APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT

Defendant appeals from an order of the Civil Court of the City of New York, New York County (Manuel J. Mendez, J.), entered May 14, 2007, which granted plaintiff’s motion for summary judgment.

Per Curiam.

Order (Manuel J. Mendez, J.), entered May 14, 2007, reversed, with $10 costs, motion denied, and upon searching the record, summary judgment awarded to defendant dismissing the action.

In this action to recover no-fault first party benefits, defendant’s documentary submissions were sufficient to give rise to a presumption that defendant’s verification requests were timely mailed and received by plaintiff (see Nassau Ins. Co. v Murray, 46 NY2d 828 [1978]). Inasmuch as an insurer is not required to pay or deny a claim until it receives verification of all relevant requested information (see 11 NYCRR 65-3.8[b][3]; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 19 AD3d 569 [2005]), and it being undisputed on this record that plaintiff did not respond to defendant’s verification requests, plaintiff’s claim for payment was premature. Under these circumstances, where no triable issue exists as to whether plaintiff provided defendant with the requested information, defendant is entitled to summary judgment dismissing the action (see Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533 [2004]).
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
Decision Date: July 16, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

Appeal from an order of the District Court of Nassau County, Third District (Norman Janowitz, J.), dated May 14, 2007. The order, insofar as appealed from, denied plaintiff’s motion for summary judgment as to the sum of $1,937.58, representing an unpaid balance of a February 15, 2001 no-fault insurance claim.

Order, insofar as appealed from, reversed without costs, plaintiff’s motion for summary judgment upon the $1,937.58 unpaid portion of its claim dated February 15, 2001 granted and matter remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees thereon.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment. Insofar as is relevant to this appeal, the court below denied plaintiff’s motion for summary judgment upon the unpaid $1,937.58 balance of its NF-3 claim form dated February 15, 2001 on the ground that defendant raised an issue of fact as to medical necessity. This appeal by plaintiff ensued.

An insurance carrier is required to either pay or deny a claim for no-fault benefits within 30 days of the date the insurer receives the proof of claim (see Insurance Department Regulations [11 NYCRR] § 65.15 [g] [3], now Insurance Department Regulations [11 NYCRR] § 65-3.8; Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 [1997]). Insurance [*2]Department Regulations (11 NYCRR) § 65.15 (d) (2) provides that additional verification required by an insurer is to be requested within 10 business days of receipt of a prescribed claim form. Where, as here, defendant requested additional verification 12 business days after receiving plaintiff’s NF-3 claim form, the 30-day period within which defendant was required to pay or deny plaintiff’s claim was correspondingly reduced to 28 days (Insurance Department Regulations [11 NYCRR] § 65.15 [g] [10], now Insurance Department Regulations [11 NYCRR] § 65-3.8 [j]; see Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 318 [2007]). Since defendant concedes that it received the requested verification on May 16, 2001, defendant was required to pay or deny the claim at issue on or before June 13, 2001. As defendant did not deny plaintiff’s claim until June 14, 2001, defendant’s denial of plaintiff’s claim was untimely and defendant is precluded from raising its proffered defense of lack of medical necessity (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274 [1997], supra).

Accordingly, plaintiff was entitled to summary judgment upon the $1,937.58 unpaid portion of its claim dated February 15, 2001, and the matter is remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees thereon pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

Rudolph, P.J., McCabe and Scheinkman, JJ., concur.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Richard Velasquez, J.), entered April 20, 2007. The order denied defendant’s motion for summary judgment.

Order affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground of res judicata. Defendant argued that plaintiff had previously commenced an identical action, which was dismissed pursuant to CPLR 3126 (3) for plaintiff’s failure to comply with a
so-ordered discovery stipulation. Plaintiff asserted that the action was proper since the prior action was not dismissed with prejudice. The court below denied defendant’s motion. The instant appeal by defendant ensued.

“Where a plaintiff’s noncompliance with a disclosure order does not result in a dismissal with prejudice, or an order of preclusion or summary judgment in favor of defendant so as to effectively close plaintiff’s proof, dismissal resulting from the noncompliance is not a merits determination so as to bar commencement of a second action” (Maitland v Trojan Elec. & Mach. Co., 65 NY2d 614, 615-616 [1985]; see Daluise v Sottile, 40 AD3d 801, 802-803 [2007]; Aguilar v Jacoby, 34 AD3d 706, 707 [2006]). In the case at bar, plaintiff’s prior action was [*2]dismissed after the court below granted defendant’s motion to strike the complaint pursuant to CPLR 3126 (3). Since plaintiff’s noncompliance did not “result in a dismissal with prejudice, or an order of preclusion or summary judgment,” plaintiff was not barred from commencing a second action (see Maitland, 65 NY2d at 615-616; Daluise, 40 AD3d at 802). Accordingly, the court below properly denied defendant’s motion for summary judgment dismissing the
complaint based on the doctrine of res judicata (cf. First Help Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., ___ Misc 3d ___, 2008 NY Slip Op 51266[U] [App Term, 2d & 11th Jud Dists 2008] [so-ordered stipulation concerning discovery provided that a failure to provide the discovery would result in preclusion]).

Pesce, P.J., Rios and Steinhardt, JJ., concur.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Arlene Bluth, J.), entered November 29, 2006. The order denied defendant’s motion to vacate the default judgment entered against it and to extend its time to appear.

Order reversed without costs and defendant’s motion to vacate the default judgment entered against it and to extend its time to appear granted. Defendant shall serve and file its answer within 20 days of the date of the order hereon.

Plaintiff, a health care provider, obtained a default judgment in this action to recover assigned first-party no-fault benefits. Defendant’s motion to, inter alia, vacate the default judgment was denied on the ground that defendant’s papers did not establish the existence of a meritorious defense. This appeal by defendant ensued.

The sole issue raised on appeal is whether defendant established that it possessed a meritorious defense to the instant action. In our opinion, since the affidavit executed by defendant’s special investigator, which was submitted in support of defendant’s motion, “suffice[d] to [demonstrate] issues as to who really operated and controlled plaintiff” (Midwood Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co., 14 Misc 3d 131[A], 2007 NY Slip Op 50052 [App Term, 2d & 11th Jud Dists 2007]), defendant established the existence of a meritorious defense to the action. Accordingly, the order is reversed and defendant’s motion granted.

Pesce, P.J., Rios and Steinhardt, JJ., concur.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Richmond County (Johnny Lee Baynes, J.), entered March 15, 2007, deemed from a judgment entered April 23, 2007 (see CPLR 5501 [c]). The judgment, entered pursuant to the March 15, 2007 order granting plaintiff’s motion for summary judgment, awarded plaintiff the principal sum of $1,328.63.

Judgment affirmed without costs.

In this action by a medical equipment provider to recover assigned first-party no-fault benefits, the court granted plaintiff’s motion for summary judgment. The instant appeal by defendant ensued. A judgment was subsequently entered.

Since defendant does not challenge plaintiff’s establishment of its prima facie case, we do not pass upon the propriety of the determination of the court below with respect thereto.

In opposition to plaintiff’s motion for summary judgment, defendant was required, in order to raise a triable issue of fact as to medical necessity, to proffer proof in admissible form (see A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86 [App Term, 2d & 11th Jud Dists 2004]). In its opposing papers, defendant submitted an affirmed peer review report which stated that there was a lack of medical necessity for the medical equipment provided by plaintiff. In its reply papers, plaintiff asserted that the peer review report upon which defendant relied was not in admissible form pursuant to CPLR 2106 because it bore a [*2]facsimile of the peer reviewer’s signature. Although defendant argues that plaintiff’s contention was improperly raised for the first time in plaintiff’s reply papers, the reply affirmation from plaintiff’s counsel was responsive to defendant’s papers, since defendant first proffered the peer review report in inadmissible form in opposition to plaintiff’s motion and plaintiff was pointing out said defect in form. Inasmuch as defendant concedes that the peer review report bears an electronic stamped facsimile of the doctor’s signature, and there is nothing in the record to indicate that the facsimile signature was placed on the report by the doctor who performed the peer review or at his direction, defendant failed to raise a triable issue of fact with respect to the claim at issue (see Vista Surgical Supplies, Inc. v Travelers Ins. Co., 50 AD3d 778 [2008]). Accordingly, the judgment is affirmed.

We note that the affirmation by Dr. Curley, annexed to defendant’s reply brief on appeal, may not be considered by the court as it is dehors the record (see Chimarios v Duhl, 152 AD2d 508 [1989]).

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

Golia, J., dissents in a separate memorandum.

Golia, J., dissents and votes to reverse the judgment, vacate the order entered March 15, 2007 and deny plaintiff’s motion for summary judgment.

A simple review of the record reveals that contrary to the holding of the lower court, this defendant did fully comply with the no-fault regulations by timely sending a NF-10 denial of claim form which contained the specific reason for denial, i.e, a peer review report.

It is, however, understandable that the lower court ruled as it did in view of the majority decision of the Appellate Term in the case of A.B. Med. Servs. PLLC v GEICO Cas. Ins. Co., 12 Misc 3d 30 [App Term, 2d & 11th Jud Dists 2006]) which found such grounds for denial of claim to be insufficient.

Subsequent to the lower court’s ruling, the Appellate Division reversed the majority’s holding in this Court and found that the regulation means what it says and the statement that a claim is being denied based upon a peer review report is sufficient (see A.B. Med. Servs., PLLC v GEICO Cas. Ins. Co. 39 AD3d 778 [2007]).

Here, on appeal, my colleagues note that plaintiff in its reply papers timely raised the issue concerning whether or not a facsimile signature of Dr. Curley that was affixed to the peer review report was sufficient to qualify that report as “admissible” evidence. They reached this conclusion based upon the fact that the peer review report was submitted to the court in the opposition papers, and therefore plaintiff addressed the “signature” issue at the earliest possible opportunity. There were no further papers to be submitted to the court and therefore there was no response by defendant.

Notwithstanding, on appeal, defendant proffered an affirmation by Dr. Curley in which he states, under penalty of perjury, that his “facsimile” signature can only be affixed to a document by him personally and only by the use of a “secure password…and no other individual, either under my employ or otherwise, has the authority or ability to apply the signature.”

Whereas the assertion by the majority that Dr. Curley’s affirmation is “dehors” the record and should not be considered might technically be correct, it is also true that Dr. Curley did not have an opportunity or a reason to draft this affirmation until plaintiff contested the propriety of his “electronic” signature in its reply. Clearly, this appeal is the first opportunity defendant had to respond to the issue raised by plaintiff.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Kings County (Dolores L. Waltrous, J.), entered March 26, 2007. The order, insofar as appealed from, denied defendant’s cross motion for summary judgment.

Order, insofar as appealed from, modified by providing that defendant’s cross motion for summary judgment is granted to the extent of dismissing the complaint insofar as it sought to recover upon plaintiff’s claim seeking the sum of $925.75; as so modified, affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary
judgment dismissing the complaint on the ground of lack of medical necessity. The court denied both plaintiff’s motion and defendant’s cross motion, holding that the affidavits in support of the motion and cross motion were insufficient to establish either party’s entitlement to summary judgment. Defendant appeals from the order insofar as it denied its cross motion.

Defendant established that it timely mailed the denial of claim forms at issue, which denied plaintiff’s claims based upon either a peer review or an independent medical examination, pursuant to its standard office practice or procedure designed to ensure that items are properly addressed and mailed (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Since the affirmed independent medical examination report submitted [*2]by defendant in support of its cross motion established prima facie that the supplies provided by plaintiff for which plaintiff sought to recover the sum of $925.75 were not medically necessary and plaintiff did not present any evidence refuting defendant’s prima facie showing, the court should have granted defendant’s cross motion for summary judgment dismissing the complaint insofar as it sought to recover upon said claim (see Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; A. Khodadadi Radiology, P.C. v N.Y. Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]). Inasmuch as the affirmed peer review report annexed to defendant’s cross motion did not establish that the supplies for which plaintiff sought to recover on the claim seeking the sum of $235.63 were medically unnecessary, defendant was not entitled to summary judgment dismissing said claim.

Golia, J.P., Rios and Steinhardt, JJ., concur.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal, on the ground of inadequacy, from a judgment of the Civil Court of the City of New York, Queens County (Bernice Daun Siegal, J.), entered May 18, 2007. The judgment, after a nonjury trial, awarded plaintiff the principal sum of $33.55.

Judgment affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, the sole issue at trial was the medical necessity of nerve testing of the assignor’s upper and lower extremities. Before trial, the parties stipulated that plaintiff proved its prima facie
case, that defendant timely and properly denied the claims and that the claims for certain diagnostic testing were in dispute and had not been paid. The trial court entered into evidence the claim forms, denial of claim forms and the transcript of the deposition testimony of defendant’s peer review doctor (see CPLR 3117 [a] [4]). After trial, the court awarded judgment in the principal sum of $33.55 to plaintiff. This appeal by plaintiff ensued on the ground of inadequacy.

“A decision rendered by a court after a nonjury trial should not be disturbed on appeal unless it is clear that its conclusions could not have been reached under any fair interpretation of the evidence” (Ardmar Realty Co. v Building Inspector of Vil. of Tuckahoe, 5 AD3d 517, 518 [*2][2004]). Since the parties stipulated to plaintiff’s prima facie case, the burden shifted to defendant to proffer sufficient evidence in support of a defense (see West Tremont Med. Diagnostic, P.C. v Geico Ins. Co., 13 Misc 3d 131[A], 2006 NY Slip Op 51871[U] [App Term, 2d & 11th Jud Dists 2006]). The testimony of defendant’s peer review doctor established that there was a lack of medical necessity for the medical services which are the subject of this appeal. As plaintiff did not offer any rebuttal evidence to show that the services were medically necessary (see id.), the record does not support plaintiff’s contention that the judgment is inadequate. As a result, the judgment is affirmed.

Pesce, P.J., Rios and Steinhardt, JJ., concur.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

Appeal from an order of the District Court of Nassau County, First District (Gary Franklin Knobel, J.), dated December 28, 2006. The order, insofar as appealed from as limited by the brief, directed plaintiff to provide defendant with an authorization executed by its assignor in order to obtain discovery of defendant’s no-fault file, and directed that plaintiff bear the costs of reproduction of said file (15 Misc 3d 270 [2006]).

Appeal dismissed.

The appeal from the order must be dismissed since no appeal as of right lies from an order which decides a motion which was not made on notice (UDCA 1702 [a] [2]; see Bottiglieri v Reilly, 15 Misc 3d 135[A], 2007 NY Slip Op 50750[U] [App Term, 9th & 10th Jud Dists 2007]; see also 1223 Bushwick, LLC v Williams, 19 Misc 3d 128[A], 2008 NY Slip Op 50512[U] [App Term, 2d & 11th Jud Dists 2008]). A motion is made on notice when a notice of motion or an order to show cause is served (CPLR 2211), and no notice of motion or order to show cause was served herein. Although, under appropriate circumstances, a court may deem a notice of appeal an application for leave to appeal and grant such leave (UDCA 1702 [c]; see e.g. Cervera v Bressler, 50 AD3d 837 [2008]; Vest v Vest, 50 AD3d 776 [2008]), we decline to do so in the instant case.

Rudolph, P.J., McCabe and Scheinkman, JJ., concur.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Queens County (Gerald Dunbar, J.), entered February 2, 2006, deemed from a judgment entered February 5, 2007 (see CPLR 5501 [c]). The judgment, entered pursuant to the January 19, 2006 order granting plaintiff’s motion for summary judgment and denying defendant’s cross motion for summary judgment, awarded plaintiff the principal sum of $1,236.99.

Judgment reversed without costs, order entered January 19, 2006 vacated, plaintiff’s motion for summary judgment denied and defendant’s cross motion for summary judgment dismissing the complaint granted.

In this action by a provider to recover assigned first-party no-fault benefits for psychological services rendered in August and September 1999, plaintiff moved for summary judgment. Defendant cross-moved for summary judgment arguing, inter alia, that plaintiff was ineligible to receive reimbursement of no-fault benefits because plaintiff was fraudulently incorporated, relying on State Farm Mut. Auto. Ins. Co. v Mallela (4 NY3d 313 [2005]). Holding that Insurance Department Regulations (11 NYCRR) § 65-3.16 (a) (12) was inapplicable to claims for services rendered prior to April 4, 2002, the court granted plaintiff’s motion for summary judgment and denied defendant’s cross motion seeking summary judgment dismissing the complaint. This appeal ensued. A judgment was subsequently entered.

In Allstate Ins. Co. v Belt Parkway Imaging, P.C. (33 AD3d 407 [2006]), the Appellate [*2]Division, First Department, held that Insurance Department Regulations (11 NYCRR) § 65-3.16 (a) (12) is to be given retroactive effect notwithstanding the fact that it would bar reimbursement of assigned first-party no-fault benefits for services rendered prior to April 4, 2002 (see also Metroscan Imaging, P.C. v GEICO Ins. Co. (13 Misc 3d 35, 37-39 [App Term, 2d & 11th Jud Dists 2006]). Defendant’s cross motion for summary judgment established that plaintiff performed psychological services in violation of Limited Liability Company Law sections 1203 and 1207. Consequently, based upon our prior determination in Multiquest, P.L.L.C. v Allstate Ins. Co. (17 Misc 3d 37 [App Term, 2d & 11th Jud Dists 2007]), plaintiff was ineligible to obtain reimbursement of assigned first-party no-fault benefits for such services and defendant was entitled to summary judgment dismissing the complaint.

Rios, J.P., Pesce and Golia, JJ., concur.
Decision Date: July 10, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal from an order of the Civil Court of the City of New York, Queens County (Diane A. Lebedeff, J.), entered January 24, 2007. The order, insofar as appealed from, denied plaintiff’s motion for summary judgment.

Order, insofar as appealed from, reversed without costs, plaintiff’s motion for summary judgment granted, and matter remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff established a prima facie entitlement to summary judgment by proof that it
submitted a claim, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Mani Med. P.C. v NY Cent. Mut. Ins. Co., 19 Misc 3d 128[A], 2008 NY Slip Op 50508[U] [App Term, 2d & 11th Jud Dists 2008]). The burden then shifted to defendant to demonstrate the existence of a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).

Inasmuch as defendant timely sought verification with respect to the medical necessity of the supplies furnished by plaintiff to its assignor, upon receipt of such verification on November 23, 2005, defendant’s 30-day claim determination period began to run (Insurance Department [*2]Regulations [11 NYCRR] § 65-3.5). While defendant argues that its time to pay or deny plaintiff’s claim was further tolled because defendant requested that plaintiff’s assignor submit to an examination under oath (EUO), the record does not indicate that defendant made such a request for additional verification within 15 days of defendant’s receipt of the letter of medical necessity. As a result, defendant failed to show that its 30-day claim determination period was still tolled (see Insurance Department Regulations [11 NYCRR] § 65-3.5). In view of the foregoing, defendant’s denial of claim form, which was not mailed until January 4, 2006, was untimely and defendant was precluded from raising fraudulent billing as a defense in this action (see Fair Price Med. Supply Corp. v Travelers Indem. Co., 10 NY3d 556 [2008]; Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]). Consequently, plaintiff’s motion for summary judgment should have been granted.

Accordingly, the matter is remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

Pesce, P.J., and Weston Patterson, J., concur.

Golia, J., concurs in a separate memorandum.

Golia, J., concurs in the result only, in the following memorandum:

I am constrained to agree with the ultimate disposition in the decision reached by the majority. I, however, wish to note that I do not agree with certain propositions of law set forth in cases cited therein which are inconsistent with my prior expressed positions and generally contrary to my views.
Decision Date: July 10, 2008