August 23, 2012

Parsons Med. Supply, Inc. v Progressive Northeastern Ins. Co. (2012 NY Slip Op 51649(U))

https://www.beynensonlaw.com/case-law/parsons-med-supply-inc-v-progressive-northeastern-ins-co-2012-ny-slip-op51649u/

Court: Appellate Term, Second Department
Decided: August 23, 2012
Citation: 2012 NY Slip Op 51649(U) · 36 Misc 3d 148(A)
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Distinguished in 1 and followed in 5 later decisions (see Cited by)
Issues: Verification requests Timeliness and preclusion

Cite as

Parsons Med. Supply, Inc. v Progressive Northeastern Ins. Co., 36 Misc 3d 148(A), 2012 NY Slip Op 51649(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012)

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 delay letters requesting no verification do not toll the 30-day period to pay or deny a no-fault claim. The insurer acknowledged receiving the provider's two claims, and neither was paid or denied within 30 days. Its letters merely advised that it was investigating and obtaining verification, including EUOs. Under Nyack Hosp. v Encompass Ins. Co., those letters did not toll the deadline. The insurer therefore failed to establish timely denials or that its medical-necessity defense was not precluded. The Appellate Term, Second Department, reversed the dismissal judgment, vacated the portion of the order granting the insurer's summary judgment cross motion, and denied that cross motion.

Reported in New York Official Reports at Parsons Med. Supply, Inc. v Progressive Northeastern Ins. Co. (2012 NY Slip Op 51649(U))

[*1]

Parsons Med. Supply, Inc. v Progressive Northeastern Ins. Co.

2012 NY Slip Op 51649(U) [36 Misc 3d 148(A)]

Decided on August 23, 2012

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This opinion is uncorrected and will not be published in the printed Official Reports.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 August 23, 2012

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., RIOS and SOLOMON, JJ
2010-2899 K C.

Parsons Medical Supply, Inc. as Assignee of JERD-MAYER ORIENTAL, Appellant, —
against
Progressive Northeastern Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Devin P. Cohen, J.), entered July 16, 2010. The order, insofar as appealed from as limited by the brief, granted defendant’s cross motion for summary judgment dismissing the complaint. The appeal is deemed to be from a judgment of the same court entered October 4, 2010 dismissing the complaint (see CPLR 5512 [a]).

ORDERED that the judgment is reversed, without costs, so much of the order entered July 16, 2010 as granted defendant’s cross motion for summary judgment dismissing the complaint is vacated and defendant’s cross motion is denied.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals, as limited by its brief, from so much of an order of the Civil Court as granted defendant’s cross motion for summary judgment dismissing the complaint. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5512 [a]).

Defendant admits that it received plaintiff’s claims for the sums of $865 and $1,737 on January 28, 2008 and February 6, 2008, respectively, and it is undisputed that the claims were not [*2]paid or denied within 30 days of their receipt. The letters sent by defendant to plaintiff after the receipt of the claims informed plaintiff that defendant was investigating the claims and was in the process of obtaining verification, which included examinations under oath. It is well settled that an insurer’s delay letters, which request no verification, are insufficient to toll the 30-day statutory time period within which a claim must be paid or denied (see Nyack Hosp. v Encompass Ins. Co., 23 AD3d 535 [2005]; Points of Health Acupuncture, P.C. v Lancer Ins. Co., 28 Misc 3d 133[A], 2010 NY Slip Op 51338[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Consequently, defendant failed to demonstrate that the claims had been timely denied and, therefore, defendant has not established that its defense of lack of medical necessity is not precluded (see Presbyterian Hosp. in City of NY v Maryland Cas. Co., 90 NY2d 274 [1997]). Accordingly, the judgment is reversed, so much of the order as granted defendant’s cross motion for summary judgment dismissing the complaint is vacated and defendant’s cross motion is denied.

Pesce, P.J., Rios and Solomon, JJ., concur.
Decision Date: August 23, 2012

Cited in this decision

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

Nyack Hosp. v Encompass Ins. Co. (2005 NY Slip Op 08962) FollowedAn insurer's letters delaying payment pending its investigation do not toll the 30-day period for paying or denying a no-fault claim.
Points of Health Acupuncture, P.C. v Lancer Ins. Co. (2010 NY Slip Op 51338(U)) FollowedThe insurer proved EUO nonappearance and timely notices for three claims, but failed to establish tolling for the remaining claims.

Cited by

A label shows how the later decision treated this one.

New York Core Chiropractic, P.C. v Ameriprise Ins. Co. (2021 NY Slip Op 50599(U)) DistinguishedAn EUO request sent after 15 business days but within 30 calendar days tolls the time to pay or deny, with a reduction for lateness.
Garden State Anesthesia Assoc., PA v Progressive Cas. Ins. Co. (2013 NY Slip Op 23332) FollowedOutstanding verification tolls payment only if it bears a rational or reasonable relationship to the specific provider's claim.
MSB Physical Therapy, P.C. v Nationwide Ins. (2021 NY Slip Op 50750(U)) FollowedEUO requests sent before receipt of a claim do not toll the insurer's 30-day period to pay or deny it.
Colonia Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 51266(U)) FollowedThe insurer failed to prove IME nonappearance because its doctor's affidavit gave inconsistent examination addresses.
Sayyed DC, P.C. v Ameriprise Ins. Co. (2021 NY Slip Op 50311(U)) FollowedThe insurer established its EUO nonappearance defense to six bills, but untimely denials barred that defense to two others.
NY Wellness Med. P.C. v Ameriprise Ins. Co. (2021 NY Slip Op 50382(U)) FollowedThe insurer's delay notices referring only to the assignor's EUO failed to toll the payment period for three provider bills.
Health Needles Acupuncture, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51831(U))A letter merely announcing delay pending an assignor's IME and EUO does not toll the time to pay or deny a no-fault claim.
Sloan v Nationwide Mut. Ins. Co. (2022 NY Slip Op 50997(U))The insurer's EUO defense failed because its initial request and its denial following the second nonappearance were untimely.

Similar decisions

Parsons Med. Supply, Inc. v Utica Mut. Ins. Co. (2012 NY Slip Op 52397(U))The insurer failed to establish timely EUO requests and tolling of its time to pay or deny the provider's claims.
Neomy Med., P.C. v GEICO Ins. Co. (2010 NY Slip Op 51252(U))The insurer established timely denials and unrebutted defenses of lack of medical necessity and charges exceeding the fee schedule.
Parsons Med. Supply, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2011 NY Slip Op 52198(U))A peer review report is not inadmissible merely because the reviewer considered medical records prepared by other providers.
Med-Tech Prod., Inc. v Progressive Northeastern Ins. Co. (2012 NY Slip Op 50930(U))The provider's third and sixth causes of action were premature because requested verification remained outstanding when suit began.
Ortho-Med Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2012 NY Slip Op 50149(U))An insurer need not attach the records reviewed by its peer reviewer to establish lack of medical necessity on summary judgment.