April 29, 2008

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072)

https://www.beynensonlaw.com/case-law/st-vincents-hosp-of-richmond-v-government-empls-ins-co-2008-ny-slip-op04072/

Court: Appellate Division, Second Department
Decided: April 29, 2008
Citation: 2008 NY Slip Op 04072 · 50 AD3d 1123
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Distinguished in 1, contrasted (cf., but see) in 4 and followed in 746 later decisions (see Cited by)
Issues: Timeliness and preclusion
Legal questions: Proof of mailing · Claimant's prima facie case on motions (see the maps)

Cite as

St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 (2d Dept 2008)

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 raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim. The hospital established mailing and receipt of billing forms, overdue payment, and a received denial that omitted required information. In opposition, an employee familiar with the insurer's standard mailing procedures attested that an earlier, complete denial had been timely issued, raising a factual issue about proper denial. The insurer's excerpts of the insured's medical records were admissible under CPLR 4518 (c) and also raised a factual issue regarding entitlement to deny the claim. The Appellate Division, Second Department, affirmed the order, insofar as appealed from, denying the hospital's summary judgment motion.

Reported in New York Official Reports at St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072)

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co.

2008 NY Slip Op 04072 [50 AD3d 1123]

April 29, 2008

Appellate Division, Second Department

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

As corrected through Wednesday, June 18, 2008

St. Vincent’s Hospital of Richmond, Appellant,
v
Government Employees Insurance Company, Respondent.

—[*1] Joseph Henig, P.C., Bellmore, N.Y. (Mark Green of counsel), for appellant.

Teresa M. Spina, Woodbury, N.Y. (Jeanne M. Ortega of counsel), for respondent.

In an action to recover no-fault medical payments, the plaintiff appeals, as limited by its brief, from so much of an order of the Supreme Court, Nassau County (Feinman, J.), dated July 25, 2007, as denied its motion for summary judgment on the complaint.

Ordered that the order is affirmed insofar as appealed from, with costs.

The plaintiff established its prima facie entitlement to judgment as a matter of law. It submitted evidentiary proof that the prescribed statutory billing forms were mailed and received, that payment of no-fault benefits was overdue (see Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d 564 [2005]), and that the denial of claim form it received from the defendant, dated June 25, 2006, was fatally insufficient in that it failed to include the information called for in the prescribed denial of claim form (see Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d 564 [2005]; Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 226 AD2d 613 [1996]; cf. Westchester Med. Ctr. v Allstate Ins. Co., 45 AD3d 579 [2007]). However, in opposition, the defendant submitted admissible evidence in the form of an affidavit of an employee with knowledge of the defendant’s standard office practices or procedures designed to ensure that items were properly addressed and mailed (see New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2006]; Hospital for Joint Diseases v Nationwide Mut. Ins. Co., 284 AD2d 374 [2001]; 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 [2007]; cf. Westchester Med. Ctr. v Countrywide Ins. Co., 45 AD3d 676 [2007]). The employee attested that a denial [*2]of claim form dated June 22, 2006, containing all the information called for in the prescribed form was timely issued to the plaintiff on that date. Thus, the defendant raised a triable issue of fact as to whether it issued a proper denial of claim form.

Contrary to the plaintiff’s further contention, the excerpts of the insured’s medical records submitted by the defendant in opposition to its motion constituted admissible evidence sufficient to raise a triable issue of fact as to whether the defendant was entitled to deny the claim (see CPLR 4518 [c]; Maxcy v County of Putnam, 178 AD2d 729 [1991]). Prudenti, P.J., Fisher, Miller and Balkin, 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.

Proof of mailing

Open the full map

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

Held an employee's affidavit describing the insurer's standard office practices designed to ensure items are properly addressed and mailed, attesting that a complete denial was timely issued, was admissible proof that raised a triable issue defeating the provider's motion.

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

Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 806 (this one included) are in the same category. 12 decisions in other departments that cite or are cited by this one are on the full map.

Claimant's prima facie case on motions

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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 by proof that the billing forms were mailed and received, payment was overdue and the denial it received was fatally deficient, but the insurer raised triable issues.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followedDistinguished or limited

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. One decision in other departments that cites or is cited by this one is on the full map.

Cited in this decision

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

Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co. (2005 NY Slip Op 02235)The insurer failed to prove mailing of its denial, and the denial was incomplete even if timely.
Westchester Med. Ctr. v Allstate Ins. Co. (2007 NY Slip Op 08447) Contrasted (cf., but see)The hospital failed to establish that the insurer's timely NF-10 denial was too vague or deficient to constitute a proper response.
New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 03558) FollowedThe providers failed to establish mailing and receipt of the hospital bill asserted in their second cause of action.
Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345) FollowedAn insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
Westchester Med. Ctr. v Countrywide Ins. Co. (2007 NY Slip Op 09024) Contrasted (cf., but see)The insurer failed to prove mailing of verification requests and waived defenses based on incomplete assignment forms.

Cited by (915)

A label shows how the later decision treated this one.

Tarnoff Chiropractic, P.C. v GEICO Ins. Co. (2012 NY Slip Op 50670(U)) DistinguishedThe insurer failed to substantiate an objective basis for the assignor's EUO to investigate a suspected staged accident.
Westchester Med. Ctr. v Philadelphia Indem. Ins. Co. (2010 NY Slip Op 00138) Contrasted (cf., but see)The insurer failed to justify vacating its default because its affidavit established neither a reasonable excuse nor a meritorious defense.
Jersey Rehab PA, P.C. v IDS Prop. Cas. Ins. Co. (2013 NY Slip Op 50652(U)) Contrasted (cf., but see)An IME demand must advise the applicant of reimbursement for lost earnings and reasonable transportation expenses to support a no-show defense.
Corona Comprehensive Med. Care, P.C. v Global Liberty Ins. Co. of N.Y. (2009 NY Slip Op 51432(U)) Contrasted (cf., but see)A workers' compensation defense is a statutory offset subject to preclusion unless timely raised in a denial.
Arco Med. NY, P.C. v Lancer Ins. Co. (2011 NY Slip Op 52383(U)) Contrasted (cf., but see)The insurer's EUO defense was precluded because its earlier denial preceded these claims and mailing of later denials was unproved.
ARCO Med. N.Y., P.C. v Lancer Ins. Co. (2011 NY Slip Op 52382(U)) FollowedA follow-up EUO request is not premature when sent within 10 days after failure to appear for the initial scheduled examination.
Crescent Radiology, PLLC v American Tr. Ins. Co. (2011 NY Slip Op 50622(U)) FollowedThe insurer established timely mailing of EUO notices and denials and the assignor's failure to appear at two scheduled EUOs. The provider obtained summary judgment after the District Court found insufficient objective justification for the EUO request.
Palafox PT, P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51653(U)) FollowedThe provider failed to identify discovery that could raise a triable issue concerning the insurer's EUO nonappearance defense.
Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 24145) FollowedThe provider's mail-record affidavit raised a triable issue as to whether the insurer mailed its verification requests.
D & R Med. Supply v American Tr. Ins. Co. (2011 NY Slip Op 51727(U)) FollowedThe provider's incomplete verification responses left the insurer's time to pay or deny untriggered and the action premature.

Show all 915 citing decisions

Similar decisions

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.
Lenox Hill Hosp. v Government Empls. Ins. Co. (2011 NY Slip Op 08330)The insurer's evidence of a timely denial raised a triable issue defeating the provider's motion based solely on untimeliness.
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.
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 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.