January 24, 2006
Mount Sinai Hosp. v Allstate Ins. Co. (2006 NY Slip Op 00490)
https://www.beynensonlaw.com/case-law/mount-sinai-hosp-v-allstate-ins-co-2006-ny-slip-op-00490/
- Decided
- January 24, 2006
- Citation
- 2006 NY Slip Op 00490 · 25 AD3d 673
- Posture
- Summary judgment
- Outcome
- Split result
- Later treatment
- Followed in 4 later decisions (see Cited by)
- 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 Mount Sinai Hosp. v Allstate Ins. Co. (2006 NY Slip Op 00490)
| Mount Sinai Hosp. v Allstate Ins. Co. |
| 2006 NY Slip Op 00490 [25 AD3d 673] |
| January 24, 2006 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| Mount Sinai Hospital, as Assignee of Trinidad Goforth, Respondent, et al., Plaintiffs, v Allstate 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 (O’Connell, J.), entered April 20, 2005, which granted that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action, asserted on behalf of the plaintiff Mount Sinai Hospital, as assignee of Trinidad Goforth, and, in effect, denied that branch of its cross motion which was for summary judgment dismissing the first cause of action.
Ordered that the order is modified, on the law, by deleting the provision thereof granting that branch of the motion which was for summary judgment on the first cause of action and substituting therefor a provision denying that branch of the motion; as so modified, the order is affirmed, with costs to the appellant.
In support of that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action, asserted on behalf of the plaintiff Mount Sinai Hospital, as assignee of Trinidad Goforth (hereinafter Mount Sinai), sufficient evidentiary proof was submitted to establish, prima facie, that the defendant, Allstate Insurance Company (hereinafter Allstate), did not pay or deny Mount Sinai’s claim for no-fault medical payments within 30 days as required by 11 NYCRR 65-3.8 (c). However, the evidence submitted by Allstate in opposition to the motion and in support of [*2]that branch of its cross motion which was for summary judgment dismissing the first cause of action, while insufficient to establish its prima facie entitlement to judgment as a matter of law, was sufficient to raise a triable issue of fact as to whether Mount Sinai complied with a demand for verification in accordance with the mandates of 11 NYCRR former 65.15 (g) (1) (i) and (2) (iii). Until it is established when the 30-day period within which Allstate was required to respond began to run, any claim for payment was premature (see 11 NYCRR former 65.15 [g] [1] [i]; [2] [iii]; Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533 [2004]; St. Vincent’s Hosp. of Richmond v American Tr. Ins. Co., 299 AD2d 338, 340 [2002]; Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553 [1999]; see also Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 [2005]).
Accordingly, the Supreme Court correctly denied that branch of the cross motion which was for summary judgment dismissing the first cause of action, but should not have granted that branch of the motion which was for summary judgment on the first cause of action. Cozier, J.P., Santucci, Spolzino and Skelos, 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.
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
Held that the insurer's evidence raised a triable issue as to whether the hospital complied with a verification demand, so the hospital's summary judgment was denied because the claim was premature until the 30-day start date was established.
Of the 374 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
- Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 05413)The hospitals' first and fifth claims were dismissed because policy limits were exhausted and requested verification remained outstanding.
Cited by
A label shows how the later decision treated this one.
- St. Barnabas Hosp. v American Tr. Ins. Co. (2008 NY Slip Op 09585) FollowedThe insurer raised a triable issue whether the provider timely complied with its verification demand, defeating the provider's summary judgment motion.
- New York Craniofacial Care, P.C. v Allstate Ins. Co. (2006 NY Slip Op 50500(U)) FollowedA provider seeking summary judgment on overdue claims must address whether those claims were timely and validly denied.
- Westchester Med. Ctr. v Country Wide Ins. Co. (2011 NY Slip Op 03838) FollowedThe insurer raised a triable issue as to whether the hospital fully complied with its verification demand.
- Elmont Open MRI & Diagnostic Radiology, P.C. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50607(U)) FollowedThe provider's summary judgment award was vacated because outstanding verification presented a triable factual issue.
- New York Univ. Hosp. Rusk Inst. v Illinois Natl. Ins. Co. (2006 NY Slip Op 05601)The insurers established a reasonable excuse for their default and potentially meritorious verification and policy-exhaustion defenses.
- Perfect Point Acupuncture, P.C. v Auto One Ins. Co. (2010 NY Slip Op 50010(U))The insurer retained its verification toll despite sending an IME follow-up request 17 days after the first request.
Similar decisions
- New York & Presbyt. Hosp. v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 01537)The hospital established receipt of its no-fault billing and the insurer's failure to respond within the required 30-day period.
- 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.
- Mount Sinai Hosp. v Country Wide Ins. Co. (2011 NY Slip Op 05680)The insurer raised factual issues about policy exhaustion during a verification toll and payment with overdue interest before suit.
- Mount Sinai Hosp. v Zurich Am. Ins. Co. (2005 NY Slip Op 01329)The insurer raised factual issues about exhaustion of policy limits and compliance with payment-priority requirements on the first claim.
- New York Hosp. Med. Ctr. of Queens v Allstate Ins. Co. (2014 NY Slip Op 00640)The providers established receipt of their claim and nonpayment or improper denial within 30 days, warranting summary judgment.