November 26, 2010

Triangle R Inc. v Praetorian Ins. Co. (2010 NY Slip Op 52041(U))

https://www.beynensonlaw.com/case-law/triangle-r-inc-v-praetorian-ins-co-2010-ny-slip-op-52041u/

Court: Appellate Term, First Department
Decided: November 26, 2010
Citation: 2010 NY Slip Op 52041(U) · 29 Misc 3d 138(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Verification requests
Legal questions: Outstanding verification and premature actions (see the maps)

Cite as

Triangle R Inc. v Praetorian Ins. Co., 29 Misc 3d 138(A), 2010 NY Slip Op 52041(U) (App Term, 1st Dept 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.

An insurer need not pay or deny a no-fault claim until it receives all relevant requested verification. The Appellate Term, First Department, reversed the order and granted the insurer summary judgment dismissing the provider's claim as premature under 11 NYCRR 65-3.8 (b) (3). It was undisputed that the insurer never received responses to requests for medical records, and the provider raised no triable issue. A blanket denial based on the assignor's IME nonappearance did not effectively deny the specific claim and did not preclude the alternative verification defense. The provider's estoppel argument was unpreserved and also failed because no competent evidence showed that it was misled or detrimentally relied on the blanket denial.

Reported in New York Official Reports at Triangle R Inc. v Praetorian Ins. Co. (2010 NY Slip Op 52041(U))

[*1]

Triangle R Inc. v Praetorian Ins. Co.

2010 NY Slip Op 52041(U) [29 Misc 3d 138(A)]

Decided on November 26, 2010

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This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on November 26, 2010

APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT

PRESENT: Shulman, J.P., McKeon, Schoenfeld, JJ
570600/10.

Triangle R Inc. a/a/o Danilo Cabarcas, Plaintiff-Respondent,
against
Praetorian Insurance Company,

Shulman, J.P., McKeon, Schoenfeld, JJ.

NY County Clerk’s No. 570600/10 Calendar No. 10-358 Triangle R Inc. a/a/o Danilo Cabarcas, Plaintiff-Respondent, -against- Praetorian Insurance Company, Defendant-Appellant. Defendant appeals from an order of the Civil Court of the City of New York, Bronx County (Mitchell J. Danziger, J.), entered October 29, 2009, which denied its motion for summary judgment dismissing the complaint. Per Curiam. Order (Mitchell J. Danziger, J.), entered October 29, 2009, reversed, without costs, and defendant’s motion for summary judgment is granted. The Clerk is directed to enter judgment in favor of defendant dismissing the complaint. An insurer is not obligated to pay or deny a claim for no-fault benefits until it has received verification of all of the relevant information requested (see 11 NYCRR 65-3.8[b][3]; Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co., 44 AD3d 903 [2007]; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 19 AD3d 569 [2005]). Inasmuch as it is undisputed that defendant-insurer never received a response to its verification requests for medical records, defendant established its prima facie entitlement to summary judgment dismissing the claim as premature (see Hospital for Joint Diseases, supra; Nyack Hosp., supra). In opposition, plaintiff-provider failed to raise a triable issue. As plaintiff correctly concedes on appeal, defendant’s issuance of a general, blanket denial of benefits arising from the subject loss based on the assignor’s failure to attend an independent medical examination was ineffective to deny the specific claim at issue (see generally A & S Med. v Allstate Ins. Co., 15 AD3d 170 [2005], affg 196 Misc 2d 322 [2003]). Therefore, we reject plaintiff’s contention that defendant’s issuance of the general, blanket denial precludes defendant from asserting, as an alternative defense, noncompliance with its verification requests (see Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553 [1999]). Plaintiff’s estoppel argument is unpreserved for appellate review, and, in any event, without merit. Plaintiff submitted no competent proof demonstrating that it was misled or that it detrimentally relied on the general, blanket denial. Moreover, any confusion on plaintiff’s part as [*2]to whether the general, blanket denial vitiated defendant’s entitlement to receive the verification requested “should have been addressed by further communication, not inaction” (id. at 555). THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT. I concur Decision Date: November 26, 2010

NOVEMBER 26, 2010
SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT

								Nove mber 2010 Term

Defendant-Appellant.

Defendant appeals from an order of the Civil Court of the City of New York, Bronx County (Mitchell J. Danziger, J.), entered October 29, 2009, which denied its motion for summary judgment dismissing the complaint.

Per Curiam.

Order (Mitchell J. Danziger, J.), entered October 29, 2009, reversed, without costs, and defendant’s motion for summary judgment is granted. The Clerk is directed to enter judgment in favor of defendant dismissing the complaint.

An insurer is not obligated to pay or deny a claim for no-fault benefits until it has received verification of all of the relevant information requested (see 11 NYCRR 65-3.8[b][3]; Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co., 44 AD3d 903 [2007]; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 19 AD3d 569 [2005]). Inasmuch as it is undisputed that defendant-insurer never received a response to its verification requests for medical records, defendant established its prima facie entitlement to summary judgment dismissing the claim as premature (see Hospital for Joint Diseases, supra; Nyack Hosp., supra). In opposition, plaintiff-provider failed to raise a triable issue.

As plaintiff correctly concedes on appeal, defendant’s issuance of a general, blanket denial of benefits arising from the subject loss based on the assignor’s failure to attend an independent medical examination was ineffective to deny the specific claim at issue (see generally A & S Med. v Allstate Ins. Co., 15 AD3d 170 [2005], affg 196 Misc 2d 322 [2003]). Therefore, we reject plaintiff’s contention that defendant’s issuance of the general, blanket denial precludes defendant from asserting, as an alternative defense, noncompliance with its verification requests (see Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553 [1999]).
Plaintiff’s estoppel argument is unpreserved for appellate review, and, in any event, without merit. Plaintiff submitted no competent proof demonstrating that it was misled or that it detrimentally relied on the general, blanket denial. Moreover, any confusion on plaintiff’s part as [*3]to whether the general, blanket denial vitiated defendant’s entitlement to receive the verification requested “should have been addressed by further communication, not inaction” (id. at 555).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur
Decision Date: November 26, 2010

Legal questions

A question 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: Timely requests went unanswered; the claim is not overdue and the action is premature

Held the claim premature because the insurer undisputedly never received a response to its medical-records verification requests, and an ineffective blanket IME denial did not bar the insurer from relying on noncompliance with verification.

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

Of the 38 decisions on this question in the First Department courts and the Court of Appeals, 23 (this one included) are in the same category. 2 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.

Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 08038) FollowedThe hospital's claim was premature because unrebutted proof showed that it ignored timely verification and follow-up requests.
Nyack Hosp. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 05278) FollowedA hospital's no-fault claim was premature because requested verification of the assignor's post-accident blood alcohol level remained outstanding.
A & S Med. P.C. v Allstate Ins. Co. (2005 NY Slip Op 00505)An insurer must timely respond to a provider's first assigned claim despite an earlier blanket denial sent to the insured.

Similar decisions

Triangle R, Inc. v Tri-State Consumer Ins. Co. (2013 NY Slip Op 50256(U))The provider's denial of receipt did not rebut proof of timely mailed verification requests, and its unanswered claims were premature.
Triangle R, Inc. v Clarendon Ins. Co. (2010 NY Slip Op 52159(U))The provider's action was premature because timely verification requests remained unanswered when it sued.
Triangle R, Inc. v GEICO Ins. Co. (2010 NY Slip Op 50885(U))The provider's action was premature because it had not supplied requested verification before commencing suit.
Darlington Med. Diagnostics, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51634(U))Under 11 NYCRR 65-3.8 (b) (3), an insurer need not pay or deny a no-fault claim until it receives the requested verification.
Triangle R Inc. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 51663(U))The provider's unsworn medical report failed to rebut the insurer's showing that the medical supplies were unnecessary.