December 26, 2013

Westchester Med. Ctr. v Allstate Ins. Co. (2013 NY Slip Op 08616)

https://www.beynensonlaw.com/case-law/westchester-med-ctr-v-allstate-ins-co-2013-ny-slip-op-08616/

Court: Appellate Division, Second Department
Decided: December 26, 2013
Citation: 2013 NY Slip Op 08616 · 112 AD3d 916
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Verification requests Provider's prima facie case Timeliness and preclusion
Legal questions: Claimant's prima facie case on motions · Outstanding verification and premature actions (see the maps)

Cite as

Westchester Med. Ctr. v Allstate Ins. Co., 112 AD3d 916 (2d Dept 2013)

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 failed to establish a verification toll because it offered no evidence of mailing a required follow-up request. The hospital established prima facie entitlement to summary judgment on its first cause of action for no-fault benefits. The insurer failed to raise a triable issue as to whether the hospital's nonresponse to an initial verification request extended the time to pay or deny. Under 11 NYCRR 65-3.6 (b), the insurer had to send a second request within 10 days after expiration of the initial 30-day response period. Following Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., the Appellate Division, Second Department, reversed the order denying the hospital's motion and granted summary judgment on that cause of action.

Reported in New York Official Reports at Westchester Med. Ctr. v Allstate Ins. Co. (2013 NY Slip Op 08616)

Westchester Med. Ctr. v Allstate Ins. Co.

2013 NY Slip Op 08616 [112 AD3d 916]

December 26, 2013

Appellate Division, Second Department

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

As corrected through Wednesday, January 29, 2014

Westchester Medical Center, as Assignee of Paul Knable, Appellant, et al., Plaintiff,
v
Allstate Insurance Company, Respondent.

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

McDonnell & Adels, P.C., Garden City, N.Y. (Jannine A. Gordineer of counsel), for respondent.

In an action to recover no-fault insurance benefits, the plaintiff Westchester Medical Center, as assignee of Paul Knable, appeals from an order of the Supreme Court, Nassau County (Brown, J.), dated November 28, 2012, which denied its motion for summary judgment on the first cause of action.

Ordered that the order is reversed, on the law, with costs, and the motion of the plaintiff Westchester Medical Center, as assignee of Paul Knable, for summary judgment on the first cause of action is granted.

Contrary to the primary argument advanced by the defendant insurance company, the plaintiff Westchester Medical Center, as assignee of Paul Knable (hereinafter the hospital), made a prima facie showing of entitlement to judgment as a matter of law on the first cause of action (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., — AD3d —, 2013 NY Slip Op 08430 [2d Dept 2013]). In opposition, the defendant failed to raise a triable issue of fact as to whether, after receiving the hospital’s NF-5 claim form, the 30-day period within which to pay, deny, or seek verification of the no-fault claim was extended or tolled indefinitely due to the hospital’s failure to comply with a certain request for verification.

Upon the hospital’s failure to timely comply with the defendant’s initial request for verification within “30 calendar days after the original request [for verification]” (11 NYCRR 65-3.6 [b]), the defendant was under a regulatory duty to issue a second request for verification within 10 days after the expiration of that 30-day period (see 11 NYCRR 65-3.6 [b]; Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 106 AD3d 157, 163-165 [2013]). In the absence of any such second request for verification, there is no merit to the defendant’s contention that the 30-day period within which it had to pay, deny, or request verification of the claim had been extended. The defendant “failed to submit any evidence that it mailed a second or follow-up request for verification at the end of the 30-day period subsequent to [its] mailing [of] the initial request for verification” (Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 106 AD3d at 165; see also Presbyterian Hosp. in City of N.Y. v Aetna Cas. & Sur. Co., 233 AD2d 431 [1996]). [*2]

The defendant’s remaining contentions either are without merit or have been rendered academic by our determination.

Accordingly, the Supreme Court should have granted the hospital’s motion for summary judgment on the first cause of action. Dillon, J.P., Angiolillo, Roman 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.

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

Rejected the insurer's primary argument and held the hospital made a prima facie showing of entitlement to judgment on its claim.

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.

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: Defense rejected because the insurer's requests or proof were deficient

Held the 30-day period was not extended because the insurer submitted no evidence that it mailed the required follow-up verification request after the hospital failed to answer the initial one.

Premature: verification outstandingNonresponse denial upheldTriable issueInsurer's showing failsProvider compliedThis decisionCites it or cited by itCited or followed

Of the 374 decisions on this question in the Second Department courts and the Court of Appeals, 78 (this one included) are in the same category.

Cited in this decision

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

Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430) FollowedA provider need not prove a claim's merits for summary judgment where the insurer failed to timely and properly deny the claim.
Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 02390) FollowedThe hospital's UB-04 form was not the functional equivalent of an NF-5 and did not support tolling before receipt of the NF-5.

Cited by

A label shows how the later decision treated this one.

Meridian Psychological Servs., PC v Government Empls. Ins. Co. (2014 NY Slip Op 24177) FollowedAn insurer cannot continue to delay payment after receiving a completed but unsigned NF-2 without seeking further verification.
Burke 2 Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. PIP/BI Claims (2021 NY Slip Op 50523(U))The provider failed to prove compliance with verification requests or a timely written justification for noncompliance.

Similar decisions

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 A Cent. Ins. Co. (2014 NY Slip Op 01319)The insurer raised a factual issue as to whether it mailed a proper denial 22 days after receiving requested verification.
Westchester Med. Ctr. v Countrywide Ins. Co. (2007 NY Slip Op 09024)The insurer failed to prove mailing of verification requests and waived defenses based on incomplete assignment forms.
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.
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.