November 28, 2006

Montefiore Med. Ctr. v Government Empls. Ins. Co. (2006 NY Slip Op 08953)

https://www.beynensonlaw.com/case-law/montefiore-med-ctr-v-government-empls-ins-co-2006-ny-slip-op-08953/

Court: Appellate Division, Second Department
Decided: November 28, 2006
Citation: 2006 NY Slip Op 08953 · 34 AD3d 771
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 5 later decisions (see Cited by)
Issues: Verification requests Policy issues Timeliness and preclusion
Legal questions: Exhaustion of policy limits (see the maps)

Cite as

Montefiore Med. Ctr. v Government Empls. Ins. Co., 34 AD3d 771 (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's additional verification request following an N-F5 submission need not use a prescribed form to toll the payment deadline. The Appellate Division, Second Department, reversed the order and denied the provider's summary judgment motion. Under 11 NYCRR 65-3.5 (b), Insurance Law § 5106 (a), and 11 NYCRR 65-3.8 (a) (1) and 11 NYCRR 65-3.8 (a) (2), the request tolled payment or denial until the requested information arrived; the insurer's subsequent partial payment and denial were timely. Admissible evidence established proper prior payments to other providers under 11 NYCRR 65-3.15. Policy exhaustion remained a triable issue because the employee's affidavit asserted exhaustion, but the business-record payment register showed benefits exceeding the provider's bill. That issue awaited further proceedings.

Reported in New York Official Reports at Montefiore Med. Ctr. v Government Empls. Ins. Co. (2006 NY Slip Op 08953)

Montefiore Med. Ctr. v Government Empls. Ins. Co.

2006 NY Slip Op 08953 [34 AD3d 771]

November 28, 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

Montefiore Medical Center, as Assignee of Juan Garcia, Respondent,
v
Government Employees Insurance Company, Appellant.

—[*1]

In an action to recover no-fault medical payments under an insurance contract, the defendant appeals from an order of the Supreme Court, Nassau County (Bucaria, J.), dated September 15, 2005, which granted the plaintiff’s motion for summary judgment.

Ordered that the order is reversed, on the law, with costs, and the plaintiff’s motion for summary judgment is denied.

Contrary to the Supreme Court’s determination, the defendant’s request for additional verification, which followed the plaintiff’s submission of an N-F5 verification, did not have to be set forth in a prescribed form (see 11 NYCRR 65-3.5 [b]; Nyack Hosp. v Progressive Cas. Ins. Co., 296 AD2d 482, 483 [2002]). Therefore, the additional verification request tolled the defendant’s time within which to pay or deny the claim (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [a] [1], [2]) until the defendant received all of the relevant information requested (see Nyack Hosp. v General Motors Acceptance Corp., 27 AD3d 96, 101 [2005]; Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533, 535 [2004]; St. Vincent’s Hosp. of Richmond v American Tr. Ins. Co., 299 AD2d 338, 340 [2002]; New York & Presbyt. Hosp. v American Tr. Ins. Co., 287 AD2d 699, 700 [2001]). Since the defendant sent a partial payment and denial of benefits to the plaintiff after the requested material was provided and within the applicable time period, its response to the claim was not untimely. [*2]

Furthermore, the affidavit and documentary evidence submitted by the defendant in opposition to the plaintiff’s motion for summary judgment were in admissible form, since the affiant adequately stated her basis of knowledge for the facts asserted in her affidavit and laid a proper foundation for the introduction of the documents. Moreover, those submissions established that other medical providers were properly paid before the plaintiff (see 11 NYCRR 65-3.15; Nyack Hosp. v General Motors Acceptance Corp., supra at 103). However, a triable issue of fact exists as to whether the no-fault benefits under the subject policy were exhausted, since the affidavit of the defendant’s employee indicates that they were, but the payment register maintained by the defendant in the regular course of business reveals a balance of no-fault benefits in excess of the amount billed by the plaintiff. Accordingly, determination of the issue of whether the policy limits were in fact exhausted before full payment could be made to the plaintiff must await further proceedings.

The plaintiff’s remaining contentions are without merit. Adams, J.P., Ritter, Mastro and Lifson, JJ., concur.

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.

Exhaustion of policy limits

Open the full map

Did the insurer prove the policy’s no-fault limits were properly exhausted before it became obligated to pay the claim?

This decision: Exhaustion cannot be decided on this record: issue of fact, framed-issue hearing, or remittal to decide the defense

Held that, although the insurer's admissible proof showed other providers were properly paid first under 65-3.15, a triable issue existed on exhaustion because its own payment register showed a balance exceeding the amount billed.

Limits exhaustedCoverage left when dueExhaustion not provedTriable issue / hearingDefense not heardThis decisionCites it or cited by itCited or followed

Of the 68 decisions on this question in the Second Department courts and the Court of Appeals, 9 (this one included) are in the same category.

Cited in this decision

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

Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 05413) FollowedThe hospitals' first and fifth claims were dismissed because policy limits were exhausted and requested verification remained outstanding.

Cited by (12)

A label shows how the later decision treated this one.

Westchester Med. Ctr. v American Tr. Ins. Co. (2009 NY Slip Op 01979) FollowedThe insurer's timely verification request and ensuing timely denial defeated the provider's motion for summary judgment.
New York & Presbyt. Hosp. v Countrywide Ins. Co. (2007 NY Slip Op 07675) FollowedThe insurer raised verification and billing-date issues on one claim, but failed to rebut proof of receipt of verification on another.
Westchester Med. Ctr. v Allstate Ins. Co. (2008 NY Slip Op 06146) FollowedThe insurer raised a factual issue about the provider's compliance with timely verification requests for toxicology information.
Mount Sinai Hosp. v Country Wide Ins. Co. (2011 NY Slip Op 05680) FollowedThe insurer raised factual issues about policy exhaustion during a verification toll and payment with overdue interest before suit.
Westchester Med. Ctr. v Hartford Cas. Ins. Co. (2009 NY Slip Op 00528) FollowedThe insurers showed an excusable default and a potentially meritorious defense based on partial exhaustion of policy limits.
Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co. (2009 NY Slip Op 00351)Judicially noticed diagnosis codes alone do not establish that treatment was wholly unrelated to an insured automobile accident.
Carle Place Chiropractic v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 51065(U))The insurer failed to prove timely denial mailing and was precluded from asserting lack of medical necessity.
Lincoln Gen. Ins. Co. v Alev Med. Supply Inc. (2009 NY Slip Op 29389)An insurer may not recover paid no-fault benefits for undelivered supplies when it failed to timely deny the claim for billing fraud.
Clear Water Psychological Servs., P.C. v Hereford Ins. Co. (2020 NY Slip Op 50847(U))The insurer's letters merely reported missing documents and did not establish proper verification requests warranting dismissal.
Uniondale Chiropractic Off. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 51687(U))The provider proved mailing of disputed bills, while the insurer failed to prove timely denials preserving its medical-necessity defense.

Show all 12 citing decisions

Similar decisions

Montefiore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 05783)The insurer raised factual issues concerning denial of one hospital's late claim and timely verification requests for another's incomplete claim.
Lenox Hill Hosp. v Government Empls. Ins. Co. (2011 NY Slip Op 08330)The insurer's evidence of a timely denial raised a triable issue defeating the provider's motion based solely on untimeliness.
Contemp. Med. Diag. & Treatment, P.C. v Government Employees Ins. Co. (2005 NY Slip Op 50254(U))The insurer's conclusory office-practice affidavit failed to prove timely mailing of verification requests.
Mount Sinai Hosp. v Government Empls. Ins. Co. (2011 NY Slip Op 05679)The insurer raised a triable issue as to whether it issued a denial of claim form to the hospital.
St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072)The insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.