June 2, 2006

Vista Surgical Supplies, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2006 NY Slip Op 51047(U))

Headnote

The court considered the submission of a claim and the amount of loss sustained by a plaintiff in a case to recover assigned no-fault benefits. It also reviewed the denial of the claims by the defendant based on peer review reports, the use of an explanation of benefits form in place of a denial of claim form, and the lack of submission of a denial of claim form by the defendant. The main issue decided was whether the plaintiff properly established its entitlement to summary judgment and whether the denial of the claims by the defendant was valid. The holding was that the plaintiff established its entitlement to summary judgment and the defendant was precluded from raising any defense as to one of the claims due to the lack of submission of a denial of claim form. The decision was modified by granting partial summary judgment in favor of the plaintiff and the matter was remanded for further proceedings.

Reported in New York Official Reports at Vista Surgical Supplies, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2006 NY Slip Op 51047(U))

Vista Surgical Supplies, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2006 NY Slip Op 51047(U)) [*1]
Vista Surgical Supplies, Inc. v Metropolitan Prop. & Cas. Ins. Co.
2006 NY Slip Op 51047(U) [12 Misc 3d 130(A)]
Decided on June 2, 2006
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This opinion is uncorrected and will not be published in the printed Official Reports.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 June 2, 2006

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., RIOS and BELEN, JJ
2005-1328 K C.
Vista Surgical Supplies, Inc., as Assignee of John Huggins, Appellant,

against

Metropolitan Property and Casualty Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Ellen M. Spodek, J.), entered March 25, 2005. The order denied plaintiff’s motion for summary judgment.

Order modified by granting plaintiff’s motion to the extent of granting partial summary judgment to plaintiff in the sum of $1,050 and matter remanded to the court below for a calculation of statutory interest and an assessment of attorney’s fees thereon, and for all further proceedings on the remaining claim; as so modified, affirmed without costs.

In an action to recover assigned first-party no-fault benefits, a plaintiff provider generally establishes its prima facie entitlement to summary judgment by proof that it submitted a claim, setting forth the fact and the amount of the loss 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]). In the instant case, plaintiff’s moving papers were insufficient to establish the mailing of the appended claim forms to defendant. However, said deficiency was cured by defendant’s acknowledgment of receipt of both of plaintiff’s claims in the affidavit of its claims adjuster (see Careplus Med. Supply Inc. v State-Wide Ins. Co., 11 Misc 3d 29 [App Term, 2d & 11th Jud Dists 2005]). Accordingly, plaintiff established its prima facie entitlement to summary judgment and the burden shifted to defendant to demonstrate the existence of a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).

Defendant established that it timely denied both claims. It asserted that the claim for $525 was denied based upon the peer review report of Dr. Corcoran. Said peer review report, which was annexed to the denial of claim form, set forth a factual basis and medical rationale for [*2]Dr. Corcoran’s opinion that the medical equipment was medically unnecessary and, as such, was sufficient to raise a triable issue of fact (see Amaze Med. Supply Inc. v Travelers Prop. Cas. Corp., 7 Misc 3d 128[A], 2005 NY Slip Op 50452[U] [App Term, 2d & 11th Jud Dists]).

In the court below, and on appeal, plaintiff asserted that defendant may not use an explanation of benefits form in lieu of the prescribed denial of claim form in denying the claim for $1,050. It is well settled that a claim can only be properly denied on the prescribed denial of claim form (see 11 NYCRR 65-3.8 [c] [1]; Mount Sinai Hosp. v Triboro Coach, 263 AD2d 11, 16 [1999]). Since the record herein fails to establish that defendant submitted a copy of the required denial of claim form, defendant is precluded from raising any defense as to said claim (see Mount Sinai Hosp. v Triboro Coach, 263 AD2d 11, supra).

Accordingly, the order is modified by granting plaintiff partial summary judgment as to its $1,050 claim and the matter is remanded to the court below for a calculation of statutory interest and an assessment of attorney’s fees thereon pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder, and for all further proceedings on the remaining claim.

Pesce, P.J., Rios and Belen, JJ., concur.
Decision Date: June 2, 2006