February 22, 2005

Mount Sinai Hosp. v Zurich Am. Ins. Co. (2005 NY Slip Op 01329)

https://www.beynensonlaw.com/case-law/mount-sinai-hosp-v-zurich-am-ins-co-2005-ny-slip-op-01329/

Court
Appellate Division, Second Department
Decided
February 22, 2005
Citation
2005 NY Slip Op 01329 · 15 AD3d 550
Posture
Summary judgment
Outcome
Split result
Later treatment
Followed in 1 later decision (see Cited by)
Issues
Policy issues
Cite as
Mount Sinai Hosp. v Zurich Am. Ins. Co., 15 AD3d 550 (2d Dept 2005)

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 raised factual issues about exhaustion of policy limits and compliance with payment-priority requirements on the first claim. Although the provider established submission of the required documents and the insurer's failure to pay or deny, an insurer need not pay after policy limits are exhausted. Questions remained whether other no-fault payments exhausted coverage and complied with 11 NYCRR 65.15 (n). The Appellate Division, Second Department, modified the order to grant another provider summary judgment on the third cause of action, its own claim, and otherwise affirmed the order, insofar as appealed from. Denial of summary judgment on the first cause of action remained in place. A separate provider's appeal was dismissed because it was not aggrieved.

Reported in New York Official Reports at Mount Sinai Hosp. v Zurich Am. Ins. Co. (2005 NY Slip Op 01329)

Mount Sinai Hosp. v Zurich Am. Ins. Co.
2005 NY Slip Op 01329 [15 AD3d 550]
February 22, 2005
Appellate Division, Second Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected through Wednesday, April 20, 2005
Mount Sinai Hospital, as Assignee of Mendel Adolph, et al., Appellants,
v
Zurich American Insurance Company, Respondent.

—[*1]

In an action to recover no-fault insurance medical payments, the plaintiffs, Mount Sinai Hospital, as assignee of Mendel Adolph, White Plains Hospital Center, as assignee of Shehan Guiragossian, and Wyckoff Heights Medical Center, as assignee of Juan Picardo, appeal from so much of an order of the Supreme Court, Nassau County (Feinman, J.), dated March 31, 2004, as denied their motion for summary judgment on the first and third causes of action in the complaint.

Ordered that the appeal by the plaintiff White Plains Hospital Center, as assignee of Shehan Guiragossian, is dismissed, without costs or disbursements, as that plaintiff is not aggrieved by the order; and it is further,

Ordered that the order is modified, on the law, by deleting the provision thereof denying that branch of the motion which was for summary judgment on the third cause of action asserted by Wyckoff Heights Medical Center, as assignee of Juan Picardo, and substituting therefor a provision granting that branch of the motion; as so modified, the order is affirmed insofar as appealed from, without costs or disbursements.

The plaintiff Mount Sinai Hospital, as assignee of Mendel Adolph (hereinafter Mount Sinai) demonstrated its entitlement to judgment as a matter of law on the first cause of action by [*2]establishing that it submitted the requisite documents to recover payment for medical services, but the defendant Zurich American Insurance Company (hereinafter Zurich) neither paid nor denied the claims (see New York & Presbyt. Hosp. v Allstate Ins. Co., 12 AD3d 579 [2004]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [2004]). However, an insurer is not required to pay a claim where the policy limits have been exhausted (see Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533, 534 [2004]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., supra). In opposition to Mount Sinai’s motion, Zurich demonstrated that there were issues of fact as to whether it exhausted the coverage limits of the policy by other “no-fault” payments and whether such payments were in compliance with 11 NYCRR 65.15 (n). Accordingly, that branch of the motion which was for summary judgment on the first cause of action asserted by Mount Sinai was properly denied.

The plaintiff Wyckoff Heights Medical Center, as assignee of Juan Picardo (hereinafter Wyckoff Heights) established its entitlement to judgment as a matter of law on the third cause of action. Therefore, the Supreme Court erred in denying summary judgment to Wyckoff Heights.

Mount Sinai’s remaining contentions are without merit. Schmidt, J.P., Santucci, Crane and Skelos, JJ., concur.

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