March 15, 2007

SZ Med., P.C. v Trumbull Ins. Co. (2007 NY Slip Op 50499(U))

https://www.beynensonlaw.com/case-law/sz-med-p-c-v-trumbull-ins-co-2007-ny-slip-op-50499u/

Court: Appellate Term, Second Department
Decided: March 15, 2007
Citation: 2007 NY Slip Op 50499(U) · 15 Misc 3d 126(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Timeliness and preclusion Verification requests
Legal questions: Proof of mailing · Claimant's prima facie case on motions (see the maps)

Cite as

SZ Med., P.C. v Trumbull Ins. Co., 15 Misc 3d 126(A), 2007 NY Slip Op 50499(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2007)

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 untimely denials precluded its fraudulent-billing defense because it failed to prove mailing of verification requests. The providers established submission of claims stating the fact and amounts of their losses and overdue payment under Insurance Law § 5106 (a). Although the insurer asserted that verification requests extended its time to deny under 11 NYCRR 65-3.5 and 65-3.8 (a) (1), its proof of mailing was inadequate. Its denials were issued more than 30 days after receipt of the claims, and the claim determination period was not tolled. Applying the preclusion rule to fraudulent billing, the Appellate Term, Second Department, affirmed summary judgment for the providers.

Reported in New York Official Reports at SZ Med., P.C. v Trumbull Ins. Co. (2007 NY Slip Op 50499(U))

[*1]

SZ Med., P.C. v Trumbull Ins. Co.

2007 NY Slip Op 50499(U) [15 Misc 3d 126(A)]

Decided on March 15, 2007

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This opinion is uncorrected and will not be published in the printed Official Reports.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 March 15, 2007

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : RUDOLPH, P.J., TANENBAUM and LaCAVA, JJ
2005-948 N C.

SZ Medical, P.C., JH Chiropractic, P.C. and New Wave Oriental Acupuncture, P.C. a/a/o Michael Boyce, Respondents,
against
Trumbull Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, Third District (Anna R. Anzalone, J.), dated March 18, 2005. The order granted plaintiffs’ motion for summary judgment.

Order affirmed without costs.

In this action to recover assigned first-party no-fault benefits for health care services provided to plaintiffs’ assignor, plaintiffs established their prima facie entitlement to summary judgment by proof that they submitted claims, setting forth the
fact and the amounts of the losses sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). As a result, the burden shifted to defendant to demonstrate the existence of a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320 [1986]).

Defendant asserts, inter alia, that it timely denied plaintiffs’ claims based on fraudulent billing. However, the denial of claim forms are dated February 17, 2004 and indicate that plaintiffs’ twelve claims were received by defendant between October 13, 2003 and December 13, 2003. Although defendant claimed to have mailed timely verification requests, which would extend the 30-day claim determination period (11 NYCRR 65-3.5, 65-3.8 [a] [1]), it failed to submit adequate proof that it did so (see New York & Prebyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2006]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]). Thus, defendant’s time to deny the claims was not tolled, the denials were untimely and defendant was [*2]precluded from raising most defenses as a result of its untimely denials (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]), including its defense of fraudulent billing (see Presbyterian Hosp. in City of N.Y., 90 NY2d at 285; Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]; Careplus Med. Supply Inc. v State-Wide Ins. Co., 11 Misc 3d 29 [App Term, 2d & 11th Jud Dists 2005]). Accordingly, the order granting plaintiffs’ motion for summary judgment is affirmed.

Rudolph, P.J., Tanenbaum and LaCava, 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 proof did not establish mailing of its denial, verification request or IME/EUO notice

Held the insurer failed to submit adequate proof that it mailed its claimed verification requests, so the claim period was not tolled and its fraud denials were untimely.

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 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 257 (this one included) are in the same category.

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 providers established prima facie entitlement by proof that they submitted claims stating the fact and amount of loss and that payment was overdue, shifting the burden to the insurer.

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

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.

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.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U))A provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
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.
Careplus Med. Supply Inc. v State-Wide Ins. Co. (2005 NY Slip Op 25545) FollowedThe insurer's completed denial form established receipt of the provider's claims and showed that the denial was untimely.

Similar decisions

A.B. Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co. (2005 NY Slip Op 25032)An insurer may assert a lack-of-coverage defense despite an untimely denial of no-fault claims.
SZ Med. P.C. v State-Wide Ins. Co. (2005 NY Slip Op 50103(U))The providers failed to establish overdue payment because their proof did not identify when the claims sued upon were submitted.
AT Med. P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50739(U))An untimely denial does not preclude a defense that the collision furthered an insurance fraud scheme.
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.
Boai Zhong Yi Acupuncture Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51202(U))The insurer established timely mailing of verification requests, tolling the 30-day period and making its denials timely.