February 26, 2014

Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 01319)

https://www.beynensonlaw.com/case-law/westchester-med-ctr-v-a-cent-ins-co-2014-ny-slip-op-01319/

Court: Appellate Division, Second Department
Decided: February 26, 2014
Citation: 2014 NY Slip Op 01319 · 114 AD3d 937
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 3 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

Westchester Med. Ctr. v A Cent. Ins. Co., 114 AD3d 937 (2d Dept 2014)

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 a factual issue as to whether it mailed a proper denial 22 days after receiving requested verification. The provider's summary judgment motion rested solely on the alleged failure to pay or deny within 30 days under Insurance Law § 5106 (a) and 11 NYCRR 65-3.8 (a) (1) and (c). The insurer therefore needed only to raise a triable issue concerning timely denial, which its submissions did. The Appellate Division, Second Department, affirmed the order, insofar as appealed from, denying the provider summary judgment. It did not reach the parties' arguments concerning the insurer's cross motion because the insurer had not appealed its denial.

Reported in New York Official Reports at Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 01319)

Westchester Med. Ctr. v A Cent. Ins. Co.

2014 NY Slip Op 01319 [114 AD3d 937]

February 26, 2014

Appellate Division, Second Department

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

As corrected through Wednesday, March 26, 2014

Westchester Medical Center, Appellant,
v
A Central Insurance Company, Respondent.

—[*1] Joseph Henig, P.C., Bellmore, N.Y., for appellant.

Gullo & Associates, LLC, Brooklyn, N.Y. (Cristina Carollo of counsel), for respondent.

In an action to recover no-fault benefits under a policy of automobile insurance, the plaintiff appeals, as limited by its brief, from so much of an order of the Supreme Court, Nassau County (Brown, J.), dated July 10, 2012, as denied its motion for summary judgment on the complaint.

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

Generally, a party opposing a motion for summary judgment need only “raise a triable issue of fact with respect to the . . . theory . . . that is the subject of the moving party’s prima facie showing” (Stukas v Streiter, 83 AD3d 18, 24 [2011]). Here, in light of the limited basis of the plaintiff’s motion for summary judgment on the complaint, which was premised solely on the defendant’s alleged failure to timely pay or deny the no-fault claim within 30 days of receipt of proof of the claim (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [a] [1]; [c]), “the defendant’s only burden in opposition . . . was to raise a triable issue of fact regarding its timely . . . denial of the [plaintiff’s] claim” (Lenox Hill Hosp. v Government Empls. Ins. Co., 89 AD3d 905, 905 [2011]; see Viviane Etienne Med. Care, P.C., v Country-Wide Ins. Co., 114 AD3d 33 [2013]; Westchester Med. Ctr. v Progressive Cas. Ins. Co., 89 AD3d 1081, 1082-1083 [2011]). In opposition to the plaintiff’s prima facie showing of entitlement to judgment as a matter of law, the defendant satisfied its burden by raising a triable issue of fact as to whether it did in fact mail a proper NF-10 denial of claim form to the plaintiff only 22 days after its receipt of the claim verification that it had previously requested (see Wyckoff Hgts. Med. Ctr. v Government Empls. Ins. Co., 114 AD3d 855 [2014]; Westchester Med. Ctr. v Lancer Ins. Co., 94 AD3d 984 [2012]; Westchester Med. Ctr. v Clarendon Natl. Ins. Co., 57 AD3d 659 [2008]).

We do not reach the parties’ remaining contentions regarding the merits of the defendant’s cross motion, since the defendant has not appealed from so much of the order as denied its cross motion. Mastro, J.P., Hall, Lott and Sgroi, 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 the insurer's opposition raised a triable issue whether it mailed a proper denial 22 days after receiving requested verification, which defeated the provider's summary judgment motion.

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 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (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.

Claimant's prima facie case on motions

Open 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)

Treated the provider as having made its prima facie showing on its motion premised on the insurer's failure to pay or deny within 30 days, but denied the motion because the insurer raised a triable issue.

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

Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (this one included) are in the same category.

Cited in this decision

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

Lenox Hill Hosp. v Government Empls. Ins. Co. (2011 NY Slip Op 08330) FollowedThe insurer's evidence of a timely denial raised a triable issue defeating the provider's motion based solely on untimeliness.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430)A provider need not prove a claim's merits for summary judgment where the insurer failed to timely and properly deny the claim.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2011 NY Slip Op 08747)The insurer's timely denial defeated summary judgment on the provider's first cause of action alleging failure to pay or deny.
Wyckoff Hgts. Med. Ctr. v Government Empls. Ins. Co. (2014 NY Slip Op 01166)An insurer's denial need not include a peer review report or other medical evidence when issued under 11 NYCRR 65-3.8.
Westchester Med. Ctr. v Lancer Ins. Co. (2012 NY Slip Op 02867)The insurer defeated the provider's summary judgment motion by proving timely verification requests and denial after verification was received.
Westchester Med. Ctr. v Clarendon Natl. Ins. Co. (2008 NY Slip Op 09786)The insurer raised a triable issue whether it timely and properly denied a claim based on alleged intoxication after receiving verification.

Cited by

A label shows how the later decision treated this one.

Liberty Mut. Ins. Co. v Brutus (2022 NY Slip Op 50799(U)) FollowedAn insurer's material-misrepresentation defense is subject to the 30-day no-fault deadline for paying or denying claims.
American Tr. Ins. Co. v Beach Med. Rehabilitation, P.C. (2026 NY Slip Op 03771) FollowedThe insurer failed to raise a triable issue on timely denials or causation in its action for de novo review of no-fault claims.
J.C. Healing Touch Rehab, P.C. v Eveready Ins. Co. (2014 NY Slip Op 50774(U)) FollowedThe insurer's cross motion for summary judgment on lack of medical necessity was denied, leaving only whether verification was outstanding for trial.

Similar decisions

Westchester Med. Ctr. v Allstate Ins. Co. (2014 NY Slip Op 00655)The provider obtained summary judgment because neither the insurer's asserted verification request nor its denial was sent within 30 days.
Westchester Med. Ctr. v Government Empls. Ins. Co. (2014 NY Slip Op 00500)The insurer's contention that a complete absence of coverage survived its untimely denial was improperly raised for the first time on appeal.
Westchester Med. Ctr. v Hereford Ins. Co. (2012 NY Slip Op 04156)The provider proved mailing and receipt of its bill and the insurer's failure to pay or deny within 30 days; the insurer failed to raise a triable issue.
Westchester Med. Ctr. v Country Wide Ins. Co. (2011 NY Slip Op 03838)The insurer raised a triable issue as to whether the hospital fully complied with its verification demand.
Westchester Med. Ctr. v Nationwide Mut. Ins. Co. (2010 NY Slip Op 08933)The provider failed to establish entitlement to summary judgment because the insurer partially paid and denied the claim within 30 days.