Essential Acupuncture Servs., P.C. v Ameriprise Auto & Home Ins. (2012 NY Slip Op 52404(U))

Reported in New York Official Reports at Essential Acupuncture Servs., P.C. v Ameriprise Auto & Home Ins. (2012 NY Slip Op 52404(U))

Essential Acupuncture Servs., P.C. v Ameriprise Auto & Home Ins. (2012 NY Slip Op 52404(U)) [*1]
Essential Acupuncture Servs., P.C. v Ameriprise Auto & Home Ins.
2012 NY Slip Op 52404(U) [38 Misc 3d 130(A)]
Decided on December 21, 2012
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This opinion is uncorrected and will not be published in the printed Official Reports.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

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., RIOS and SOLOMON, JJ
2010-2777 K C.
Essential Acupuncture Services, P.C. as Assignee of TELMA GARIJO, Respondent, —

against

Ameriprise Auto & Home Insurance, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin S. Garson, J.), entered August 17, 2010, deemed from a judgment of the same court entered September 13, 2010 (see CPLR 5501 [c]). The judgment, entered pursuant to the August 17, 2010 order granting plaintiff’s motion for summary judgment and denying defendant’s cross motion for summary judgment dismissing the complaint, awarded plaintiff the principal sum of $2,204.77.

ORDERED that the judgment is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court which granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment dismissing the complaint. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).

Inasmuch as defendant raises no issue on appeal regarding whether plaintiff established its prima facie entitlement to summary judgment, we do not pass upon the propriety of the Civil [*2]Court’s determination with respect thereto.

To raise a triable issue of fact based on the failure of plaintiff’s owner to appear at scheduled examinations under oath (EUOs), defendant was required to demonstrate that its initial and follow-up EUO scheduling letters had been timely mailed (see Insurance Department Regulations [11 NYCRR] §§ 65-3.5 [b]; 65-3.6 [b]) and to establish, through an affidavit by one with personal knowledge, that plaintiff’s owner had failed to appear for the EUOs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Since defendant failed to establish that the EUO scheduling letters had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]), defendant failed to demonstrate that the 30-day claim determination period (Insurance Department Regulations [11 NYCRR] § 65-3.8) had been tolled. As a result, defendant failed to establish that its denial of claim forms were timely and, thus, that it is not precluded from raising as a defense the failure of plaintiff’s owner to appear for the EUOs (see Presbyterian Hosp. in City of NY v Maryland Cas. Co., 90 NY2d 274, 282 [1997]).

Accordingly, the judgment is affirmed.

Pesce, P.J., Rios and Solomon, JJ., concur.
Decision Date: December 21, 2012

W & Z Acupuncture, P.C. v Unitrin Auto & Home Ins. Co. (2012 NY Slip Op 52400(U))

Reported in New York Official Reports at W & Z Acupuncture, P.C. v Unitrin Auto & Home Ins. Co. (2012 NY Slip Op 52400(U))

W & Z Acupuncture, P.C. v Unitrin Auto & Home Ins. Co. (2012 NY Slip Op 52400(U)) [*1]
W & Z Acupuncture, P.C. v Unitrin Auto & Home Ins. Co.
2012 NY Slip Op 52400(U) [38 Misc 3d 130]
Decided on December 21, 2012
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

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., WESTON and RIOS, JJ
2010-2452 K C.
W & Z Acupuncture, P.C. as Assignee of BENJAMIN ANDRA, Appellant, —

against

Unitrin Auto & Home Insurance Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Alan L. Lebowitz, J.H.O.), entered June 29, 2010. The order, insofar as appealed from, granted, to a limited extent, the branch of defendant’s motion seeking to compel plaintiff to appear for an examination before trial.

ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and the branch of defendant’s motion seeking to compel plaintiff to appear for an examination before trial is denied.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from so much of an order of the Civil Court as granted the branch of defendant’s motion seeking to compel plaintiff to appear for an examination before trial (EBT) to the extent of compelling plaintiff to appear for an EBT limited to the issue of the relationship between plaintiff and the treating acupuncturists.

In an affirmation in support of defendant’s motion to compel, defendant’s attorney argued that the treating acupuncturists were not plaintiff’s employees; rather, they were independent [*2]contractors and, therefore, plaintiff was ineligible to recover the assigned no-fault benefits at issue. However, defendant’s denial of claim forms did not deny plaintiff’s claims on the ground that the treatment at issue had been rendered by independent contractors. Therefore, defendant is precluded from asserting that ground for denial of coverage as a defense in this litigation (A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co., ___ AD3d ___, 2012 NY Slip Op 06902 [2d Dept, Oct 17, 2012]). Consequently, the branch of defendant’s motion seeking to compel plaintiff to appear for an EBT in support of this defense should have been denied, as this discovery demand is palpably improper (see Midwood Acupuncture, P.C. v State Farm Fire & Cas. Co., 21 Misc 3d 144[A], 2008 NY Slip Op 52468[U] [App Term, 2d & 11th Jud Dists 2008]; Great Wall Acupuncture v State Farm Mut. Auto. Ins. Co., 20 Misc 3d 136[A], 2008 NY Slip Op 51529[U] [App Term, 2d & 11th Jud Dists 2008]).

Accordingly, the order, insofar as appealed from, is reversed and the branch of defendant’s motion seeking to compel plaintiff to appear for an examination before trial is denied.

Pesce, P.J., Weston and Rios, JJ., concur.
Decision Date: December 21, 2012

Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52398(U))

Reported in New York Official Reports at Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52398(U))

Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52398(U)) [*1]
Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co.
2012 NY Slip Op 52398(U) [38 Misc 3d 129(A)]
Decided on December 21, 2012
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

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., WESTON and RIOS, JJ
2010-1887 K C.

against

Brooklyn Heights Physical Therapy, P.C. as Assignee of RAYMOND BONE, Respondent, New York Central Mutual Fire Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Genine D. Edwards, J.), entered September 24, 2009. The order denied defendant’s motion for summary judgment dismissing the complaint and granted plaintiff’s cross motion for summary judgment. The appeal from the order entered September 24, 2009 brings up for review so much of an order of the same court entered September 2, 2010 as, upon granting the branch of defendant’s motion seeking leave to reargue defendant’s prior motion for summary judgment dismissing the complaint and plaintiff’s prior cross motion for summary judgment, adhered to the portions of the prior order which denied defendant’s prior motion and granted the branches of plaintiff’s prior cross motion seeking summary judgment with respect to so much of the complaint as sought to recover upon claims for $1,180, $550.44, $780.98, and $489.28 (see CPLR 5517 [b]).

ORDERED that the appeal from the order entered September 24, 2009 is dismissed, as that order was superseded by the order entered September 2, 2010, made upon reargument; and it is further,

ORDERED that the order entered September 2, 2010, insofar as reviewed, is modified by [*2]providing that, upon reargument, the branches of plaintiff’s cross motion seeking summary judgment with respect to so much of the complaint as sought to recover upon claims for $1,180, $550.44, $780.98, and $489.28 are denied; as so modified, the order entered September 2, 2010, insofar as reviewed, is affirmed, without costs.

Plaintiff commenced this action to recover assigned first-party no-fault benefits and asserted seven causes of action seeking to recover upon claims for $1,180, $550.44, $780.98, $489.28, $305.80, $183.48, and $122.32, respectively. Defendant moved for summary judgment dismissing the complaint, and plaintiff cross-moved for summary judgment. The Civil Court, by order entered September 24, 2009, denied defendant’s motion and granted plaintiff’s cross motion. Thereafter, defendant moved for leave to reargue. By order entered September 2, 2010, the Civil Court granted reargument and, upon reargument, adhered to so much of the prior order as denied defendant’s motion for summary judgment dismissing the complaint and granted the branches of plaintiff’s cross motion seeking summary judgment with respect to so much of the complaint as sought to recover upon claims for $1,180, $550.44, $780.98, and $489.28.

The affidavit of defendant’s litigation examiner was insufficient to establish timely mailing of the NF-10 denial of claim forms at issue (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Consequently, defendant failed to establish its entitlement to summary judgment dismissing the complaint.

A no-fault provider establishes its prima facie entitlement to summary judgment by proof of the submission to the defendant of a claim form, proof of the fact and the amount of the loss sustained, and proof either that the defendant had failed to pay or deny the claim within the requisite 30-day period, or that the defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law (see Insurance Law § 5106 [a]; Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]; Avenue T MPC Corp. v Auto One Ins. Co., 33 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d, 11th & 13th Jud Dists 2011]). Inasmuch as plaintiff failed to demonstrate that defendant had untimely denied the claims or that defendant had issued NF-10 denial of claim forms which were conclusory, vague or without merit as a matter of law, plaintiff failed to established its prima facie entitlement to summary judgment with respect to its claims for $1,180, $550.44, $780.98, and $489.28.

Accordingly, the order entered September 2, 2010, insofar as reviewed, is modified by providing that, upon reargument, the branches of plaintiff’s cross motion seeking summary judgment with respect to so much of the complaint as sought to recover upon claims for $1,180, $550.44, $780.98, and $489.28 are denied.

Pesce, P.J., Weston and Rios, JJ., concur.

Decision Date: December 21, 2012
Parsons Med. Supply, Inc. v Utica Mut. Ins. Co. (2012 NY Slip Op 52397(U))

Reported in New York Official Reports at Parsons Med. Supply, Inc. v Utica Mut. Ins. Co. (2012 NY Slip Op 52397(U))

Parsons Med. Supply, Inc. v Utica Mut. Ins. Co. (2012 NY Slip Op 52397(U)) [*1]
Parsons Med. Supply, Inc. v Utica Mut. Ins. Co.
2012 NY Slip Op 52397(U) [38 Misc 3d 129(A)]
Decided on December 21, 2012
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

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., WESTON and RIOS, JJ
2010-1537 K C.
Parsons Medical Supply, Inc. as Assignee of MARLON McLEOD, Respondent, —

against

Utica Mutual Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Dawn Jimenez Salta, J.), entered October 16, 2009. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court which denied defendant’s motion for summary judgment dismissing the complaint.

In support of its motion, defendant was required, but failed, to demonstrate that its initial and follow-up requests for examinations under oath (EUOs) of plaintiff had been timely sent (see Insurance Department Regulations [11 NYCRR] §§ 65-3.5 [b]; 65-3.6 [b]). Since defendant failed to establish that it had tolled its time to pay or deny plaintiff’s claims, and, thus, that it is not precluded from raising its proffered defense that plaintiff’s principal failed to appear for an EUO (see Presbyterian Hosp. in City of NY v Maryland Cas. Co., 90 NY2d 274, 282 [1997]; Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045 [2009]), defendant is not entitled to summary judgment dismissing the complaint (see NYU-Hosp. for Joint Diseases v American [*2]Intl. Group, Inc., 89 AD3d 702 [2011]; Westchester Med. Ctr., 60 AD3d 1045).

Accordingly, the order is affirmed.

Pesce, P.J., Weston and Rios, JJ., concur.
Decision Date: December 21, 2012

Infinity Health Prods., Ltd. v Liberty Mut. Fire Ins. Co. (2012 NY Slip Op 52396(U))

Reported in New York Official Reports at Infinity Health Prods., Ltd. v Liberty Mut. Fire Ins. Co. (2012 NY Slip Op 52396(U))

Infinity Health Prods., Ltd. v Liberty Mut. Fire Ins. Co. (2012 NY Slip Op 52396(U)) [*1]
Infinity Health Prods., Ltd. v Liberty Mut. Fire Ins. Co.
2012 NY Slip Op 52396(U) [38 Misc 3d 129(A)]
Decided on December 21, 2012
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

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., WESTON and RIOS, JJ
2010-968 Q C.
Infinity Health Products, Ltd. as Assignee of MARY OSEI, Respondent,

against

Liberty Mutual Fire Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Richard G. Latin, J.), entered March 5, 2010, deemed from a judgment of the same court entered March 24, 2010 (see CPLR 5512 [a]). The judgment, entered pursuant to the March 5, 2010 order granting plaintiff’s motion for summary judgment and denying defendant’s cross motion, in effect, for summary judgment dismissing the complaint, awarded plaintiff the principal sum of $1,061.

ORDERED that the judgment is reversed, with $30 costs, the order entered March 5, 2010 is vacated, plaintiff’s motion for summary judgment is denied, and defendant’s cross motion, in effect, for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court entered March 5, 2010, granting plaintiff’s motion for summary judgment and denying defendant’s cross motion, in effect, for summary judgment dismissing the complaint. Plaintiff’s appeal from the order is deemed to be from the judgment that was entered pursuant to the order (see CPLR 5512 [a]). [*2]

The affidavit of defendant’s claim specialist established that defendant had timely mailed requests and follow-up requests for verification (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Contrary to the finding of the Civil Court, the affidavit of defendant’s claim specialist was also sufficient to establish that plaintiff had failed to respond to those requests. It is noted that plaintiff never alleged that it had responded.

Consequently, the 30-day period within which defendant was required to pay or deny plaintiff’s claims did not commence to run and plaintiff’s action is premature (see Insurance Department Regulations [11 NYCRR] § 65-3.8 [a]; Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 [2005]; Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533 [2004]). Thus, plaintiff’s motion should have been denied and defendant’s cross motion should have been granted (see Infinity Health Prods. Ltd. v Liberty Mut. Fire Ins. Co., 35 Misc 3d 135[A], 2012 NY Slip Op 50774[U] [App Term, 2d, 11th & 13th Jud Dists 2012]). In light of the foregoing, we reach no other issue.

Accordingly, the judgment is reversed, the order entered March 5, 2010 is vacated, plaintiff’s motion for summary judgment is denied, and defendant’s cross motion, in effect, for summary judgment is granted.

Pesce, P.J., Weston and Rios, JJ., concur.
Decision Date: December 21, 2012

Lenox Hill Hosp. v Tower Ins. Co. of N.Y. (2012 NY Slip Op 52391(U))

Reported in New York Official Reports at Lenox Hill Hosp. v Tower Ins. Co. of N.Y. (2012 NY Slip Op 52391(U))

Lenox Hill Hosp. v Tower Ins. Co. of N.Y. (2012 NY Slip Op 52391(U)) [*1]
Lenox Hill Hosp. v Tower Ins. Co. of N.Y.
2012 NY Slip Op 52391(U) [38 Misc 3d 129]
Decided on December 20, 2012
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 December 20, 2012

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS


PRESENT: : MOLIA, J.P., NICOLAI and IANNACCI, JJ
2011-2152 S C.
Lenox Hill Hospital as Assignee of CHARLES BARCLAY, Appellant, —

against

Tower Insurance Company of New York, Respondent.

Appeal from an order of the District Court of Suffolk County, Second District (Stephen L. Ukeiley, J.), dated June 13, 2011. The order denied plaintiff’s motion for summary judgment.

ORDERED that the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, the District Court properly denied plaintiff’s motion for summary judgment on the ground that plaintiff had not demonstrated its prima facie entitlement to judgment as a matter of law (see New York Hosp. Med. Ctr. of Queens v Statewide Ins. Co., 33 Misc 3d 130[A], 2011 NY Slip Op 51863[U] [App Term, 9th & 10th Jud Dists 2011]).

Accordingly, the order is affirmed.

Molia, J.P., Nicolai and Iannacci, JJ., concur.
Decision Date: December 20, 2012

New York Hosp. Med. Ctr. of Queens v Utica Mut. Ins. Co. (2012 NY Slip Op 52388(U))

Reported in New York Official Reports at New York Hosp. Med. Ctr. of Queens v Utica Mut. Ins. Co. (2012 NY Slip Op 52388(U))

New York Hosp. Med. Ctr. of Queens v Utica Mut. Ins. Co. (2012 NY Slip Op 52388(U)) [*1]
New York Hosp. Med. Ctr. of Queens v Utica Mut. Ins. Co.
2012 NY Slip Op 52388(U) [38 Misc 3d 128(A)]
Decided on December 20, 2012
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 December 20, 2012

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS


PRESENT: : MOLIA, J.P., NICOLAI and IANNACCI, JJ
2011-2064 N C.
The New York Hospital Medical Center of Queens as Assignee of VICTOR MORALES, Respondent,

against

Utica Mutual Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, First District (Michael A. Ciaffa, J.), dated June 21, 2011. The order, insofar as appealed from, denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, without costs, and defendant’s cross motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from so much of an order of the District Court as denied defendant’s cross motion for summary judgment dismissing the complaint.

In support of its cross motion, defendant submitted an affidavit by its insured who stated that plaintiff’s assignor had jumped on the hood of the insured’s car, while it was parked, and got off of the car without incident or injury. The insured, according to his sworn statement, drove away without further contact with plaintiff’s assignor. Consequently, defendant argued that plaintiff’s assignor’s alleged injuries did not arise out of an insured incident. In opposition to defendant’s cross motion, plaintiff submitted a police accident report and plaintiff’s assignor’s hospital records. According to plaintiff, these records demonstrate that its assignor was injured when defendant’s insured drove his car into plaintiff’s assignor, as reported to the police and [*2]hospital personnel by plaintiff’s assignor. The District Court found that the assignor’s hearsay statements that are contained within the records, in conjunction with the medical information, raised a triable issue of fact as to how plaintiff’s assignor was injured.

The police report offered by plaintiff did not constitute proof in admissible form, as it was not certified pursuant to CPLR 4518 (c) and no foundation establishing its authenticity and accuracy was offered (see Cheul Soo Kang v Violante, 60 AD3d 991, 991 [2009]). In any event, “the statements in the report attributed to the [plaintiff’s assignor] constituted inadmissable hearsay” (id. at 991-992).

The hospital records that plaintiff submitted to the court purport to include a description of the alleged accident as reported to hospital staff by plaintiff’s assignor. Such statements are considered reliable only when they are relevant to diagnosis or treatment (see Williams v Alexander, 309 NY 283, 286 [1955]). Here, the hospital records do not contain any allegations that rebut the allegations contained in defendant’s insured’s sworn statement. Furthermore, plaintiff failed to lay the requisite foundation for the hospital records (see CPLR 4518 [a], [c]). Thus, contrary to the finding of the District Court, even assuming the hospital records were admissible at all, and therefore could be used as proof that plaintiff’s assignor was injured by a motor vehicle, they still did not raise a triable issue of fact as to whether defendant’s insured was involved, thereby triggering defendant’s liability.

Since defendant demonstrated that the injuries in question did not arise out of an insured incident, and plaintiff failed to raise a triable issue of fact, defendant’s cross motion for summary judgment dismissing the complaint should have been granted (see St. Vincent’s Hosp. & Med. Ctr. v Allstate Ins. Co., 69 AD3d 923 [2010]; Andromeda Med. Care, P.C. v NY Cent. Mut. Fire Ins. Co., 26 Misc 3d 126[A], 2009 NY Slip Op 52601[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).

Molia, J.P., Nicolai and Iannacci, JJ., concur.
Decision Date: December 20, 2012

NYU-Hospital for Joint Diseases v American Tr. Ins. Co. (2012 NY Slip Op 52387(U))

Reported in New York Official Reports at NYU-Hospital for Joint Diseases v American Tr. Ins. Co. (2012 NY Slip Op 52387(U))

NYU-Hospital for Joint Diseases v American Tr. Ins. Co. (2012 NY Slip Op 52387(U)) [*1]
NYU-Hospital for Joint Diseases v American Tr. Ins. Co.
2012 NY Slip Op 52387(U) [38 Misc 3d 128(A)]
Decided on December 20, 2012
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 December 20, 2012

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS


PRESENT: : MOLIA, J.P., NICOLAI and IANNACCI, JJ
2011-1883 N C.
NYU-Hospital for Joint Diseases as Assignee of DERLY MARTE, Appellant, —

against

American Transit Insurance Company, Respondent.

Appeal from an order of the District Court of Nassau County, First District (Bonnie P. Chaikin, J.), dated October 6, 2010. The order denied plaintiff’s motion for summary judgment.

ORDERED that the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, the District Court properly denied plaintiff’s motion for summary judgment on the ground that plaintiff had not demonstrated its prima facie entitlement to judgment as a matter of law (see New York Hosp. Med. Ctr. of Queens v Statewide Ins. Co., 33 Misc 3d 130[A], 2011 NY Slip Op 51863[U] [App Term, 9th & 10th Jud Dists 2011]).

Accordingly, the order is affirmed.

Molia, J.P., Nicolai and Iannacci, JJ., concur. [*2]
Decision Date: December 20, 2012

NYU Hosp. for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 22379)

Reported in New York Official Reports at NYU Hosp. for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 22379)

NYU Hosp. for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 22379)
NYU Hosp. for Joint Diseases v State Farm Mut. Auto. Ins. Co.
2012 NY Slip Op 22379 [38 Misc 3d 41]
Accepted for Miscellaneous Reports Publication
AT2
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected through Friday, April 12, 2013

[*1]

NYU Hospital for Joint Diseases, as Assignee of Michael Samilo, Appellant,
v
State Farm Mutual Automobile Insurance Company, Respondent.

Supreme Court, Appellate Term, Second Department, 9th and 10th Judicial Districts, December 18, 2012

APPEARANCES OF COUNSEL

Joseph Henig, P.C., Bellmore (Mark A. Green of counsel), for appellant. Rossillo & Licata, P.C., Westbury (John J. Rossillo of counsel), for respondent.

{**38 Misc 3d at 42} OPINION OF THE COURT

Memorandum.

Ordered that the order, insofar as appealed from, is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, we find that the District Court properly denied plaintiff’s motion for summary judgment on the ground that plaintiff had not demonstrated its prima facie entitlement to judgment as a matter of law (see New York Hosp. Med. Ctr. of Queens v Statewide Ins. Co., 33 Misc 3d 130[A], 2011 NY Slip Op 51863[U] [App Term, 2d Dept, 9th & 10th Jud Dists 2011]).

A plaintiff seeking to recover for no-fault benefits must submit proof of the fact and the amount of the loss sustained, i.e., that health care services or supplies were provided and the amount thereof (see Insurance Law § 5106 [a]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]; King’s Med. Supply, Inc. v Hereford Ins. Co., 5 Misc 3d 55 [App Term, 2d Dept, 9th & 10th Jud Dists 2004]). In this case, plaintiff submitted an NF-5, UB-04 and DRG master output report in support of its motion for summary judgment. However, in order for such documents to constitute prima facie proof of the fact and the amount of the loss sustained, plaintiff would have had to demonstrate that such documents were admissible, pursuant to CPLR 4518 (a), as proof of the acts, transactions, occurrences and/or events recorded therein (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 31 Misc 3d 21 [App{**38 Misc 3d at 43} Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]; see generally Matter of Carothers v GEICO Indem. Co., 79 AD3d 864 [2010]; Art of Healing Medicine, P.C. v Travelers Home & Mar. Ins. Co., 55 AD3d 644 [2008]). Plaintiff failed to do so.

Plaintiff’s argument that hospitals should not be held to the same standards of proof as other healthcare providers, because hospitals are required to use a different claim form (an NF-4 or NF-5 rather than an NF-3), is without merit. The NF-3 (verification of treatment by [*2]attending physician or other provider of health service), NF-4 (verification of hospital treatment) and NF-5 (hospital facility form) are all prescribed by the no-fault regulations (Insurance Department Regulations [11 NYCRR] Appendix 13), and one is not inherently more reliable than the others. The fact that a certain form was used to submit a claim to an insurer is irrelevant to the question of whether the health care provider demonstrated to the court that it is entitled to recover no-fault benefits.

We recognize that CPLR 4518 (b) allows hospital records to be used as prima facie proof of the facts contained in those records. However, CPLR 4518 (b) does not apply to “any action instituted by or on behalf of a hospital to recover payment . . . for services rendered by or in such hospital.” Even assuming, without deciding, that a hospital’s records could be used by the plaintiff hospital in an assigned first-party no-fault case, pursuant to CPLR 4518 (b), under the theory that the hospital is suing as the assignee of a patient seeking to recover benefits from an insurance company, and not on its own behalf, such documents must, in any event, “bear[ ] a certification by the head of the hospital or by a responsible employee in the controller’s or accounting office that the bill is correct, that each of the items was necessarily supplied and that the amount charged is reasonable.” No such certification was provided here, nor did plaintiff submit an affidavit of a hospital employee attesting to the truth of any of the contents of the records submitted by plaintiff. Instead, the only sworn statements submitted by plaintiff were made by plaintiff’s attorney and by an employee of a third-party billing company, neither of whom claimed any knowledge as to the truth of the contents of the records.

Finally, we note that the cases cited by plaintiff (e.g. Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 34 AD3d 532 [2006]), for the proposition that hospitals are not required to submit proof of the fact and the amount of the loss sustained to the court in order to demonstrate their entitlement to no-fault{**38 Misc 3d at 44} benefits, do not impact our decision in this case. In those cases, there is no indication that the defendants had ever objected to the plaintiffs’ prima facie showing on the ground that those plaintiffs had failed to submit such proof. Thus, plaintiff has not demonstrated that any appellate court in New York has been presented with the question of whether a plaintiff hospital is required to offer proof of the fact and the amount of the loss sustained in order to recover no-fault benefits in court and, upon considering that question, held that the hospital is not required to offer such proof. The Appellate Division has specifically held, twice, that a health care provider has not demonstrated its entitlement to recover no-fault benefits after finding that the provider’s claim forms were inadmissible pursuant to CPLR 4518 (a) (see Matter of Carothers, 79 AD3d 864; Art of Healing Medicine, P.C., 55 AD3d 644), and plaintiff has not provided a compelling reason to distinguish the instant case from those cases.

Accordingly, the order, insofar as appealed from, is affirmed.

We decline defendant’s request to search the record and award it summary judgment dismissing the complaint.

Molia, J.P., Iannacci and LaSalle, JJ., concur.

Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U))

Reported in New York Official Reports at Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U))

Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U)) [*1]
Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co.
2012 NY Slip Op 52315(U) [38 Misc 3d 126(A)]
Decided on December 13, 2012
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 December 13, 2012

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : RIOS, J.P., ALIOTTA and SOLOMON, JJ
2011-866 Q C.
Bay Plaza Chiropractic, P.C. as Assignee of SIMONE HENDRICKSON, Respondent, —

against

Praetorian Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Maureen A. Healy, J.), entered February 2, 2011. The order, insofar as appealed from as limited by the brief, denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint and plaintiff cross-moved for summary judgment. The Civil Court found that plaintiff and defendant had established their prima facie cases and that the sole issue for trial was the medical necessity of the services rendered to plaintiff’s assignor. Defendant appeals, as limited by its brief, from so much of the order as denied its motion.

In support of its motion, defendant submitted, among other things, a sworn peer review report which set forth a factual basis and medical rationale for the doctor’s determination that there was a lack of medical necessity for the chiropractic services rendered. In opposition to the motion, plaintiff submitted an affidavit by its chiropractor which was sufficient to demonstrate that there was an issue of fact as to the medical necessity of the services at issue (see Quality Psychological Servs., P.C. v Mercury Ins. Group, 27 Misc 3d 129[A], 2010 NY Slip Op 50601[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; cf. Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).

Accordingly, the order, insofar as appealed from, is affirmed.

Rios, J.P., Aliotta and Solomon, JJ., concur.
Decision Date: December 13, 2012