March 8, 2011

St. Vincent’s Hosp. & Med. Ctr. v New Jersey Mfrs. Ins. Co. (2011 NY Slip Op 01828)

https://www.beynensonlaw.com/case-law/st-vincents-hosp-med-ctr-v-new-jersey-mfrs-ins-co-2011-ny-slip-op01828/

Court: Appellate Division, Second Department
Decided: March 8, 2011
Citation: 2011 NY Slip Op 01828 · 82 AD3d 871
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Contrasted (cf., but see) in 1 and followed in 2 later decisions (see Cited by)
Issues: Timeliness and preclusion

Cite as

St. Vincent's Hosp. & Med. Ctr. v New Jersey Mfrs. Ins. Co., 82 AD3d 871 (2d Dept 2011)

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 insurer's timely denials were fatally defective because they misstated the bill and disputed amounts and named the wrong applicant. The hospital moved for summary judgment, and the insurer cross-moved to dismiss on the ground that the claim was untimely. Although both denials issued within 30 days of receipt of completed hospital facility forms, they identified the assignor rather than the hospital as applicant. Under 11 NYCRR 65-3.4 (c) (11), timely issuance did not cure those defects. The Appellate Division, Second Department, reversed, granted the hospital's motion and denied the insurer's cross motion. Separately, it granted the insurer's motion to strike a point in the hospital's reply brief and denied the hospital's cross motion to strike material from the insurer's brief.

Reported in New York Official Reports at St. Vincent’s Hosp. & Med. Ctr. v New Jersey Mfrs. Ins. Co. (2011 NY Slip Op 01828)

St. Vincent’s Hosp. & Med. Ctr. v New Jersey Mfrs. Ins. Co.

2011 NY Slip Op 01828 [82 AD3d 871]

March 8, 2011

Appellate Division, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, May 11, 2011

St. Vincent’s Hospital & Medical Center, as Assignee of Tula Huillca, Appellant,
v
New Jersey Manufacturers Insurance Company, Respondent.

—[*1] Joseph Henig, P.C., Bellmore, N.Y., for appellant.

Litchfield Cavo LLP, New York, N.Y. (Mark A. Everett of counsel), for respondent.

In an action to recover no-fault medical payments, the plaintiff, St. Vincent’s Hospital & Medical Center, as assignee of Tula Huillca, appeals from an order of the Supreme Court, Nassau County (Phelan, J.), entered April 23, 2010, which denied its motion for summary judgment on the complaint and granted the defendant’s cross motion for summary judgment dismissing the complaint on the ground that the claim was untimely.

Ordered that the order is reversed, on the law, with costs, the plaintiff’s motion for summary judgment on the complaint is granted, and the defendant’s cross motion for summary judgment dismissing the complaint is denied.

“A proper denial of [a] claim [for no-fault benefits] must include the information called for in the prescribed denial of claim form (see 11 NYCRR 65-3.4 [c] [11]) and must ‘promptly apprise the claimant with a high degree of specificity of the ground or grounds on which the disclaimer is predicated’ ” (Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 11 AD3d 664, 664 [2004], quoting General Acc. Ins. Group v Cirucci, 46 NY2d 862, 864 [1979]). However, a timely denial of a no-fault insurance medical claim alone does not avoid precluding an insurer from disclaiming or denying liability where the denial is factually insufficient, conclusory, vague, or otherwise involves a defense which has no merit as a matter of law (see Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d 564, 565 [2005]).

The plaintiff, St. Vincent’s Hospital & Medical Center, as assignee of Tula Huillca, demonstrated its prima facie entitlement to judgment as a matter of law. While the defendant insurer timely issued two denials of claim within 30 days of its receipt of the completed hospital facility forms (NYS form N-F 5), those denials of claim, which incorrectly stated the amount of the bill and the amount in dispute, and incorrectly listed Tula Huillca as the applicant for benefits instead of the plaintiff, were fatally defective (see St. Barnabas Hosp. v Allstate Ins. Co., 66 AD3d 996, 996-997 [2009]; Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d at 565). In opposition, the defendant failed to raise a triable issue of fact.

Accordingly, the Supreme Court should have granted the plaintiff’s motion for summary [*2]judgment on the complaint, and denied the defendant’s cross motion for summary judgment dismissing the complaint. Dillon, J.P., Dickerson, Hall and Roman, JJ., concur.

Motion by the respondent on an appeal from an order of the Supreme Court, Nassau County, entered April 23, 2010, to strike Point I of the appellant’s reply brief on the ground, inter alia, that it improperly raises issues for the first time on appeal. Cross motion by the appellant to strike lines 11 through 19 of page 3 of the respondent’s brief on the ground that those lines refer to matter dehors the record. By decision and order on motion of this Court dated December 6, 2010, the motion and cross motion were held in abeyance and referred to the panel of Justices hearing the appeal for determination upon the argument or submission thereof.

Upon the papers filed in support of the motion and cross motion, the papers filed in opposition thereto, and upon the argument of the appeal, it is

Ordered that the motion is granted and Point I of the appellant’s reply brief is deemed stricken and has not been considered in the determination of the appeal; and it is further,

Ordered that the cross motion is denied. Dillon, J.P., Dickerson, Hall and Roman, JJ., concur.

Cited in this decision

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

Nyack Hosp. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 07663)A timely but fatally defective denial cannot be cured by supplying omitted information after the 30-day denial period expires.
Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co. (2005 NY Slip Op 02235) FollowedThe insurer failed to prove mailing of its denial, and the denial was incomplete even if timely.
St. Barnabas Hosp. v Allstate Ins. Co. (2009 NY Slip Op 07824) FollowedThe insurer failed to establish a meritorious defense because its timely denial misstated the claim amount and gave an invalid reason.

Cited by

A label shows how the later decision treated this one.

NYU-Hospital for Joint Diseases v Allstate Ins. Co. (2014 NY Slip Op 08613) Contrasted (cf., but see)The hospital failed to establish entitlement to summary judgment because its own papers included a timely and sufficient denial.
NYU Hosp. for Joint Diseases v Country Wide Ins. Co. (2011 NY Slip Op 04219) FollowedThe insurer's denial was fatally defective because it omitted required information and named the assignor as the benefits applicant.
Apple Tree Acupuncture, P.C. v Interboro Ins. Co. (2011 NY Slip Op 52364(U)) FollowedThe insurer's fee-schedule motion relied on a ground absent from its denials, and the provider raised a medical-necessity issue on other claims.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430)A provider need not prove a claim's merits for summary judgment where the insurer failed to timely and properly deny the claim.

Similar decisions

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. Vincent’s Hosp. & Med. Ctr. v Allstate Ins. Co. (2010 NY Slip Op 00668)An insurer's failure to pay or deny a no-fault claim within 30 days does not preclude a defense that the accident was not an insured incident.
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.
St. Vincent’s Hosp. & Med. Ctr. v County Wide Ins. Co. (2005 NY Slip Op 10114)A hospital's no-fault claim was dismissed because it was submitted more than 45 days after medical services were rendered.
St. Vincent’s Hosp. & Med. Ctr. v Nationwide Mut. Ins. Co. (2007 NY Slip Op 06226)The hospital's challenge to the adequacy of the insurer's IME-based denial was raised for the first time in reply and was not considered.