November 26, 2010

St. Vincent’s Hosp. & Med. Ctr. v American Tr. Ins. Co. (2010 NY Slip Op 52063(U))

https://www.beynensonlaw.com/case-law/st-vincents-hosp-med-ctr-v-american-tr-ins-co-2010-ny-slip-op52063u/

Court: Appellate Term, Second Department
Decided: November 26, 2010
Citation: 2010 NY Slip Op 52063(U) · 29 Misc 3d 139(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Verification requests Timeliness and preclusion
Legal questions: Outstanding verification and premature actions · Challenging the assignment of benefits · Proof of mailing (see the maps)

Cite as

St. Vincent's Hosp. & Med. Ctr. v American Tr. Ins. Co., 29 Misc 3d 139(A), 2010 NY Slip Op 52063(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2010)

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 hospital satisfied requests for signed NF-5 forms by supplying the assignors' executed release authorizations and assignments. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, granting the hospital summary judgment on the first two causes of action and denying the insurer's cross motion alleging prematurity. Although the insurer established timely mailing of its verification requests, it already possessed NF-5 forms marked signature "on file." Because the only portions requiring an injured person's signature authorized information release and assignment or direct payment, the requests effectively sought those underlying documents. The hospital established that it provided them. Counsel's assertion that the insurer never received signed assignments lacked probative value because counsel had no personal knowledge.

Reported in New York Official Reports at St. Vincent’s Hosp. & Med. Ctr. v American Tr. Ins. Co. (2010 NY Slip Op 52063(U))

[*1]

St. Vincent’s Hosp. & Med. Ctr. v American Tr. Ins. Co.

2010 NY Slip Op 52063(U) [29 Misc 3d 139(A)]

Decided on November 26, 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This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on November 26, 2010

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : IANNACCI, J.P., NICOLAI and MOLIA, JJ
2009-2147 N C.

St. Vincent’s Hospital & Medical Center as Assignee of LUIGI GANDINI and AHSAN SHABAIN, THE NEW YORK AND PRESBYTERIAN HOSPITAL as Assignee of JACQUELINE SOCARIDES, WESTCHESTER MEDICAL CENTER as Assignee of ZEV WERTBERGER and THE NYACK HOSPITAL, as Assignee of AROLDO LOPEZ, Respondents,
against
American Transit Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, First District (Gary Franklin Knobel, J.), dated July 9, 2009. The order, insofar as appealed from as limited by the brief, granted the branches of a motion by plaintiff St. Vincent’s Hospital & Medical Center seeking summary judgment upon the first and second causes of action and denied the branches of defendant’s cross motion seeking summary judgment dismissing those causes of action.

ORDERED that the order, insofar as appealed from, is affirmed without costs.

In this action to recover assigned first-party no-fault benefits, insofar as is relevant to this appeal, plaintiff St. Vincent’s Hospital & Medical Center (SVHMC) moved for summary judgment upon the first and second causes of action, and defendant cross-moved for summary judgment dismissing those causes of action on the ground that they were premature since SVHMC had failed to fully comply with defendant’s verification requests. The District Court granted SVHMC’s motion for summary judgment upon the first and second causes of action, and denied defendant’s cross motion, finding that defendant had failed to establish the mailing of its initial and follow-up verification requests. This appeal by defendant ensued.

Contrary to the determination of the District Court, the affidavit of defendant’s claims examiner was sufficient to establish that the initial and follow-up verification requests were timely mailed in accordance with defendant’s standard office practices and procedures (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]). However, defendant’s contention that SVHMC failed to provide requested verification lacks merit. Defendant’s verification requests sought copies of NF-5 forms signed by SVHMC’s assignors. However, the only [*2]portions of an NF-5 form which may bear the signature of an eligible injured person are the portions which authorize the release of health service or treatment information in accordance with the No-Fault Law and which either assign no-fault benefits to a provider or authorize the provider to receive payments directly from the insurer. As defendant was already in possession, prior to its verification requests, of the subject NF-5 forms, which each bore notations that the assignor’s signature was “on file,” defendant’s verification requests, in effect, sought a copy of the document(s) “on file” which had been signed by the assignors. Since SVHMC established that it had, in response to the verification requests, provided defendant with copies of the authorizations to release information and the assignments executed by the assignors, SVHMC established that it had complied with those requests. While defendant’s attorney asserted that defendant had never received the signed assignment of benefits forms, defendant’s attorney’s affirmation was without probative value as defendant’s attorney lacked personal knowledge of same (see Wolfson v Rockledge Scaffolding Corp., 67 AD3d 1001 [2009]; Fiveborough Chiropractic & Acupuncture, PLLC v American Employers’ Ins. Co. Div. of Onebeacon Am. Ins. Co., 24 Misc 3d 133[A], 2009 NY Slip Op 51395[U] [App Term, 9th & 10th Jud Dists 2009]).

Accordingly, the order, insofar as appealed from, is affirmed.

Iannacci, J.P., Nicolai and Molia, JJ., concur.
Decision Date: November 26, 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.

Outstanding verification and premature actions

Open the full map

Did unanswered verification requests make the provider’s claim premature, or justify denying it for nonresponse?

This decision: Defense rejected because the provider supplied the verification or justified noncompliance

Rejected the prematurity defense because the requests for NF-5 forms signed by the assignors were satisfied when the hospital supplied the signed release authorizations and assignments; counsel's affirmation of non-receipt lacked personal knowledge.

Premature: verification outstandingNonresponse denial upheldTriable issueInsurer's showing failsProvider compliedThis decision

Of the 385 decisions on this question in the Second Department courts and the Court of Appeals, 9 (this one included) are in the same category.

Challenging the assignment of benefits

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Could the insurer contest the validity of the provider’s assignment of benefits, or had it waived that defense?

This decision: On the merits, the assignment or the claimant's showing is adequate, or the alleged defect is not a defect

Held the hospital complied with verification requests for NF-5 forms signed by the assignors, marked signature 'on file', by supplying the executed assignments and authorizations, and the insurer's attorney's denial of receipt lacked personal knowledge.

Defense waivedAssignment sufficientAssignment defense upheldIssue of factThis decision

Of the 96 decisions on this question in the Second Department courts and the Court of Appeals, 31 (this one included) are in the same category.

Proof of mailing

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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, contrary to the lower court, that the claims examiner's affidavit established timely mailing of the initial and follow-up verification requests under the insurer's standard office practices and procedures.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

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.

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
Fiveborough Chiropractic & Acupuncture, PLLC v American Employers’ Ins. Co. Div. of Onebeacon Am. Ins. Co. (2009 NY Slip Op 51395(U)) FollowedThe insurer established that it never received the provider's claims, and the provider failed to prove mailing.

Similar decisions

St. Barnabas Hosp. v American Tr. Ins. Co. (2008 NY Slip Op 09585)The insurer raised a triable issue whether the provider timely complied with its verification demand, defeating the provider's summary judgment motion.
St. Vincent’s Hosp. & Med. Ctr. v New Jersey Mfrs. Ins. Co. (2011 NY Slip Op 01828)The insurer's timely denials were fatally defective because they misstated the bill and disputed amounts and named the wrong applicant.
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.
Nyack Hosp. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 52184(U))An insurer must accept a completed hospital facility form in place of an application for motor vehicle no-fault benefits.
St. Vincent Med. Care, P.C. v Country Wide Ins. Co. (2011 NY Slip Op 00214)The insurer's follow-up verification requests on the 30th day were effective, and the provider's incomplete compliance made the action premature.