March 14, 2008

P.L.P. Acupuncture, P.C. v Travelers Indem. Co. (2008 NY Slip Op 50484(U))

https://www.beynensonlaw.com/case-law/p-l-p-acupuncture-p-c-v-travelers-indem-co-2008-ny-slip-op-50484u/

Court: Appellate Term, First Department
Decided: March 14, 2008
Citation: 2008 NY Slip Op 50484(U) · 19 Misc 3d 126(A)
Posture: Trial
Outcome: Provider prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Provider's prima facie case Assignments and standing Timeliness and preclusion
Legal questions: Claimant's prima facie case at trial · Proof of mailing (see the maps)

Cite as

P.L.P. Acupuncture, P.C. v Travelers Indem. Co., 19 Misc 3d 126(A), 2008 NY Slip Op 50484(U) (App Term, 1st Dept 2008)

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 insurers' admission of receipt defeated their challenge to the provider's proof that its no-fault claims were mailed and received. The Appellate Term, First Department, affirmed the judgment for the provider after a nonjury trial. The insurers waived objections to proof of a valid assignment by failing to request verification, following Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. Their excessive-fee defense was also unavailable because they failed to establish timely denials or that excessive fees were a stated ground for denying benefits.

Reported in New York Official Reports at P.L.P. Acupuncture, P.C. v Travelers Indem. Co. (2008 NY Slip Op 50484(U))

[*1]

P.L.P. Acupuncture, P.C. v Travelers Indem. Co.

2008 NY Slip Op 50484(U) [19 Misc 3d 126(A)]

Decided on March 14, 2008

Appellate Term, First 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This opinion is uncorrected and will not be published in the printed Official Reports.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 March 14, 2008

APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT

PRESENT: DAVIS, J.P., SCHOENFELD, HEITLER, JJ
.

P.L.P. Acupuncture, P.C. a/a/o Mercedes Marinez, Mersedes Marinez,Plaintiff-Respondent, No.570686/07

against

Travelers Indemnity Co. & Travelers Property Casualty Co. all d/b/a the Travelers, Defendants-Appellants.

Defendants appeal from a judgment of the Civil Court of the City of New York, Bronx County (Larry S. Schachner, J.), dated February 22, 2006, after a nonjury trial, in favor of plaintiff in the principal sum of $4,795.98.

Per Curiam.

Judgment (Larry S. Schachner, J.), dated February 22, 2006, affirmed, with $25 costs.

Having admitted receipt of plaintiff’s claims for no-fault first party benefits, defendants may not now be heard to argue that plaintiff failed to establish that the claims had been mailed and received (see Fair Price Med. Supply, Inc. v St. Paul Travelers Ins. Co., 16 Misc 3d 8 [2007]; Devonshire Surgical Facility v GEICO, 16 Misc 3d 130[A], 2007 NY Slip Op 51308[U] [2007]). Defendants waived any objections based on lack of proof of a valid assignment since they did not seek verification of the assignment (see Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312 [2007]). Nor may defendants now assert a defense of excessive fees, inasmuch as they failed to establish the issuance of timely denials of the claims (see Westchester Med. Ctr. v American Tr. Ins. Co., 17 AD3d 581 [[2005]; New York Hosp. Med. Ctr. of Queens v Country-wide Ins. Co., 295 AD2d 583 [2002]) or that such a defense was the stated basis for the denial of no-fault benefits (see Todaro v Geico Gen. Ins. Co., 46 AD3d 1086 [2007]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
Decision Date: March 14, 2008

Legal questions (2)

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.

Claimant's prima facie case at trial

Open the full map

What must a no-fault claimant prove at trial to make out its prima facie case for overdue benefits?

This decision: Claimant's trial proof held to make out its prima facie case

Held that, having admitted receipt of the claims, the insurer could not argue the claimant failed to establish that the claims were mailed and received.

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

Of the 14 decisions on this question in the First Department courts and the Court of Appeals, 6 (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.

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 provider's or claimant's proof established mailing of its claim form, NF-2 or verification response (rules on the question, but another ground decided the case)

Held the insurer's admission of receipt foreclosed its challenge to the provider's proof that the claims were mailed and received.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decision

Of the 133 decisions on this question in the First Department courts and the Court of Appeals, 12 (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.

Cited in this decision

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

Fair Price Med. Supply, Inc. v St. Paul Travelers Ins. Co. (2007 NY Slip Op 27173) FollowedThe insurer's verified interrogatory answers established receipt and partial payment of the claims and defeated its proof-of-billing objection.
Devonshire Surgical Facility v GEICO (2007 NY Slip Op 51308(U)) FollowedThe insurer raised licensing issues as to the surgical facility but was precluded from asserting fraudulent billing against the orthopedic provider.
Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (2007 NY Slip Op 09067) FollowedAn insurer that fails to timely seek verification of an assignment cannot later contest its validity when the underlying claim is covered.
Westchester Med. Ctr. v American Tr. Ins. Co. (2005 NY Slip Op 03046) FollowedAn insurer's failure to timely deny a hospital claim precluded its defense that the hospital used the wrong DRG billing code.
Todaro v GEICO Gen. Ins. Co. (2007 NY Slip Op 09863) FollowedAn insured incurs medical expenses upon treatment, and payment by other sources does not extinguish the no-fault insurer's obligation.

Cited by

A label shows how the later decision treated this one.

Davydov v Progressive Ins. Co. (2009 NY Slip Op 29299) FollowedThe insurer's assignment defense was precluded because it neither sought verification of the facial discrepancy nor denied on that ground.
Advanced Tempromandibular Disorder & Dental Surgery v Progressive Northeastern Ins. Co. (2010 NY Slip Op 20047)A provider may establish its prima facie no-fault case at trial through an unanswered notice to admit without witness testimony.

Similar decisions

Empire State Psychological Servs., P.C. v Travelers Ins. Co. (2006 NY Slip Op 51869(U))The provider failed to prove its prima facie case at trial by offering only the insurer's interrogatory response acknowledging bills.
A.B. Med. Servs. v Travelers Prop. Cas. Corp. (2004 NY Slip Op 50517(U))The providers failed to establish their prima facie case because the billing manager's affidavit did not identify the provider served.
Impulse Chiropractic P.C. v Travelers Ins. Co. (2006 NY Slip Op 52469(U))The provider failed to prove submission of its claims, and the insurer's delay letters did not establish receipt of the particular claims.
A.B. Med. Servs. PLLC v Travelers Prop. Cas. Corp. (2004 NY Slip Op 50779(U))The providers' billing-manager affidavit failed to establish their prima facie case because it did not identify which provider it covered.
Boai Zhong Yi Acupuncture Servs., P.C. v Travelers Ins. Co. (2006 NY Slip Op 52516(U))The provider failed to establish submission of its claim, and the insurer's delay letter did not identify the claim at issue.