November 22, 2004

New York & Presbyt. Hosp. v Allstate Ins. Co. (2004 NY Slip Op 08669)

https://www.beynensonlaw.com/case-law/new-york-presbyt-hosp-v-allstate-ins-co-2004-ny-slip-op-08669/

Court
Appellate Division, Second Department
Decided
November 22, 2004
Citation
2004 NY Slip Op 08669 · 12 AD3d 579
Posture
Summary judgment
Outcome
Insurer prevailed
Later treatment
Followed in 11 later decisions (see Cited by)
Issues
Policy issues Timeliness and preclusion
Legal questions
Exhaustion of policy limits · Claimant's prima facie case on motions (see the maps)
Cite as
New York & Presbyt. Hosp. v Allstate Ins. Co., 12 AD3d 579 (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.

An untimely denial does not preclude an exhaustion defense or establish entitlement to judgment on a previously denied duplicate claim. The Appellate Division, Second Department, reversed summary judgment for the hospital on both causes of action and denied its motion. On the first claim, the hospital established submission of the required documents and the insurer's failure to pay, deny, or request verification timely. The insurer nevertheless raised factual issues concerning partial exhaustion through other no-fault payments and compliance with 11 NYCRR 65.15 (n). On the second claim, the insurer showed that the disputed bill duplicated an earlier claim for the same services that had been properly denied. Failure to timely deny the duplicate did not warrant summary judgment.

Reported in New York Official Reports at New York & Presbyt. Hosp. v Allstate Ins. Co. (2004 NY Slip Op 08669)

New York & Presbyt. Hosp. v Allstate Ins. Co.
2004 NY Slip Op 08669 [12 AD3d 579]
November 22, 2004
Appellate Division, Second Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected through Wednesday, January 19, 2005
New York and Presbyterian Hospital, Respondent,
v
Allstate Insurance Company, Appellant.

—[*1]

In an action to recover no-fault medical payments, the defendant appeals from an order of the Supreme Court, Nassau County (O’Connell, J.), dated November 17, 2003, which granted the plaintiff’s motion for summary judgment on its first and second causes of action.

Ordered that the order is reversed, on the law, with costs, and the motion is denied.

In its first cause of action, the plaintiff alleged that it submitted a “no-fault” claim as assignee of Adrian Leaf and, in effect, that the defendant failed to issue a denial of the claim within 30 days of its receipt thereof. In its second cause of action, the plaintiff alleged that it submitted a “no-fault” claim as assignee of Noemi Gomez and, in effect, that the defendant failed to issue a denial of the claim within 30 days of its receipt thereof. The plaintiff asserts that the defendant is liable for the full amount of each claim on the ground that it failed to timely deny the claims.

With respect to the plaintiff’s first cause of action, the plaintiff demonstrated its entitlement to judgment as a matter of law by establishing that it “submitted the requisite documents for payment, but [the defendant] neither paid nor denied the claims, nor requested verification within the requisite periods” (New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 570 [2004]). In opposition thereto, the defendant demonstrated that there were issues of fact as to whether it [*2]partially 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). The defendant’s failure to issue a denial of the claim within 30 days does not “preclude a defense that the coverage limits of the subject policy have been exhausted” (Presbyterian Hosp. in City of N.Y. v General Acc. Ins. Co. of Am., 229 AD2d 479, 480 [1996]; see Presbyterian Hosp. of N.Y. v Liberty Mut. Ins. Co., 216 AD2d 448 [1995]).

With respect to the plaintiff’s second cause of action to recover for services provided to Gomez, the defendant, in opposition to the plaintiff’s demonstration of its entitlement to summary judgment, submitted evidence that the disputed claim was the second of two successive claims for the same services, the first of which was properly denied. A failure to issue a timely written denial of the second of these two successive but identical claims would not warrant granting the plaintiff judgment as a matter of law (see Hospital for Joint Diseases v Allstate Ins. Co., 5 AD3d 441 [2004]). Ritter, J.P., Goldstein, Adams and Crane, JJ., concur.

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