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March 17, 2009

Westchester Med. Ctr. v American Tr. Ins. Co. (2009 NY Slip Op 01979)

https://www.beynensonlaw.com/case-law/westchester-med-ctr-v-american-tr-ins-co-2009-ny-slip-op-01979/

Court
Appellate Division, Second Department
Decided
March 17, 2009
Citation
2009 NY Slip Op 01979 · 60 AD3d 848
Posture
Summary judgment
Outcome
Insurer prevailed
Earlier history
Appeal from Westchester Med. Ctr. v American Tr. Ins. Co. (2008 NY Slip Op 50546(U)) (Reversed)
Later treatment
Distinguished in 1, contrasted (cf., but see) in 17 and followed in 3 later decisions (see Cited by)
Issues
Verification requests Timeliness and preclusion Priority, other coverage
Legal questions
Workers' comp or other insurer primary (see the maps)
Cite as
Westchester Med. Ctr. v American Tr. Ins. Co., 60 AD3d 848 (2d Dept 2009)

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 timely verification request and ensuing timely denial defeated the provider's motion for summary judgment. The Appellate Division, Second Department, reversed the judgment, insofar as appealed from, and denied summary judgment on the provider's first cause of action. Although the insurer neither paid nor denied within 30 days of receiving the claim, it demonstrated a timely additional verification request under 11 NYCRR 65-3.5 (b) and a timely denial measured from receipt of verification under 11 NYCRR 65-3.8 (b). The verification allegedly revealed workers' compensation eligibility. The court declined to award the insurer summary judgment or refer the matter to the Workers' Compensation Board because the insurer lacked competent admissible evidence supporting that contention.

Reported in New York Official Reports at Westchester Med. Ctr. v American Tr. Ins. Co. (2009 NY Slip Op 01979)

Westchester Med. Ctr. v American Tr. Ins. Co.
2009 NY Slip Op 01979 [60 AD3d 848]
March 17, 2009
Appellate Division, Second Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected through Wednesday, May 6, 2009
Westchester Medical Center, as Assignee of Daphne McPherson, Respondent, et al., Plaintiffs,
v
American Transit Insurance Company, Appellant.

—[*1] Short & Billy, P.C., New York, N.Y. (Helene Jnane of counsel), for appellant.

Joseph Henig, P.C., Bellmore, N.Y., for respondent.

In an action to recover no-fault medical payments under certain insurance contracts, the defendant appeals, as limited by its brief, from (1) so much of an order of the Supreme Court, Nassau County (McCormack, J.), dated January 21, 2008, as granted that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action asserted by the plaintiff Westchester Medical Center, as assignee of Daphne McPherson, and (2) so much of a judgment of the same court entered April 16, 2008, as, upon the order, is in favor of the plaintiff Westchester Medical Center, as assignee of Daphne McPherson, and against it in the principal sum of $6,993.96. The notice of appeal from the order is deemed also to be a notice of appeal from the judgment (see CPLR 5501 [c]).

Ordered that the appeal from the order dated January 21, 2008 is dismissed; and it is further,

Ordered that the judgment is reversed insofar as appealed from, on the law, that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action asserted by the plaintiff Westchester Medical Center, as assignee of Daphne McPherson, is denied, and the order dated January 21, 2008 is modified accordingly; and it is further,

Ordered that one bill of costs is awarded to the appellant.

The appeal from the intermediate order must be dismissed because the right of direct appeal therefrom terminated with the entry of judgment in the action (see Matter of Aho, 39 NY2d 241, 248 [1976]). [*2]The issues raised on the appeal from the order are brought up for review and have been considered on the appeal from the judgment (see CPLR 5501 [a] [1]).

The plaintiff Westchester Medical Center (hereinafter WMC), among others, commenced this action to recover no-fault medical benefits allegedly owed its patient/assignor Daphne McPherson for injuries sustained by her in a motor vehicle accident involving an insured of the defendant American Transit Insurance Company. The plaintiffs moved for summary judgment on the first cause of action asserted by WMC, as assignee of McPherson, arguing that the defendant received a demand for payment of such benefits on February 20, 2007 and neither paid nor denied such benefits within 30 days. WMC asserted that the defendant did not deny benefits until April 5, 2007. Thus, WMC argued, the benefits were now “overdue” (see 11 NYCRR 65-3.8). In opposition, the defendant argued, inter alia, that its denial of benefits was timely as a result of the toll of its time within which to pay or deny a claim arising from its demand for additional verification of the claim. The Supreme Court, among other things, awarded WMC summary judgment on the first cause of action. We reverse the judgment entered upon the order insofar as appealed from.

The defendant does not dispute that it received a demand for no-fault benefits from WMC on February 20, 2007 and that it neither paid nor denied such benefits within 30 days thereof (see 11 NYCRR 65-3.8 [c]; Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co., 44 AD3d 750 [2007]). However, the defendant demonstrated, prima facie, that it made a timely request for additional verification of the claim, and that its denial of benefits was timely as measured from the receipt of additional verification which allegedly revealed that McPherson was entitled to workers’ compensation benefits for the underlying accident (see 11 NYCRR 65-3.5 [b]; 65-3.8 [b]; Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co., 44 AD3d 750 [2007]; Montefiore Med. Ctr. v Government Empls. Ins. Co., 34 AD3d 771 [2006]). Thus, that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action asserted by WMC, as assignee of McPherson, should have been denied.

We decline the defendant’s request, in effect, to search the record and award it summary judgment dismissing WMC’s cause of action and to refer the matter to the Workers’ Compensation Board for a determination as to whether McPherson is entitled to workers’ compensation benefits for the underlying accident (see generally O’Hurley-Pitts v Diocese of Rockville Ctr., 57 AD3d 633 [2008]; Catapane v Half Hollow Hills Cent. School Dist., 45 AD3d 517 [2007]). The defendant, inter alia, failed to proffer competent evidence in admissible form of the alleged facts giving rise to its contention that workers’ compensation benefits are available. Rivera, J.P., Spolzino, Ritter and Miller, JJ., concur. [See 19 Misc 3d 1104(A), 2008 NY Slip Op 50546(U).]

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.

Workers' comp or other insurer primary

Open the full map

Can a no-fault insurer deny or delay payment because workers’ compensation or another insurer is primary?

This decision: The insurer did not show that workers' compensation may apply; no referral, and the defense fails (rules on the question, but another ground decided the case)

Declined to dismiss and refer the matter to the Workers' Compensation Board because the insurer offered no competent evidence in admissible form that workers' compensation benefits were available.

  • Appellate DivisionApp Div 8
  • Appellate TermApp Term 42
  • Trial courtsTrial 19
2014, Appellate Division: 1 decision (1 First insurer must pay)2010, Appellate Division: 1 decision (1 Referred to WC Board)2009, Appellate Division: 3 decisions (1 Referred to WC Board, 1 WC defense not shown, 1 WC defense precluded)2007, Appellate Division: 2 decisions (1 Referred to WC Board, 1 WC defense not shown)2024, Appellate Division: 1 decision (1 Referred to WC Board)2021, Appellate Term: 1 decision (1 Referred to WC Board)2020, Appellate Term: 1 decision (1 Referred to WC Board)2019, Appellate Term: 6 decisions (4 Referred to WC Board, 1 WC primary: claim fails, 1 WC defense precluded)2018, Appellate Term: 4 decisions (1 Referred to WC Board, 3 WC primary: claim fails)2017, Appellate Term: 4 decisions (3 Referred to WC Board, 1 WC primary: claim fails)2016, Appellate Term: 1 decision (1 WC defense precluded)2015, Appellate Term: 1 decision (1 Referred to WC Board)2014, Appellate Term: 2 decisions (1 Referred to WC Board, 1 WC primary: claim fails)2013, Appellate Term: 4 decisions (3 Referred to WC Board, 1 WC defense not shown)2012, Appellate Term: 4 decisions (1 Referred to WC Board, 3 WC primary: claim fails)2011, Appellate Term: 1 decision (1 Referred to WC Board)2010, Appellate Term: 3 decisions (3 Referred to WC Board)2009, Appellate Term: 6 decisions (3 Referred to WC Board, 1 WC defense not shown, 2 WC defense precluded)2007, Appellate Term: 1 decision (1 Referred to WC Board)2005, Appellate Term: 2 decisions (1 WC defense not shown, 1 First insurer must pay)2008, Appellate Term: 1 decision (1 Referred to WC Board)2023, Trial courts: 3 decisions (1 WC primary: claim fails, 2 WC defense not shown)2022, Trial courts: 1 decision (1 No coverage, not priority)2021, Trial courts: 2 decisions (1 Referred to WC Board, 1 WC defense not shown)2019, Trial courts: 1 decision (1 No coverage, not priority)2018, Trial courts: 1 decision (1 Referred to WC Board)2016, Trial courts: 1 decision (1 Referred to WC Board)2009, Trial courts: 3 decisions (1 WC defense not shown, 2 WC defense precluded)2008, Trial courts: 2 decisions (1 WC defense not shown, 1 WC defense precluded)2007, Trial courts: 1 decision (1 First insurer must pay)2005, Trial courts: 1 decision (1 Referred to WC Board)2026, Trial courts: 3 decisions (2 WC defense precluded, 1 First insurer must pay)This decision
20052010201520202025
Referred to WC BoardWC primary: claim failsWC defense not shownWC defense precludedFirst insurer must payNo coverage, not priorityThis decisionCites it or cited by itCited or followedDistinguished or limitedDeclined to follow, questioned, overruled or reversed

Of the 69 decisions on this question in the Second Department courts and the Court of Appeals, 10 (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.

  • Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co. (2007 NY Slip Op 07690) FollowedThe insurer failed to establish intoxication or causation as a matter of law, but raised factual issues defeating the provider's motion.
  • Montefiore Med. Ctr. v Government Empls. Ins. Co. (2006 NY Slip Op 08953) FollowedAn insurer's additional verification request following an N-F5 submission need not use a prescribed form to toll the payment deadline.
  • Westchester Med. Ctr. v American Tr. Ins. Co. (2008 NY Slip Op 50546(U)) ReversedThe insurer's untimely denial precluded its workers' compensation defense to one hospital claim, but two other claims remained unresolved.

Cited by (22)

A label shows how the later decision treated this one.

  • Advantage Radiology, P.C. v ACE Am. Ins. Co. (2026 NY Slip Op 50245(U)) DistinguishedAn insurer's defense that an assignor is eligible for workers' compensation benefits is subject to preclusion for an untimely denial.
  • D.A.V. Chiropractic, P.C. v American Tr. Ins. Co. (2010 NY Slip Op 51738(U)) Contrasted (cf., but see)The Workers' Compensation Board has primary jurisdiction to resolve factual questions about workers' compensation coverage.
  • Jamaica Med. Supply, Inc. v American Tr. Ins. Co. (2011 NY Slip Op 52371(U)) Contrasted (cf., but see)The insurer raised a triable workers' compensation eligibility issue requiring initial resolution by the Workers' Compensation Board.
  • Arce Med. & Diagnostic Svce v American Tr. Ins. Co. (2013 NY Slip Op 50531(U)) Contrasted (cf., but see)The insurer obtained a stay because admissible evidence raised an issue whether the assignor was eligible for workers' compensation benefits.
  • A.B. Med. Servs., PLLC v American Tr. Ins. Co. (2009 NY Slip Op 29271) Contrasted (cf., but see)The insurer's proof raised a factual question about the assignor's employment status that required Workers' Compensation Board resolution.
  • AR Med. Rehabilitation, P.C. v American Tr. Ins. Co. (2010 NY Slip Op 50708(U)) Contrasted (cf., but see)The insurer's evidence required the Workers' Compensation Board to resolve the assignor's alleged eligibility for workers' compensation benefits.
  • Compas Med., P.C. v American Tr. Ins. Co. (2015 NY Slip Op 51675(U)) Contrasted (cf., but see)The assignor's sworn no-fault application raised a workers' compensation issue requiring a stay pending a Workers' Compensation Board determination.
  • Devonshire Surgical Facility, L.L.C. v Hereford Ins. Co. (2010 NY Slip Op 52297(U)) Contrasted (cf., but see)The Workers' Compensation Board must first resolve the factual question whether the assignor's loss falls under the Workers' Compensation Law. The insurer alleged that the loss occurred during employment, and its submissions raised a factual issue concerning workers' compensation coverage.
  • Great Health Care Chiropractic, P.C. v Lancer Ins. Co. (2014 NY Slip Op 50340(U)) Contrasted (cf., but see)The insurer raised a triable issue of workers' compensation eligibility requiring initial resolution by the Workers' Compensation Board.
  • New Millennium Radiology, P.C. v American Tr. Ins. Co. (2018 NY Slip Op 50940(U)) Contrasted (cf., but see)The insurer's evidence raised an employment-related coverage issue requiring an initial Workers' Compensation Board determination.
Show all 22 citing decisions
  • Quality Health Prod., Inc. v American Tr. Ins. Co. (2019 NY Slip Op 51950(U)) Contrasted (cf., but see)The insurer established an employment-related coverage issue requiring an initial determination by the Workers' Compensation Board.
  • Madison Prods. of USA, Inc. v American Tr. Ins. Co. (2020 NY Slip Op 50749(U)) Contrasted (cf., but see)A workers' compensation defense is precluded by an untimely denial, requiring a threshold timeliness determination before a stay.
  • B.Y., M.D., P.C. v American Tr. Ins. Co. (2010 NY Slip Op 51902(U)) Contrasted (cf., but see)The insurer's proof raised a factual question about employment at the time of the accident for the Workers' Compensation Board to resolve first.
  • B.Y., M.D., P.C. v Global Liberty Ins. Co. of N.Y. (2012 NY Slip Op 50156(U)) Contrasted (cf., but see)The insurer's proof raised a factual question about the assignor's employment status that required Workers' Compensation Board resolution.
  • W.H.O. Acupuncture, P.C. v American Tr. Ins. Co. (2013 NY Slip Op 50532(U)) Contrasted (cf., but see)The insurer's evidence raised a workers' compensation eligibility issue requiring initial resolution by the Workers' Compensation Board.
  • Metro Psychological Servs., P.C. v Travelers Prop. & Cas. Ins. Co. (2017 NY Slip Op 51804(U)) Contrasted (cf., but see)The Workers' Compensation Board must resolve whether the assignor acted as an employee at the time of the accident.
  • Active Care Med. Supply Corp. v American Tr. Ins. Co. (2019 NY Slip Op 50419(U)) Contrasted (cf., but see)The Workers' Compensation Board must first resolve eligibility when evidence raises an issue whether the assignor was injured in the course of employment.
  • Metro Psychological Servs., P.C. v Travelers Prop. & Cas. Ins. Co. (2019 NY Slip Op 51150(U)) Contrasted (cf., but see)The Workers' Compensation Board has primary jurisdiction to decide whether an assignor was acting as an employee when injured.
  • Matter of Global Liberty Ins. Co. of N.Y. v North Shore Family Chiropractic, PC (2019 NY Slip Op 08951) Followed
  • Westchester Med. Ctr. v Lancer Ins. Co. (2012 NY Slip Op 02867) Followed
  • A.B. Med. Servs., PLLC v American Tr. Ins. Co. (2009 NY Slip Op 51261(U)) Followed
  • Mani Med., P.C. v American Tr. Ins. Co. (2010 NY Slip Op 51185(U))

Similar decisions

  • 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.
  • LMK Psychological Serv., P.C. v American Tr. Ins. Co. (2009 NY Slip Op 06004)The Workers' Compensation Board has primary jurisdiction to determine factual issues concerning workers' compensation coverage.
  • Westchester Med. Ctr. v Lincoln Gen. Ins. Co. (2009 NY Slip Op 02589)The insurer's investigation letters did not toll the 30-day period to pay or deny the provider's claim.
  • Westchester Med. Ctr. v GMAC Ins. Co. Online, Inc. (2011 NY Slip Op 00217)The insurers' verification letters failed to toll the payment period, and their untimely denial precluded the residence-misrepresentation defense.
  • 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.
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