hill Radiology & Mia, P.C. v American Mfrs. Mut. Ins. Co. (2013 NY Slip Op 51750(U))

[*1]

Lenox Hill Radiology & Mia, P.C. v American Mfrs. Mut. Ins. Co.

2013 NY Slip Op 51750(U) [41 Misc 3d 131(A)]

Decided on October 15, 2013

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This opinion is uncorrected and will not be published in the printed Official Reports.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 October 15, 2013

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ
2011-2886 K C.

Lenox Hill Radiology and Mia, P.C. as Assignee of BERNARD MANU, Respondent, —
against
American Manufacturers Mutual Ins. Co., AMERICAN MOTORISTS INS. CO., AMERICAN PROTECTION INS. CO. and LUMBERMENS MUTUAL CASUALTY COMPANY All Doing Business as KEMPER INSURANCE COMPANIES, Appellants.

Appeal from an order of the Civil Court of the City of New York, Kings County (Reginald A. Boddie, J.), entered October 18, 2011. The order denied defendants’ motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, with $30 costs, and defendants’ motion for summary judgment dismissing the complaint is granted.

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

In support of their motion, defendants proffered an affidavit by their claims examiner which was sufficient to establish that defendants’ denial of claim form had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]) and that plaintiff had submitted its claims to defendants more than 45 days after the date the services had been rendered to plaintiff’s assignor (see Insurance Department Regulations [11 NYCRR] § 65-1.1). Defendants’ denial of claim form adequately advised plaintiff of the basis for the denial, and it further advised plaintiff that the late submission of the claim would be excused if plaintiff provided a reasonable justification for the lateness (see Insurance Department Regulations [11 NYCRR] § 65-3.3 [e]). Plaintiff failed to offer any explanation for the delay.

Accordingly, the order is reversed and defendants’ motion for summary judgment dismissing the complaint is granted.
Pesce, P.J., Aliotta and Solomon, JJ., concur. [*2]
Decision Date: October 15, 2013

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.

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 claims examiner's affidavit sufficient to establish timely mailing of the denial, supporting dismissal because the claims were submitted beyond 45 days without any explanation.

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 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 806 (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.
Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345) FollowedAn insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.

Cited by

A label shows how the later decision treated this one.

New York Med. & Diagnostic Ctr. v GEICO Ins. Co. (2021 NY Slip Op 51138(U)) FollowedThe insurer established untimely submission of five claims but failed to prove its fee-schedule defense to the remaining claim.

Similar decisions

Lenox Hill Radiology v Great N. Ins. Co. (2016 NY Slip Op 50206(U))The provider's mailing affidavit raised a triable issue over submission of the claim form despite the insurer's proof of nonreceipt.
Lenox Hill Radiology & MIA, P.C. v Global Liberty Ins. Co. of N.Y. (2018 NY Slip Op 51810(U))The provider's action was premature because timely verification requests remained unanswered when the action was commenced.
Lenox Hill Radiology, P.C. v Redland Ins. Co. (2012 NY Slip Op 52263(U))The insurer proved that its denial was issued in duplicate, resolving the sole issue left by its unopposed summary judgment motion.
Health Plus Med., P.C. v American Mfrs. Mut. Ins. Co. (2008 NY Slip Op 51444(U))The provider failed to lay a business-record foundation, and the insurers failed to prove timely mailing of verification requests and denials.
Lynbrook Med., P.C. v GEICO Gen. Ins. Co. (2011 NY Slip Op 51841(U))The providers failed to establish entitlement to summary judgment because they did not show that the insurer's timely denials lacked merit.