June 3, 2005

Ocean Diagnostic Imaging P.C. v GMAC Ins. F/k/a Integon Ins. (2005 NYSlipOp 50865(U))

https://www.beynensonlaw.com/case-law/ocean-diagnostic-imaging-p-c-v-gmac-ins-f-k-a-integon-ins-2005-nyslipop-50865u/

Court: Appellate Term, Second Department
Decided: June 3, 2005
Citation: 2005 NY Slip Op 50865(U)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Contrasted (cf., but see) in 1 later decision (see Cited by)
Issues: Timeliness and preclusion
Legal questions: Claimant's prima facie case on motions (see the maps)

Cite as

Ocean Diagnostic Imaging P.C. v GMAC Ins. F/k/a Integon Ins., 2005 NY Slip Op 50865(U) (App Term, 2d Dept, 2d & 11th Jud Dists 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 a preserved triable issue whether notice of the accident was provided within the required 90 days. The provider established a prima facie entitlement to summary judgment by proving submission of a claim stating the fact and amount of the loss and overdue payment under Insurance Law § 5106 (a). Although the insurer timely denied the claim, it still had to rebut that showing with admissible evidence. The record sufficiently raised the accident-notice issue under the insurance regulations. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, denying the provider's motion for summary judgment.

Reported in New York Official Reports at Ocean Diagnostic Imaging P.C. v GMAC Ins. F/k/a Integon Ins. (2005 NYSlipOp 50865(U))

[*1]

Ocean Diagnostic Imaging P.C. v GMAC Ins. F/k/a Integon Ins.

2005 NYSlipOp 50865(U)

Decided on June 3, 2005

Appellate Term, Second Department

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

This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on June 3, 2005

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: June 3, 2005 SUPREME COURT OF THE STATE OF NEW YORK APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS PRESENT : PESCE, P.J., PATTERSON and BELEN, JJ.
2004-1269 K C

Ocean Diagnostic Imaging P.C. a/a/o WILMON JOSEPH, Appellant,
against
GMAC Insurance F/k/a Integon Insurance, Respondent.

Appeal by plaintiff from so much of an order of the Civil Court, Kings County (A. O’Shea, J.), entered July 7, 2004, as denied its motion for summary judgment.

Order insofar as appealed from unanimously affirmed without costs.

In this action to recover first-party no-fault benefits for medical services rendered to its assignor, plaintiff health care provider established its prima facie entitlement to summary judgment by proof that it submitted a claim, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86 [App Term, 2d & 11th Jud Dists 2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). While defendant timely denied the claim, it nevertheless had to submit proof in admissible form in opposition to the motion to rebut plaintiff’s prima facie showing (A.B. Med. Servs. PLLC, 4 Misc 3d at 86).
Upon a review of the record, we find that defendant sufficiently rebutted plaintiff’s prima facie showing by raising the preserved triable issue of fact as to whether it was provided with notice of the accident within 90 days as required by the insurance regulations. Accordingly, the court below properly denied plaintiff’s motion for summary judgment (see e.g. Hackensack Univ. Med. Ctr. v New York City Tr. Auth., 10 AD3d 675 [2004]). [*2]
Decision Date: June 03, 2005

Legal questions

A question 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.

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 provider established its prima facie case by proof that it submitted a claim and that payment was overdue, though the motion failed because the insurer raised a triable issue on timely notice of the accident.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followedDistinguished or limited

Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (this one included) are in the same category.

Cited in this decision

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

Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359)The hospitals established entitlement to summary judgment by proving that statutory billing forms were mailed and received and payment was overdue.
A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co. (2004 NY Slip Op 24194) FollowedAn insurer's timely medical-necessity denial does not replace admissible proof opposing a provider's summary judgment motion.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U))A provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
Hackensack Univ. Med. Ctr. v New York City Tr. Auth. (2004 NY Slip Op 06632)The provider's claim against the self-insurer failed because the first accident notice was a bill submitted beyond the 90-day deadline.

Cited by

A label shows how the later decision treated this one.

Radiology Today P.C. v Allstate Ins. Co. (2006 NY Slip Op 50472(U)) Contrasted (cf., but see)An insurer's untimely denial precludes a defense that the provider failed to submit its bill within the applicable 180-day period.

Similar decisions

Ocean Diagnostic Imaging P.C. v Utica Mut. Ins. Co. (2005 NYSlipOp 50611(U))The insurer raised a factual issue as to whether the collision furthered an insurance fraud scheme despite its late denial.
Ocean Diagnostic Imaging P.C. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 50607(U))The insurer's accident analysis report and supporting affidavit raised a coverage issue despite its untimely denial.
Ocean Diagnostic Imaging, P.C. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51624(U))An insurer's untimely denial does not preclude a defense that the collision furthered an insurance fraud scheme.
Ocean Diagnostic Imaging, P.C. v Geico Ins. (2004 NY Slip Op 51038(U))The insurer's attorney affidavit lacked personal knowledge and offered only conclusory fraud allegations, failing to raise a coverage issue.
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2005 NYSlipOp 50535(U))The insurer's fraud evidence raised a coverage issue but did not establish lack of coverage as a matter of law.