December 2, 2008
St. Barnabas Hosp. v American Tr. Ins. Co. (2008 NY Slip Op 09585)
https://www.beynensonlaw.com/case-law/st-barnabas-hosp-v-american-tr-ins-co-2008-ny-slip-op-09585/
- Decided
- December 2, 2008
- Citation
- 2008 NY Slip Op 09585 · 57 AD3d 517
- Posture
- Summary judgment
- Outcome
- Split result
- Later treatment
- Followed in 1 later decision (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 St. Barnabas Hosp. v American Tr. Ins. Co. (2008 NY Slip Op 09585)
| St. Barnabas Hosp. v American Tr. Ins. Co. |
| 2008 NY Slip Op 09585 [57 AD3d 517] |
| December 2, 2008 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| St. Barnabas Hospital, as Assignee of Miguel Jimenez, et al.,
Respondents, v American Transit Insurance Company, Appellant. |
—[*1] Stern & Montana, LLP, New York, N.Y. (Richard Montana of counsel), for appellant.
Joseph Henig, P.C., Bellmore, N.Y., for respondents.
In an action to recover no-fault medical payments under insurance contracts, the defendant appeals from so much of an order of the Supreme Court, Nassau County (Mahon, J.), dated January 28, 2008, as granted that branch of the motion of the plaintiff St. Barnabas Hospital, as assignee of Miguel Jimenez, which was for summary judgment on the first cause of action and denied that branch of its cross motion which was for summary judgment dismissing the first cause of action.
Ordered that the order is modified, on the law, by deleting the provision thereof granting that branch of the motion of the plaintiff St. Barnabas Hospital, as assignee of Miguel Jimenez, which was for summary judgment on the first cause of action and substituting therefor a provision denying that branch of the motion; as so modified, the order is affirmed insofar as appealed from, without costs or disbursements.
The plaintiff St. Barnabas Hospital, as assignee of Miguel Jimenez (hereinafter the Hospital), made a prima facie showing of entitlement to judgment as a matter of law on the first cause of action to recover no-fault benefits by demonstrating that the prescribed statutory billing forms were mailed to and received by the defendant and that payment was overdue (see Westchester Med. Ctr. v Allstate Ins. Co., 53 AD3d 481 [2008]; Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co., 44 AD3d 903, 904 [2007]; New York & Presbyt. Hosp. v Countrywide Ins. Co., 44 AD3d 729, 730 [2007]). [*2]
However, in opposition, the defendant raised a triable issue of fact as to whether the Hospital timely complied with the demand for verification (see Mount Sinai Hosp. v Allstate Ins. Co., 25 AD3d 673, 674 [2006]). The defendant was not obligated to pay or deny the claim until all demanded verification was provided by the Hospital (see New York & Presbyt. Hosp. v Allstate Ins. Co., 31 AD3d 512, 513 [2006]; Nyack Hosp. v General Motors Acceptance Corp., 27 AD3d 96, 100-101 [2005], mod on other grounds 8 NY3d 294 [2007]; Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492, 493 [2005]).
Accordingly, the Supreme Court correctly denied that branch of the defendant’s cross motion which was for summary judgment dismissing the first cause of action, but should not have granted that branch of the Hospital’s motion which was for summary judgment on the first cause of action. Mastro, J.P., Rivera, Fisher and Eng, JJ., concur.
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.
Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?
This decision: Fact issues remain on whether the verification defense applies
Held the insurer raised a triable issue as to whether the hospital timely complied with the verification demand, since the insurer need not pay or deny until all verification is provided, so the hospital's summary judgment was denied.
Of the 374 decisions on this question in the Second Department courts and the Court of Appeals, 114 (this one included) are in the same category.
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 hospital made a prima facie showing by demonstrating the billing forms were mailed to and received by the insurer and payment was overdue, but the insurer raised a triable issue.
Of the 1,063 decisions on this question in the Second Department courts and the Court of Appeals, 511 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- Westchester Med. Ctr. v Allstate Ins. Co. (2008 NY Slip Op 06146)The insurer raised a factual issue about the provider's compliance with timely verification requests for toxicology information.
- Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 08038)The hospital's claim was premature because unrebutted proof showed that it ignored timely verification and follow-up requests.
- New York & Presbyt. Hosp. v Countrywide Ins. Co. (2007 NY Slip Op 07675)The insurer raised verification and billing-date issues on one claim, but failed to rebut proof of receipt of verification on another.
- Mount Sinai Hosp. v Allstate Ins. Co. (2006 NY Slip Op 00490) FollowedThe insurer raised a triable issue about the provider's verification compliance but failed to establish entitlement to dismissal.
- New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 05602) FollowedThe insurer proved a timely denial but failed to establish that the provider's treatment was unrelated to the accident.
- Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co. (2005 NYSlipOp 09484) FollowedAn insurer need not pay or deny a no-fault claim until it receives all relevant verification requested.
Cited by (12)
A label shows how the later decision treated this one.
- Westchester Med. Ctr. v Country Wide Ins. Co. (2011 NY Slip Op 03838) FollowedThe insurer raised a triable issue as to whether the hospital fully complied with its verification demand.
- New York Hosp. Med. Ctr. of Queens v QBE Ins. Corp. (2014 NY Slip Op 00639)Outstanding verification warranted dismissal of the first cause of action, but defective verification proof supported payment on the second.
- Victory Med. Diagnostics, P.C. v Nationwide Prop. & Cas. Ins. Co. (2012 NY Slip Op 22149)A provider's reasoned objection to a verification request preserves its propriety for determination by the trier of fact.
- Lincoln Gen. Ins. Co. v Alev Med. Supply Inc. (2009 NY Slip Op 29389)An insurer may not recover paid no-fault benefits for undelivered supplies when it failed to timely deny the claim for billing fraud.
- Exclusive Med. Supply, Inc. v MVAIC (2012 NY Slip Op 50616(U))MVAIC's qualification letters did not toll the 30-day claim determination period because they did not seek verification of the claims.
- Westchester Med. Ctr. v Philadelphia Indem. Ins. Co. (2010 NY Slip Op 00138)The insurer failed to justify vacating its default because its affidavit established neither a reasonable excuse nor a meritorious defense.
- Brownsville Advance Med., P.C. v Country-Wide Ins. Co. (2011 NY Slip Op 52255(U))An insurer must establish a reasonable basis and rational need to demand anew documentation the provider has already supplied.
- Tarnoff Chiropractic, P.C. v GEICO Ins. Co. (2012 NY Slip Op 50670(U))The insurer failed to substantiate an objective basis for the assignor's EUO to investigate a suspected staged accident.
- Garden State Anesthesia Assoc., PA v Progressive Cas. Ins. Co. (2013 NY Slip Op 23332)Outstanding verification tolls payment only if it bears a rational or reasonable relationship to the specific provider's claim.
- Advanced Neurological Care, P.C. v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 52203(U))The insurer's affidavits failed to establish proper addressing and timely mailing of verification requests, leaving factual issues.
Similar decisions
- 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.
- 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.
- St. Vincent’s Hosp. & Med. Ctr. v American Tr. Ins. Co. (2010 NY Slip Op 52063(U))The hospital satisfied requests for signed NF-5 forms by supplying the assignors' executed release authorizations and assignments.
- St. Luke’s Roosevelt Hosp. v American Tr. Ins. Co. (2003 NY Slip Op 18448)The providers' summary judgment motion for no-fault payments was granted because the insurer raised no triable issue.