August 15, 2006
New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co. (2006 NY Slip Op 06223)
https://www.beynensonlaw.com/case-law/new-york-univ-hosp-rusk-inst-v-hartford-acc-indem-co-2006-ny-slip-op-06223/
- Court
- Appellate Division, Second Department
- Decided
- August 15, 2006
- Citation
- 2006 NY Slip Op 06223 ยท 32 AD3d 458
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Later treatment
- Distinguished in 2, contrasted (cf., but see) in 1 and followed in 7 later decisions (see Cited by)
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 New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co. (2006 NY Slip Op 06223)
| New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co. |
| 2006 NY Slip Op 06223 [32 AD3d 458] |
| August 15, 2006 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| New York University Hospital Rusk Institute, as Assignee of Norman Dell, et al., Appellants, v Hartford Accident & Indemnity Company et al., Respondents. |
—[*1]
In an action to recover no-fault insurance medical payments, the plaintiffs appeal from so much of an order of the Supreme Court, Nassau County (Martin, J.), dated September 27, 2005, as denied their motion for summary judgment on the second cause of action.
Ordered that the appeal by the plaintiff New York University Hospital Rusk Institute, as assignee of Norman Dell, is dismissed as that plaintiff is not aggrieved by the order appealed from (see CPLR 5511); and it is further,
Ordered that the order is reversed insofar as appealed from by the plaintiff Mary Immaculate Hospital, as assignee of Bibi Leitzsey, on the law, the motion is granted, and the first cause of action asserted by the plaintiff New York University Hospital Rusk Institute, as assignee of Norman Dell, is severed; and it is further,
Ordered that one bill of costs is awarded to the plaintiff Mary Immaculate Hospital, as assignee of Bibi Leitzsey.
On July 3, 2004, Bibi Leitzsey was injured in an automobile accident. At the time of the accident, Leitzsey was covered by a no-fault insurance policy issued by the defendants Hartford Accident & Indemnity Company, Hartford Casualty Insurance Company, and Property and Casualty Insurance Company of Hartford (hereinafter collectively the defendants). On August 20, 2004, the plaintiff Mary Immaculate Hospital, as assignee of Bibi Leitzsey (hereinafter the hospital), sent to [*2]the defendants, by certified mail, return receipt requested, a hospital facility form (N-F5) and a UB-92 form, demanding payment of its $18,145.76 bill.
The defendants received the forms on August 23, 2004, and extended their time in which to pay or deny the claim on September 7, 2004, by demanding verification of Leitzsey’s treatment (see 11 NYCRR 65-3.8 [a] [1]). On September 28, 2004, or within 30 days of their receipt of the requested verification, the defendants timely denied a portion (i.e., $10,385.08) of the claim, asserting that the hospital utilized an incorrect DRG code, and that the correct DRG code corresponded to a lower reimbursement amount. In lieu of the prescribed denial of claim form (N-F10), the defendants issued their September 28, 2004, partial denial by letter.
Contrary to the hospital’s contention, “[a] ‘letter’ of disclaimer is permissible, provided that it is approved by the New York State Department of Insurance, issued in duplicate, and ‘contains substantially the same information as the prescribed form which is relevant to the claim denied’ ” (Presbyterian Hosp. in City of N.Y. v Atlanta Cas. Co., 210 AD2d 210, 211 [1994], quoting 11 NYCRR 65.15 [g] [3] [i], now 65-3.8 [c] [1]). “A proper denial of claim must include the information called for in the prescribed denial of claim form (see 11 NYCRR 65-3.4 [c] [11]) and must ‘promptly apprise the claimant with a high degree of specificity of the ground or grounds on which the disclaimer is predicated’ ” (Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 11 AD3d 664, 664 [2004], quoting General Acc. Ins. Group v Cirucci, 46 NY2d 862, 864 [1979]). “A timely denial alone does not avoid preclusion where said denial is factually insufficient, conclusory, vague or otherwise involves a defense which has no merit as a matter of law” (Nyack Hosp. v State Farm Mut. Auto. Ins. Co., supra at 665, quoting Amaze Med. Supply v Allstate Ins. Co., 3 Misc 3d 43, 44 [2004]).
Here, the defendants’ September 28, 2004, letter adequately conveyed the information mandated by the prescribed form including, but not limited to, the precise ground on which the partial denial was predicated. However, the defendants failed to establish that the letter had been issued in duplicate and approved by the Department of Insurance (see 11 NYCRR 65-3.8 [c] [1], supra). Accordingly, having failed to pay or properly deny that portion of the hospital’s claim within the statutory time frame, the defendants were precluded from interposing a defense (Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 286 [1997]; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., supra), and the Supreme Court should have granted the plaintiff’s motion for summary judgment on the second cause of action. Adams, J.P., Mastro, Fisher and Covello, JJ., concur.
Cited in this decision
A label shows how this decision treated the case it cites.
- Nyack Hosp. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 07663) FollowedA timely but fatally defective denial cannot be cured by supplying omitted information after the 30-day denial period expires.
- Amaze Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 24119)An insurer may not deny equipment fees as exceeding local prevailing rates when the applicable schedule limits reimbursement to 150% of cost.
Cited by (13)
A label shows how the later decision treated this one.
- Mollo Chiropractic, PLLC v American Commerce Ins. Co. (2013 NY Slip Op 23419) DistinguishedAn insurer's failure to send an NF-10 denial in duplicate does not, by itself, preclude an otherwise meritorious defense.
- Prime Psychological Servs., P.C. v American Tr. Ins. Co. (2008 NY Slip Op 28273) DistinguishedAn insurer's failure to send a denial in duplicate does not invalidate an otherwise sufficient denial absent claimed notice defects or prejudice.
- Westchester Med. Ctr. v Nationwide Mut. Ins. Co. (2010 NY Slip Op 08933) Contrasted (cf., but see)The provider failed to establish entitlement to summary judgment because the insurer partially paid and denied the claim within 30 days.
- Forrest Chen Acupuncture Servs., P.C. v GEICO Ins. Co. (2008 NY Slip Op 07211) FollowedThe insurer established that acupuncture reimbursement was properly limited to charges for similar procedures under existing fee schedules.
- Olympic Chiropractic, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50011(U)) FollowedA timely but factually insufficient IME denial does not preserve a medical-necessity defense.
- Excel Imaging, P.C. v MVAIC (2010 NY Slip Op 50998(U)) FollowedMVAIC was denied summary judgment because factual issues remained concerning whether its denial was issued in duplicate.
- All Borough Group Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51417(U)) FollowedThe insurer's denial preserved its medical-necessity defense, and an unrebutted affirmed peer review established that the supplies were unnecessary.
- Vista Surgical Supplies, Inc. v GEICO Ins. Co. (2009 NY Slip Op 50739(U)) FollowedA denial form is not invalid for omitting irrelevant sections if it is approved and specifically identifies the medical-necessity defense.
- Mega Supplies Billing, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51418(U)) FollowedThe insurer's denial was not fatally defective, and its unrebutted affirmed peer review established lack of medical necessity for the supplies.
- T & M Rehab PT, P.C. v Unitrin Auto & Home Ins. Co. (2012 NY Slip Op 52407(U)) FollowedThe provider's renewal motion failed because Excel Imaging, P.C. v MVAIC did not change the law on duplicate denial forms.
Similar decisions
- Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co. (2005 NY Slip Op 02235)The insurer failed to prove mailing of its denial, and the denial was incomplete even if timely.
- New York Univ Hosp. Tisch Inst. v New York City Tr. Auth. (2004 NY Slip Op 01159)The defendant was precluded from disclaiming coverage because it failed to reject the provider's claim within 30 days.
- New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 05602)The insurer proved a timely denial but failed to establish that the provider's treatment was unrelated to the accident.
- New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 05626)The insurer failed to establish mailing of assignment-verification requests and could not defeat the hospitals' summary judgment motion.
- New York & Presbyt. Hosp. v American Tr. Ins. Co. (2007 NY Slip Op 09376)The insurer raised a factual issue by showing a timely denial based on bills submitted more than 45 days after the last medical service.