March 10, 2010
St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. (2010 NY Slip Op 50444(U))
https://www.beynensonlaw.com/case-law/st-vincent-med-care-p-c-v-country-wide-ins-co-2010-ny-slip-op50444u/
- Decided
- March 10, 2010
- Citation
- 2010 NY Slip Op 50444(U) · 26 Misc 3d 144(A)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
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. Vincent Med. Care, P.C. v Country-Wide Ins. Co. (2010 NY Slip Op 50444(U))
| St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. |
| 2010 NY Slip Op 50444(U) [26 Misc 3d 144(A)] |
| Decided on March 10, 2010 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : WESTON, J.P., GOLIA and RIOS, JJ
2008-1963 Q C.
against
Country-Wide Insurance Company, Appellant.
Appeal from a judgment of the Civil Court of the City of New York, Queens County (Thomas D. Raffaele, J.), entered August 15, 2008. The judgment, entered pursuant to an order of the same court entered June 20, 2008 granting plaintiff’s motion for summary judgment and denying defendant’s cross motion for summary judgment dismissing the complaint, awarded plaintiff the principal sum of $4,012.91.
ORDERED that the judgment is reversed without costs, the portions of the order entered June 20, 2008 which granted plaintiff’s motion for summary judgment and which denied the branches of defendant’s cross motion seeking summary judgment dismissing the first, second, third, fifth, sixth, eighth and ninth causes of action are vacated, plaintiff’s motion for summary judgment is denied, and the branches of defendant’s cross motion seeking summary judgment dismissing the first, second, third, fifth, sixth, eighth and ninth causes of action are granted, and the matter is remitted to the Civil Court for all further proceedings on the fourth and seventh causes of action.
In this action by a provider to recover assigned first-party no-fault benefits, the Civil Court granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment dismissing the complaint. A judgment was subsequently entered, and this appeal by defendant ensued.
Since the affidavit of defendant’s claims representative conceded receipt of the claims in question (see East Acupuncture, P.C. v Electric Ins. Co., 16 Misc 3d 128[A], 2007 NY Slip Op 51281[U] [App Term, 2d & 11th Jud Dists 2007]; Oleg Barshay, D.C., P.C. v State Farm Ins. Co., 14 Misc 3d 74 [App Term, 2d & 11th Jud Dists 2006]) and the affidavit of plaintiff’s billing manager established that the documents annexed to plaintiff’s motion were admissible pursuant to CPLR 4518 (see Art of Healing Medicine, P.C. v Travelers Home & Mar. Ins. Co., 55 AD3d 644 [2008]; Dan Med., P.C. v New York Cent. Mut. Fire Ins. Co., 14 Misc 3d 44 [App [*2]Term, 2d & 11th Jud Dists 2006]), plaintiff’s prima facie entitlement to summary judgment was established.
The affidavit of defendant’s no-fault litigation supervisor sufficiently established the timely mailing of the NF-10 denial of claim forms and verification requests since it described, in detail, based on the affiant’s personal knowledge, defendant’s standard office practices or procedures used to ensure that said documents were properly mailed (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]).
In regard to plaintiff’s first, second, third, fifth, sixth, eighth and ninth causes of action, defendant established that it had timely mailed its initial requests for verification (see Insurance Department Regulations [11 NYCRR] § 65-3.5 [b]), and plaintiff had failed to provide the information requested. Plaintiff also did not provide the information requested in defendant’s follow-up verification requests, which were mailed on the 30th day after the initial verification requests, but prior to the expiration of the full 30-day period within which plaintiff was required to respond to defendant’s initial requests for verification. As the foregoing facts are nearly identical to those in Infinity Health Prods., Ltd. v Eveready Ins. Co. (67 AD3d 862 [2d Dept 2009]), “the 30-day period within which the defendant was required to pay or deny the claim[s] did not commence to run [and] plaintiff’s action is premature” (id. at 865 [citations omitted]). As a result, defendant was entitled to summary judgment dismissing these causes of action.
Defendant also established that it had timely denied the two $365.68 claims (plaintiff’s fourth and seventh causes of action) on the ground that the services for which payment was sought were part of another service and, thus, were not separately reimbursable. Consequently, defendant raised a triable issue of fact with respect to the fourth and seventh causes of action (see St. Vincent’s Med. Care, P.C. v Country-Wide Ins. Co., ___ Misc 3d ___, 2009 NY Slip Op 29508 [App Term, 2d, 11th & 13th Jud Dists 2009]).
Accordingly, the judgment is reversed, the portions of the order entered June 20, 2008 which granted plaintiff’s motion for summary judgment and which denied the branches of defendant’s cross motion seeking summary judgment dismissing the first, second, third, fifth, sixth, eighth and ninth causes of action are vacated, plaintiff’s motion for summary judgment is denied, the branches of defendant’s cross motion seeking summary judgment dismissing the first, second, third, fifth, sixth, eighth and ninth causes of action are granted, and the matter is remitted to the Civil Court for all further proceedings on the fourth and seventh causes of action.
Weston, J.P., Golia and Rios, JJ., concur.
Decision Date: March 10, 2010
Legal questions (3)
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: Timely requests went unanswered; the claim is not overdue and the action is premature
Held the action premature on seven causes of action because the insurer timely mailed initial and follow-up verification requests that went unanswered, and a follow-up sent on day 30 was effective, so the 30-day period never began.
Of the 385 decisions on this question in the Second Department courts and the Court of Appeals, 153 (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 provider made its prima facie showing because the insurer's claims representative conceded receipt of the claims and the billing manager's affidavit made the annexed documents admissible under CPLR 4518.
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.
Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?
This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)
Held the insurer's litigation supervisor's affidavit established timely mailing of its denials and verification requests because it described in detail, from personal knowledge, the standard office practices ensuring proper mailing.
Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- East Acupuncture, P.C. v Electric Ins. Co. (2007 NY Slip Op 51281(U))The insurer's late denials did not bar its coverage defense, and its evidence raised a triable issue of a staged incident.
- Oleg Barshay, D.C., P.C. v State Farm Ins. Co. (2006 NY Slip Op 26496)A provider's deficient proof of claim submission may be cured by an insurer's denial form submitted in opposition to summary judgment.
- Art of Healing Medicine, P.C. v Travelers Home & Mar. Ins. Co. (2008 NY Slip Op 07846)The providers failed to establish a prima facie case because they did not demonstrate the admissibility of their billing records.
- Dan Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 26483)The provider failed to establish its prima facie case because its corporate officer did not lay a business-records foundation for the claim documents.
- Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345)An insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
- Infinity Health Prods., Ltd. v Eveready Ins. Co. (2009 NY Slip Op 08585) FollowedA provider that ignored two verification requests was estopped from invoking preclusion based on a follow-up sent three days early.
- St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. (2009 NY Slip Op 29508) FollowedFollow-up verification requests mailed on the 30th day after the initial requests are premature and do not toll claim determination periods.
Similar decisions
- St. Vincent Med. Care, P.C. v Country Wide Ins. Co. (2010 NY Slip Op 50488(U))Unanswered verification requests kept eight claims premature despite a follow-up mailed before the full response period expired.
- First Aid Occupational Therapy, PLLC v Country-Wide Ins. Co. (2010 NY Slip Op 50594(U))The provider's claims failed in part for outstanding verification and duplicate billing, while separate reimbursement remained disputed.
- St. Vincent Med. Care, P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 51728(U))The insurer established lack of medical necessity for the first cause of action and IME nonappearance for the other three causes.
- Vincent Med. Servs., P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 50431(U))The insurer's unrebutted IME reports established lack of medical necessity for the first through third and sixth through tenth causes of action.
- St. Vincent Med. Care, P.C. v Mercury Cas. Co. (2009 NY Slip Op 50810(U))The provider's principal's affirmation was inadmissible under CPLR 2106 and failed to rebut the insurer's medical-necessity showing.