December 9, 2008

Westchester Med. Ctr. v Clarendon Natl. Ins. Co. (2008 NY Slip Op 09786)

https://www.beynensonlaw.com/case-law/westchester-med-ctr-v-clarendon-natl-ins-co-2008-ny-slip-op-09786/

Court
Appellate Division, Second Department
Decided
December 9, 2008
Citation
2008 NY Slip Op 09786 · 57 AD3d 659
Posture
Summary judgment
Outcome
Insurer prevailed
Later treatment
Followed in 2 later decisions (see Cited by)
Issues
Timeliness and preclusion Verification requests
Cite as
Westchester Med. Ctr. v Clarendon Natl. Ins. Co., 57 AD3d 659 (2d Dept 2008)

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 triable issue whether it timely and properly denied a claim based on alleged intoxication after receiving verification. The Appellate Division, Second Department, reversed the order, insofar as appealed from, and denied the provider's summary judgment motion on the first cause of action. The provider established that the claim had not been paid or denied within 30 days of receipt of the prescribed forms under 11 NYCRR 65-3.8 (a) (1) and (c). The insurer's opposition raised a factual issue concerning a denial issued within 30 days after receiving requested additional verification under 11 NYCRR 65-3.5 and 11 NYCRR 65-3.8 (e) and (g). The insurer had paid the separate claim comprising the second cause of action.

Reported in New York Official Reports at Westchester Med. Ctr. v Clarendon Natl. Ins. Co. (2008 NY Slip Op 09786)

Westchester Med. Ctr. v Clarendon Natl. Ins. Co.
2008 NY Slip Op 09786 [57 AD3d 659]
December 9, 2008
Appellate Division, Second Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected through Wednesday, February 11, 2009
mWestchester Medical Center, as Assignee of Josh Logan and Edward Caruso, Respondent,
v
Clarendon National Insurance Company, Appellant.

—[*1] Moira A. Doherty, Uniondale, N.Y. (Janice P. Rosen of counsel), for appellant.

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

In an action to recover no-fault medical payments under insurance contracts, the defendant appeals, as limited by its brief, from so much of an order of the Supreme Court, Nassau County (Brandveen, J.), dated December 3, 2007, as granted that branch of the plaintiff’s motion which was for summary judgment on the first cause of action.

Ordered that the order is reversed insofar as appealed from, on the law, with costs, and that branch of the plaintiff’s motion which was for summary judgment on the first cause of action is denied.

The plaintiff, as assignee of two insureds under policies issued by the defendant, commenced this action to recover no-fault medical payments. The plaintiff moved for summary judgment on the complaint, arguing that the defendant had failed to timely pay or deny the claim of either insured under the relevant no-fault regulations (see 11 NYCRR 65-1.1 et seq.). The defendant thereafter paid the claim of Edward Caruso (the subject of the second cause of action) and made partial payment on the claim of Josh Logan (the subject of the first cause of action). In the order appealed from, the Supreme Court, inter alia, granted that branch of the plaintiff’s motion which was for summary judgment on the first cause of action regarding Logan’s claim. We reverse the order insofar as appealed from.

The plaintiff demonstrated its prima facie entitlement to judgment as a matter of law on the [*2]first cause of action regarding Logan’s claim with evidence that the claim was neither paid nor denied within 30 days of the defendant’s receipt of the prescribed claim forms (see Westchester Med. Ctr. v Progressive Cas. Ins. Co., 51 AD3d 1014 [2008]; Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co., 44 AD3d 750 [2007]; 11 NYCRR 65-3.8 [a] [1], [c]). However, in opposition, the defendant raised a triable issue of fact as to whether it timely and properly denied the claim based on Logan’s alleged intoxication at the time of the accident by issuance of a denial of coverage on that ground within 30 days of the receipt of additional verification it requested concerning the claim (see Westchester Med. Ctr. v Progressive Cas. Ins. Co., 51 AD3d 1014 [2008]; Westchester Med. Ctr. v State Farm Mut. Auto. Ins. Co., 44 AD3d 750 [2007]; 11 NYCRR 65-3.5; 11 NYCRR 65-3.8 [e], [g]). Thus, that branch of the plaintiff’s motion which was for summary judgment on the first cause of action should have been denied.

The plaintiff’s remaining contention is without merit. Ritter, J.P., Florio, Miller and Carni, JJ., concur.

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