November 16, 2005
SZ Med. P.C. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 51842(U))
https://www.beynensonlaw.com/case-law/sz-med-p-c-v-state-farm-mut-auto-ins-co-2005-ny-slip-op-51842u/
- Decided
- November 16, 2005
- Citation
- 2005 NY Slip Op 51842(U) · 9 Misc 3d 139(A)
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Later treatment
- Distinguished in 1 and followed in 1 later decisions (see Cited by)
- Issues
- EUO no-show Policy issues
- Legal questions
- No-show defense: insurer's proof · Claimant's prima facie case on motions (see the maps)
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 SZ Med. P.C. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 51842(U))
| SZ Med. P.C. v State Farm Mut. Auto. Ins. Co. |
| 2005 NY Slip Op 51842(U) [9 Misc 3d 139(A)] |
| Decided on November 16, 2005 |
| Appellate Term, First 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT
PRESENT: November 16, 2005 October 2004 Term Suarez, P.J., Davis, Schoenfeld, JJ.
against
State Farm Mutual Automobile Insurance CompanyCalendar No. ,04-229 Defendant-Respondent.
Plaintiffs appeal from that portion of an order of Civil Court, New York County (Debra Rose Samuels, J.), entered February 6, 2004, which denied their motion for summary judgment.
PER CURIAM:
Order (Debra Rose Samuels, J.) entered February 6, 2004, reversed, with $10 costs, plaintiffs’ motion for summary judgment is granted in the amount demanded in the complaint and the matter is remanded to Civil Court for a calculation of statutory interest and an assessment of attorneys’ fees due thereon, and for entry of judgment.
In this action to recover first party no-fault benefits for medical services rendered to its assignors, the plaintiff health care providers established a prima facie entitlement to summary judgment by evidentiary proof that they submitted claims between December 27, 2002 and April 8, 2003, setting forth the facts and the amounts thereof, and that payment of no-fault benefits was overdue as defendant neither paid nor denied the claims within 30 days as required by Insurance Law § 5106(a) (see Mary Immaculate Hospital v Allstate Ins. Co., 5 AD3d 742 [2004]).
We find unavailing defendant’s argument that plaintiffs are not entitled to judgment because the assignors failed to submit to examinations under oath (EUOs). While the prescribed No-Fault Mandatory Personal Injury Protection Endorsement under 11 NYCRR §65-1.1(d) provides in the “Conditions” section that an injured person “shall … as may reasonably be [*2]required submit to examinations under oath …,” defendant did not establish that the insurance policy in effect contained the no-fault endorsement authorizing EUOs. Although plaintiffs’ claims were submitted after the April 5, 2002 effective date of the revised insurance regulations, the provisions of said regulations are not applicable to claims until new or renewed policies containing the revised endorsement are issued (see Elite Psychological Services, P.C. v Trumball Ins. Co., 2005 NY Slip Op 51427U [App Term 1st Dept]); Star Medical Services, P.C. v Eagle Insurance Company, 6 Misc 3d 56 [2004]). Consequently, absent a showing that the subject policy contained a no-fault endorsement permitting EUOs, defendant cannot rely on the revised regulations to argue that plaintiffs vitiated coverage by failing to comply with a condition precedent.
Nor may defendant base its right to an EUO on the policy provisions providing for “cooperation” because the no-fault protection created by the statute and implementing regulations cannot be qualified by the conditions of the liability portion of the policy (see Utica Mut. Ins. Co. v Timms, 293 AD2d 669, 670 [2002], lv dismissed 98 NY2d 727 [2002]; Bronx Med. Serv. P.C. v Lumbermans Mut. Cas. Co., 2003 NY Slip Op 51022U [App Term, 1st Dept]).
This constitutes the decision and order of the court.
Decision Date: November 16, 2005
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 the insurer prove its IME/EUO no-show defense: mailed, compliant scheduling requests and the claimant’s nonappearance?
This decision: Insurer did not show its requests met the regulatory timing, follow-up or justification requirements
Rejected the EUO no-show defense because the insurer did not show the policy contained the revised endorsement authorizing EUOs, and the liability policy's cooperation clause could not supply that right.
Of the 164 decisions on this question in the First Department courts and the Court of Appeals, 39 (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.
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 providers established prima facie entitlement by proof that they submitted claims setting forth the facts and amounts and that the insurer neither paid nor denied them within 30 days.
Of the 52 decisions on this question in the First Department courts and the Court of Appeals, 45 (this one included) are in the same category. 3 decisions in other departments that cite or are cited by this one are on the full map.
Cited in this decision
A label shows how this decision treated the case it cites.
- Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359)The hospitals established entitlement to summary judgment by proving that statutory billing forms were mailed and received and payment was overdue.
- Elite Psychological Servs., P.C. v Trumbull Ins. Co. (2005 NY Slip Op 51427(U)) FollowedThe insurer failed to establish that the policy authorized EUOs, so its denial based on the assignor's nonattendance was untimely.
- Star Med. Servs. P.C. v Eagle Ins. Co. (2004 NY Slip Op 24482) FollowedThe insurer failed to establish that the policy contained an endorsement authorizing EUOs. The Appellate Term, Second Department, reversed the order denying the provider's summary judgment motion, granted the motion, and remanded for statutory interest and attorney's fees under Insurance Law § 5106 (a).
Cited by
A label shows how the later decision treated this one.
- Woolfson v Government Empls. Ins. Co. (2008 NY Slip Op 28290) DistinguishedAn insurer need not produce the policy to enforce the mandatory 45-day claim deadline when the policy is subject to the new regulations.
- Mega Supply & Billing Inc. v Allstate Ins. Co. (2005 NY Slip Op 52168(U)) FollowedThe insurer failed to raise a triable staged-accident defense or establish tolling of its time to deny the provider's claim.
Similar decisions
- West Tremont Med. Diagnostic, P.C. v Allstate Ins. Co. (2006 NY Slip Op 51374(U))The insurer failed to establish that the policy contained an endorsement authorizing EUOs. The provider proved submission of a claim stating the fact and amount of the loss and overdue payment under Insurance Law § 5106 (a).
- Star Med. Servs. P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50505(U))The insurer failed to establish an EUO-authorizing endorsement or submit admissible evidence of a staged-accident defense.
- Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 25336)The insurer's investigator affidavit raised a triable coverage issue based on a founded belief that the collision furthered insurance fraud.
- Flatlands Med., P.C. v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 50763(U))The provider's objections to the insurer's EUO requests were not heard because it had not responded to the requests.
- Rigid Med. of Flatbush, P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 50582(U))The insurer failed to establish an EUO-authorizing policy endorsement or proper EUO notices, leaving its denial untimely.