May 31, 2011

Nyack Hosp. v Allstate Ins. Co. (2011 NY Slip Op 04644)

https://www.beynensonlaw.com/case-law/nyack-hosp-v-allstate-ins-co-2011-ny-slip-op-04644/

Court: Appellate Division, Second Department
Decided: May 31, 2011
Citation: 2011 NY Slip Op 04644 · 84 AD3d 1331
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Timeliness and preclusion Policy issues

Cite as

Nyack Hosp. v Allstate Ins. Co., 84 AD3d 1331 (2d Dept 2011)

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 insurer's untimely denial precludes a policy exclusion defense based on the assignor's allegedly intentional self-injury. The hospital established mailing and receipt of its prescribed billing form and the insurer's failure to pay or deny within 30 days under Insurance Law § 5106 (a) and 11 NYCRR 65-3.5. The insurer acknowledged its late denial but submitted evidence that the assignor intentionally caused injury in an attempted suicide. That evidence did not raise a triable issue because the exclusion defense was precluded. The Appellate Division, Second Department, reversed the order, insofar as appealed from, and granted the providers' motion for summary judgment on the hospital's first cause of action; it did not reach the providers' remaining contention.

Reported in New York Official Reports at Nyack Hosp. v Allstate Ins. Co. (2011 NY Slip Op 04644)

Nyack Hosp. v Allstate Ins. Co.

2011 NY Slip Op 04644 [84 AD3d 1331]

May 31, 2011

Appellate Division, Second Department

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

As corrected through Wednesday, July 6, 2011

Nyack Hospital, as Assignee of Rochelle Ferguson, et al., Appellants,
v
Allstate Insurance Company, Respondent.

—[*1] Joseph Henig, P.C., Bellmore, N.Y., for appellants. McDonnell & Adels, PLLC, Garden City, N.Y. (Jannine A. Gordineer of counsel), for respondent.

In an action to recover no-fault medical payments under an insurance contract, the plaintiffs appeal, as limited by their brief, from so much of an order of the Supreme Court, Nassau County (Murphy, J.), entered December 29, 2010, as denied that branch of their motion which was for summary judgment on the first cause of action.

Ordered that the order is reversed insofar as appealed from, on the law, with costs, and that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action is granted.

The plaintiffs made a prima facie showing that the plaintiff Nyack Hospital, as assignee of Rochelle Ferguson, was entitled to judgment as a matter of law on its cause of action to recover no-fault insurance medical payments by submitting evidence that the prescribed statutory billing form had been mailed and received by the defendant and that the defendant had failed to either pay or deny the claim within the requisite 30-day period (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.5; Westchester Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 81 AD3d 929 [2011]; Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045, 1045-1046 [2009]).

In opposition to the motion, the defendant failed to raise a triable issue of fact. The defendant acknowledged that it failed to timely deny that claim, but contended that it raised a triable issue of fact by submitting evidence which indicates that Ferguson intentionally caused her injury in an attempt to commit suicide. However, the failure to establish timely denial of the claim results in the preclusion of the defense that Ferguson’s allegedly intentional act was the cause of the accident and subject to exclusion under the insurance contract (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 286 [1997]; Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]). Accordingly, the Supreme Court should have granted that branch of the plaintiff’s motion which was for summary judgment on the first cause of action.

In light of our determination, we need not address the plaintiffs’ remaining contention. Mastro, J.P., Leventhal, Austin and Cohen, JJ., concur.

Cited in this decision

Westchester Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 01458)The insurer's defective denial and insufficient mailing proof precluded its intoxication exclusion defense.
Westchester Med. Ctr. v Lincoln Gen. Ins. Co. (2009 NY Slip Op 02589)The insurer's investigation letters did not toll the 30-day period to pay or deny the provider's claim.

Cited by

Jae Ook Park v GEICO Gen. Ins. Co. (2011 NY Slip Op 52379(U))The provider failed to establish its prima facie case because it did not show an untimely or legally insufficient denial.

Similar decisions

New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 02731)The insurer proved exhaustion of policy limits before it became obligated to pay the provider's claim.
Hospital for Joint Diseases v Allstate Ins. Co. (2005 NY Slip Op 06192)An insurer waived assignment objections by failing to timely object to hospital forms or seek verification of the assignments.
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 & Presbyt. Hosp. v Selective Ins. Co. of Am. (2007 NY Slip Op 06848)The insurer's conclusory medical affidavit failed to raise a factual issue that the treated condition was unrelated to the automobile accident.
Westchester Med. Ctr. v Allstate Ins. Co. (2013 NY Slip Op 08616)The insurer failed to establish a verification toll because it offered no evidence of mailing a required follow-up request.