June 28, 2004

New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 05626)

https://www.beynensonlaw.com/case-law/new-york-hosp-med-ctr-of-queens-v-new-york-cent-mut-fire-ins-co-2004-ny-slip-op-05626/

Court: Appellate Division, Second Department
Decided: June 28, 2004
Citation: 2004 NY Slip Op 05626 · 8 AD3d 640
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Declined to follow in 1 and followed in 11 later decisions (see Cited by)
Issues: Timeliness and preclusion Verification requests Assignments and standing
Legal questions: Proof of mailing · Outstanding verification and premature actions · Claimant's prima facie case on motions (see the maps)

Cite as

New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co., 8 AD3d 640 (2d Dept 2004)

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 failed to establish mailing of assignment-verification requests and could not defeat the hospitals' summary judgment motion. The Appellate Division, Second Department, affirmed the judgment, upholding summary judgment on the second, third, and fourth causes of action. The hospitals proved mailing and receipt of facility forms establishing their losses and the insurer's failure to pay or deny within 30 days under Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3). The insurer's affidavits did not establish mailing of requests for verification of the assignments under 11 NYCRR 65.15 (d), leaving its assignment objections without merit. The hospitals were entitled to statutory interest and attorney fees; the separate appeal from the intermediate order was dismissed.

Reported in New York Official Reports at New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 05626)

New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co.

2004 NY Slip Op 05626 [8 AD3d 640]

June 28, 2004

Appellate Division, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, August 25, 2004

New York Hospital Medical Center of Queens et al., Plaintiffs, and St. Luke’s Roosevelt Hospital et al., Respondents,
v
New York Central Mutual Fire Insurance Company, Appellant.

—[*1]

In an action to recover no-fault medical payments under certain insurance contracts, the defendant appeals (1), as limited by its brief, from so much of an order of the Supreme Court, Nassau County (Franco, J.), dated July 29, 2003, as granted that branch of the plaintiffs’ motion which was for summary judgment on the second, third, and fourth causes of action, and (2) from a judgment of the same court, entered August 21, 2003, which, upon the order, is in favor of the plaintiffs St. Luke’s Roosevelt Hospital, New York and Presbyterian Hospital, Mary Immaculate Hospital, and St. John’s Hospital-Catholic Medical Center and against it in the principal sum of $14,043.92.

Ordered that the appeal from the order is dismissed; and it is further,

Ordered that the judgment is affirmed; and it is further,

Ordered that one bill of costs is awarded to the respondents.

The appeal from the intermediate order must be dismissed because the right of direct appeal therefrom terminated with the entry of judgment in the action (see Matter of Aho,39 NY2d 241, 248 [1976]). The issues raised on the appeal from the order are brought up for review and have been [*2]considered on the appeal from the judgment (see CPLR 5501 [a] [1]).

In support of their motion for summary judgment, the respondents submitted proof, inter alia, with respect to the second, third, and fourth causes of action, that they mailed and the appellant received the hospital facility forms for the related claims demonstrating the amounts of loss sustained, and that the appellant failed to either pay or deny each respective claim within the 30-day statutory period under Insurance Law § 5106 (a). Accordingly, the respondents established their prima facie entitlement to judgment as a matter of law on their claims, including statutory interest and an award of an attorney’s fee (see Insurance Law § 5106 [a]; 11 NYCRR 65.15 [g] [3]; Alvarez v Prospect Hosp., 68 NY2d 320 [1986]; St. Luke’s Roosevelt Hosp. v American Tr. Ins. Co., 1 AD3d 498 [2003]).

In opposition, the appellant failed to raise a triable issue of fact (see Zuckerman v City of New York, 49 NY2d 557, 562 [1980]). The affidavits submitted by the appellant failed to establish that it mailed the requests for verification of the assignments upon which the respondents’ claims were based (see Hospital for Joint Diseases v Nationwide Mut. Ins. Co., 284 AD2d 374, 375 [2001]). Thus, the appellant’s objections to the claims on the basis of lack of proof of the assignments were without merit (see 11 NYCRR 65.15 [d]; St. Clare’s Hosp. v Allcity Ins. Co., 201 AD2d 718 [1994]).

Accordingly, the Supreme Court properly granted that branch of the plaintiffs’ motion which was for summary judgment on the second, third, and fourth causes of action.

The parties’ remaining contentions either are academic or without merit. Krausman, J.P., Luciano, Cozier and Spolzino, JJ., concur.

Legal questions (3)

Questions 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 proof did not establish mailing of its denial, verification request or IME/EUO notice

Held the insurer's affidavits failed to establish that it mailed its requests for verification of the assignments, so its objections based on lack of proof of assignment failed.

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, 257 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Outstanding verification and premature actions

Open the full map

Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?

This decision: Defense rejected because the insurer's requests or proof were deficient

Rejected the insurer's verification-based objection to the assignments because it did not prove the verification requests were mailed, so the claims were overdue and the hospitals won summary judgment.

Premature: verification outstandingNonresponse denial upheldTriable issueInsurer's showing failsProvider compliedThis decisionCites it or cited by itCited or followed

Of the 374 decisions on this question in the Second Department courts and the Court of Appeals, 78 (this one included) are in the same category.

Claimant's prima facie case on motions

Open the full map

On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?

This decision: Claimant's proof held to make out its prima facie case (rules on the question, but another ground decided the case)

Held the hospitals made their prima facie showing by proof that they mailed and the insurer received the facility forms and that the insurer neither paid nor denied the claims within 30 days.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followedDeclined to follow, questioned, overruled or reversed

Of the 1,063 decisions on this question in the Second Department courts and the Court of Appeals, 511 (this one included) are in the same category. 2 decisions in other departments that cite or are cited by this one are on the full map.

Cited in this decision

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

St. Luke’s Roosevelt Hosp. v American Tr. Ins. Co. (2003 NY Slip Op 18448) FollowedThe providers' summary judgment motion for no-fault payments was granted because the insurer raised no triable issue.

Cited by (51)

A label shows how the later decision treated this one.

Siegel v Progressive Cas. Ins. Co. (2004 NY Slip Op 24532) Declined to followAn assignment is an essential element of a provider's no-fault claim, and an insurer cannot waive its complete absence.
Hospital for Joint Diseases v Allstate Ins. Co. (2005 NY Slip Op 06192) FollowedAn insurer waived assignment objections by failing to timely object to hospital forms or seek verification of the assignments.
Rockaway Blvd. Med. P.C. v Progressive Ins. (2005 NY Slip Op 25278) FollowedA provider's omission of its relationship with the treating physician from claim forms does not defeat its prima facie case.
A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2005 NY Slip Op 25032) FollowedAn insurer may assert a lack-of-coverage defense despite an untimely denial of no-fault claims.
A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2006 NY Slip Op 50504(U)) FollowedThe providers obtained partial summary judgment because denials were untimely or defenses lacked evidentiary support.
Summit Psychological, P.C. v General Assur. Co. (2005 NY Slip Op 25263) FollowedThe insurer failed to establish timely mailing of its denials or proper mailing of preclaim IME requests.
Pine Hollow Med., P.C. v Progressive Cas. Ins. Co. (2006 NY Slip Op 51870(U)) FollowedA billing company's records may incorporate provider information without the preparer having personal knowledge of its accuracy.
Medwide Med. Supply Inc. v Country-Wide Ins. Co. (2005 NYSlipOp 51078(U)) FollowedThe insurer's defenses failed because one denial was late, its medical reviews were incompetent, and assignment objections were waived.
Amaze Med. Supply Inc. v Lumbermens Mut. Cas. Co. (2005 NY Slip Op 50084(U)) FollowedThe insurer's unsworn peer review report failed to raise a triable issue against the provider's prima facie showing.
Ocean Diagnostic Imaging P.C. v Allstate Ins. Co. (2006 NY Slip Op 50140(U)) FollowedThe insurer's EUO request did not toll one claim, and its opposition failed to rebut medical necessity on the other.

Show all 51 citing decisions

Similar decisions

New York Hosp. Med. Ctr. of Queens v AIU Ins. Co. (2004 NY Slip Op 05217)The insurer waived objections to missing signatures by failing to challenge the hospital forms' completeness within 10 days of receipt.
Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 09484)An insurer need not pay or deny a no-fault claim until it receives all relevant verification requested.
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.
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.
New York Hosp. Med. Ctr. of Queens v Country Wide Ins. Co. (2011 NY Slip Op 01628)The hospital satisfied verification requests by supplying the precise version of the NF-5 and assignment forms the insurer requested.