MB Advanced Equip., Inc. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50863(U))

Reported in New York Official Reports at MB Advanced Equip., Inc. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50863(U))

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

MB Advanced Equipment, Inc., as Assignee of MARCUS ERIE, SACHELL ERIE and RUTH JEAN-TOUSSAINT, Respondent,

against

New York Central Mutual Fire Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Devin P. Cohen, J.), entered June 13, 2013. The order, insofar as appealed from, 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 on the ground that it had timely and properly denied the claims at issue based on the failure of plaintiff’s assignors to appear for duly scheduled independent medical examinations (IMEs), and plaintiff cross-moved for summary judgment. The Civil Court denied defendant’s motion but made, in effect, CPLR 3212 (g) findings that defendant’s denial of claim forms had been timely and proper, that plaintiff had established its prima facie case and that the sole issue for trial was whether plaintiff’s assignors had failed to appear for duly scheduled IMEs.

On appeal, defendant fails to articulate a sufficient basis to strike the Civil Court’s CPLR 3212 (g) findings in plaintiff’s favor (see EMC Health Prods., Inc. v Geico Ins. Co., 43 Misc 3d 139[A], 2014 NY Slip Op 50786[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]).

In support of its motion, defendant submitted affidavits from the doctor and chiropractor who were to perform the IMEs, which affidavits were sufficient to establish that plaintiff’s assignors had failed to appear for duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). However, in opposition, plaintiff submitted affidavits in which the doctor and chiropractor had previously sworn, under penalty of perjury, that when the IMEs were scheduled to occur, they were at a location other than the address set forth in the IME scheduling letters. To the extent defendant’s counsel asserted in a reply affirmation that the discrepancy was due to typographical errors in the prior affidavits, counsel did not demonstrate that she possessed personal knowledge sufficient to establish, as a matter of law, that the doctor and chiropractor were at the correct location when the IMEs were to be held.

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

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: June 03, 2016
LMS Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50862(U))

Reported in New York Official Reports at LMS Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50862(U))

LMS Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 50862(U)) [*1]
LMS Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co.
2016 NY Slip Op 50862(U) [51 Misc 3d 151(A)]
Decided on June 3, 2016
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 June 3, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-1639 K C
LMS Acupuncture, P.C., as Assignee of JOHN H. SOSA, Respondent,

against

New York Central Mutual Fire Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Devin P. Cohen, J.), entered May 16, 2013. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order 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 on the ground that plaintiff’s assignor had failed to appear for duly scheduled independent medical examinations (IMEs). In the alternative, defendant sought summary judgment dismissing two claims on the ground of lack of medical necessity and dismissing theportion of each of plaintiff’s claims which exceeded the amount permitted by the workers’ compensation fee schedule.

While defendant submitted properly sworn statements by the doctor who was scheduled to perform the IMEs, the doctor did not establish that she possessed personal knowledge of the nonappearance of plaintiff’s assignor for the IMEs. Therefore, defendant failed to establish its entitlement, as a matter of law, to judgment dismissing the complaint on the ground that plaintiff’s assignor had failed to appear for IMEs (see Bright Med. Supply Co. v IDS Prop. & Cas. Ins. Co., 40 Misc 3d 130[A], 2013 NY Slip Op 51123[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]; Alrof, Inc. v Safeco Natl. Ins. Co., 39 Misc 3d 130[A], 2013 NY Slip Op 50458[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]).

In opposition to the branches of defendant’s motion seeking summary judgment on the grounds of lack of medical necessity and that the amounts sought exceeded the amounts permitted by the workers’ compensation fee schedule, plaintiff submitted affidavits from its owner, which affidavits were sufficient to demonstrate the existence of triable issues of fact.

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: June 03, 2016
Harvard Med., P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50860(U))

Reported in New York Official Reports at Harvard Med., P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50860(U))

Harvard Med., P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50860(U)) [*1]
Harvard Med., P.C. v Tri State Consumers Ins. Co.
2016 NY Slip Op 50860(U) [51 Misc 3d 151(A)]
Decided on June 3, 2016
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 June 3, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-1427 K C
Harvard Medical, P.C., as Assignee of LENFORD CARTY, Appellant,

against

Tri State Consumers Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Harriet L. Thompson, J.), entered April 12, 2013. The order granted defendant’s motion for summary judgment.

ORDERED that the order 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, arguing that it had fully paid plaintiff in accordance with the workers’ compensation fee schedule. The Civil Court granted defendant’s motion.

For the reasons stated in Renelique, as Assignee of Yvon Delgado v Tri State Consumers Ins. Co. (___ Misc 3d ___, 2016 NY Slip Op ___ [appeal No. 2013-1709 Q C], decided herewith), the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: June 03, 2016
GBI Acupuncture, P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50859(U))

Reported in New York Official Reports at GBI Acupuncture, P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50859(U))

GBI Acupuncture, P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50859(U)) [*1]
GBI Acupuncture, P.C. v Tri State Consumers Ins. Co.
2016 NY Slip Op 50859(U) [51 Misc 3d 150(A)]
Decided on June 3, 2016
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 June 3, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-1419 K C
GBI Acupuncture, P.C., as Assignee of SOFIA GJONBALAJ, Appellant,

against

Tri State Consumers Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Harriet L. Thompson, J.), entered April 12, 2013. The order granted defendant’s motion for summary judgment.

ORDERED that the order 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, arguing that it had fully paid plaintiff in accordance with the workers’ compensation fee schedule. The Civil Court granted defendant’s motion.

For the reasons stated in Renelique, as Assignee of Yvon Delgado v Tri State Consumers Ins. Co. (___ Misc 3d ___, 2016 NY Slip Op _____ [appeal No. 2013-1709 Q C], decided herewith), the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: June 03, 2016
Great Health Care Chiropractic, P.C. v Hereford Ins. Co. (2016 NY Slip Op 50858(U))

Reported in New York Official Reports at Great Health Care Chiropractic, P.C. v Hereford Ins. Co. (2016 NY Slip Op 50858(U))

Great Health Care Chiropractic, P.C. v Hereford Ins. Co. (2016 NY Slip Op 50858(U)) [*1]
Great Health Care Chiropractic, P.C. v Hereford Ins. Co.
2016 NY Slip Op 50858(U) [51 Misc 3d 150(A)]
Decided on June 3, 2016
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 June 3, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-1336 Q C
Great Health Care Chiropractic, P.C., as Assignee of CARLOS THOMAS, Respondent,

against

Hereford Insurance Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Maureen A. Healy, J.), entered April 25, 2013. The order, insofar as appealed from and 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. By order entered April 25, 2013, insofar as appealed from and as limited by the brief, the Civil Court denied defendant’s motion.

In support of defendant’s motion for summary judgment dismissing the complaint, defendant established that it had timely mailed its verification request and follow-up verification request (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Defendant also demonstrated prima facie that it had not received the requested verification and, thus, that plaintiff’s action is premature (see Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 [2005]). However, in opposition to the motion, plaintiff submitted an affidavit from plaintiff’s owner, which affidavit was sufficient to give rise to a presumption that the requested verification had been mailed to, and received by, defendant (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]). In light of the foregoing, there is a triable issue of fact as to whether this action is premature (see Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co., 44 Misc 3d 59 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014]).

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

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: June 03, 2016
Matter of GEICO Ins. Co. v AAAMG Leasing Corp. (2016 NY Slip Op 03879)

Reported in New York Official Reports at Matter of GEICO Ins. Co. v AAAMG Leasing Corp. (2016 NY Slip Op 03879)

Matter of GEICO Ins. Co. v AAAMG Leasing Corp. (2016 NY Slip Op 03879)
Matter of GEICO Ins. Co. v AAAMG Leasing Corp.
2016 NY Slip Op 03879 [139 AD3d 947]
May 18, 2016
Appellate Division, Second Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected through Wednesday, June 29, 2016

[*1]

 In the Matter of GEICO Insurance Company, Respondent,
v
AAAMG Leasing Corp., as Assignee of Dawn Channer, Appellant.

[Recalled and vacated, see 148 AD3d 703.]

Israel Israel & Purdy, LLP, Great Neck, NY (Justin Skaferowsky of counsel), for appellant.

Printz & Goldstein, Woodbury, NY (Lawrence J. Chanice of counsel), for respondent.

In a proceeding pursuant to CPLR article 75 to vacate a master arbitration award dated August 4, 2014, AAAMG Leasing Corp., as assignee of Dawn Channer, appeals from so much of an order and judgment (one paper) of the Supreme Court, Nassau County (Feinman, J.), entered March 3, 2015, as denied that branch of its cross petition which was for an award of an additional attorney’s fee pursuant to Insurance Department Regulations (11 NYCRR) § 65-4.10 (j) (4).

Ordered that the order and judgment is reversed insofar as appealed from, on the law and in the exercise of discretion, with costs, and that branch of the cross petition of AAAMG Leasing Corp., as assignee of Dawn Channer, which was for an award of an additional attorney’s fee pursuant to Insurance Department Regulations (11 NYCRR) § 65-4.10 (j) (4) is granted to the extent of awarding an additional attorney’s fee in the sum of $650, and is otherwise denied.

AAAMG Leasing Corp., as assignee of Dawn Channer (hereinafter the appellant), is a medical provider which made a claim for no-fault benefits from the petitioner insurance carrier. The petitioner denied the claim, stating that the supplies provided were not medically necessary.

The appellant sought arbitration of the claim, and in an award dated April 28, 2014, the arbitrator awarded the appellant the sum of $3,870.45, plus interest, and an attorney’s fee in the sum of $850.

The petitioner sought review of the arbitrator’s award by a master arbitrator. In a determination dated August 4, 2014, the master arbitrator affirmed the original arbitration award, and awarded an additional attorney’s fee in the sum of $650 pursuant to Insurance Department Regulations (11 NYCRR) § 65-4.10 (j) (2) (i), which the master arbitrator stated was the maximum allowable fee.

The petitioner then commenced the instant proceeding pursuant to CPLR article 75 to vacate the master arbitration award dated August 4, 2014. The appellant cross-petitioned to [*2]confirm the arbitration award, and sought an additional attorney’s fee pursuant to Insurance Department Regulations (11 NYCRR) § 65-4.10 (j) (4). The petitioner opposed that demand for relief. In the alternative, the petitioner stated that the appellant’s fee should be limited to $650.

In the order and judgment appealed from, the Supreme Court confirmed the arbitration award. That branch of the cross petition which was for an award of an additional attorney’s fee was denied without comment. The appeal is limited to so much of the order and judgment as denied that branch of the cross petition which was for an award of an additional attorney’s fee.

The general rule is that in proceedings involving arbitration, as in other litigation, an attorney’s fee is not recoverable unless provided for by agreement or statute (see Myron Assoc. v Obstfeld, 224 AD2d 504 [1996]). Pursuant to Insurance Law § 5106 (a), if a valid claim or portion of a claim for no-fault benefits is overdue, “the claimant shall also be entitled to recover his attorney’s reasonable fee, for services necessarily performed in connection with securing payment of the overdue claim, subject to [the] limitations promulgated by the superintendent in regulations.” In a proceeding for judicial review of an award by a master arbitrator, an attorney’s fee shall be fixed by the court adjudicating the matter (see Insurance Department Regulations [11 NYCRR] § 65-4.10 [j] [4]; Matter of Hempstead Gen. Hosp. v National Grange Mut. Ins. Co., 179 AD2d 645 [1992]).

The limitations of an attorney’s fee recoverable in an appeal from a master arbitration award are set forth in Insurance Department Regulations (11 NYCRR) § 65-4.10 (j). Insurance Department Regulations (11 NYCRR) § 65-4.10 (j) (5) states: “No attorney shall demand, request or receive from the insurer any payment or fee in excess of the fees permitted by this subdivision for services rendered with respect to a no-fault master arbitration dispute.”

The maximum attorney’s fee for a master arbitration dispute is $65 per hour, up to a maximum fee of $650, plus an additional fee of $80 per hour for oral argument, if oral argument is requested (see Insurance Department Regulations [11 NYCRR] § 65-4.10 [j] [2] [i], [ii]). Additional fees may be awarded “if the master arbitrator determines that the issues in dispute were of such a novel or unique nature as to require extraordinary skills or services” (Insurance Department Regulations [11 NYCRR] § 65-4.10 [j] [3]).

In this case, the appellant did not ask for an attorney’s fee for oral argument, and there was no finding that the issues involved were novel or unique. Accordingly, the appellant was entitled to an award of an additional attorney’s fee in the sum of $650. Leventhal, J.P., Hall, Hinds-Radix and LaSalle, JJ., concur.

Brand Med. Supply, Inc. v Infinity Ins. Co. (2016 NY Slip Op 50739(U))

Reported in New York Official Reports at Brand Med. Supply, Inc. v Infinity Ins. Co. (2016 NY Slip Op 50739(U))

Brand Med. Supply, Inc. v Infinity Ins. Co. (2016 NY Slip Op 50739(U)) [*1]
Brand Med. Supply, Inc. v Infinity Ins. Co.
2016 NY Slip Op 50739(U) [51 Misc 3d 145(A)]
Decided on May 5, 2016
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 May 5, 2016

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


PRESENT: : WESTON, J.P., ALIOTTA and ELLIOT, JJ.
2014-2068 K C
Brand Medical Supply, Inc., as Assignee of VLADIMIR JEAN, Respondent,

against

Infinity Ins. Co., Appellant.

Appeal from a decision of the Civil Court of the City of New York, Kings County (Carol Ruth Feinman, J.), dated April 18, 2013, deemed from a judgment of the same court entered May 30, 2014 (see CPLR 5512 [a]). The judgment, after a nonjury trial, awarded plaintiff the principal sum of $1,150.

ORDERED that the judgment is reversed, with $30 costs, and the matter is remitted to the Civil Court for a new trial.

In this action by a provider to recover assigned first-party no-fault benefits, the Civil Court, following a nonjury trial, awarded plaintiff judgment in the principal sum of $1,150.

For the reasons stated in Brand Med. Supply, Inc., as Assignee of Steven Thomas v Infinity Ins. Co. (— Misc 3d &mdash, 2016 NY Slip Op — [appeal No. 2014-2032 K C], decided herewith), the judgment is reversed and the matter is remitted to the Civil Court for a new trial.

Weston, J.P., Aliotta and Elliot, JJ., concur.


Decision Date: May 05, 2016
Brand Med. Supply, Inc. v Infinity Ins. Co. (2016 NY Slip Op 50738(U))

Reported in New York Official Reports at Brand Med. Supply, Inc. v Infinity Ins. Co. (2016 NY Slip Op 50738(U))

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

Brand Medical Supply, Inc., as Assignee of STEVEN THOMAS, Respondent,

against

Infinity Ins. Co., Appellant.

Appeal from a decision of the Civil Court of the City of New York, Kings County (Carol Ruth Feinman, J.), dated April 18, 2013, deemed from a judgment of the same court entered May 30, 2014 (see CPLR 5512 [a]). The judgment, after a nonjury trial, awarded plaintiff the principal sum of $1,772.59.

ORDERED that the judgment is reversed, with $30 costs, and the matter is remitted to the Civil Court for a new trial.

Following a nonjury trial in this action by a provider to recover assigned first-party no-fault benefits, the Civil Court awarded judgment to plaintiff in the principal sum of $1,772.59. In reviewing a determination made after a nonjury trial, the power of this court is as broad as that of the trial court, and this court may render the judgment it finds warranted by the facts, bearing in mind that the determination of a trier of fact as to issues of credibility is given substantial deference, as a trial court’s opportunity to observe and evaluate the testimony and demeanor of the witnesses affords it a better perspective from which to assess their credibility (see Northern Westchester Professional Park Assoc. v Town of Bedford, 60 NY2d 492 [1983]; Hamilton v Blackwood, 85 AD3d 1116 [2011]; Zeltser v Sacerdote, 52 AD3d 824 [2008]).

Contrary to defendant’s assertion, plaintiff established its prima facie case, inasmuch as plaintiff’s bill and proof of mailing were admitted into evidence through the testimony of plaintiff’s owner, who testified that he had personally mailed the bill and that the bill had not been paid (see Viviane Etienne Med. Care., P.C. v Country-Wide Ins. Co., 25 NY3d 498, 502 [2015]; V.S. Med. Servs., P.C. v Travelers Ins. Co., 49 Misc 3d 152[A], 2015 NY Slip Op 51760[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]).

In support of its defense of exhaustion of the policy limits, defendant unsuccessfully attempted to have the applicable insurance policy’s declaration page, which set forth, among other things, the coverage limits of the policy (see e.g. Matter of Government Empls. v Ally, 106 AD3d 736 [2013]; Matter of State Farm Mut. Auto. Ins. Co. v Gray, 68 AD3d 1002 [2009]), admitted into evidence. Upon a review of the record, we find that the Civil Court erred in excluding the insurance policy declaration page from evidence. Defendant was not required to lay a CPLR 4518 (a) foundation for the declaration page, since a declaration page is not hearsay, but rather, as part of an insurance contract, it “has independent legal significance and need only be authenticated to be admissible” (All Borough Group Med. Supply, Inc. v GEICO Ins. Co., 43 [*2]Misc 3d 27, 28-29 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014], citing Kepner-Tregoe, Inc. v Leadership Software, Inc., 12 F3d 527, 540 [5th Cir 1994] and Beal-Medea Prods., Inc. v NY Cent. Mut. Fire Ins. Co., 36 Misc 3d 135[A], 2012 NY Slip Op 51347[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]). Here, the testimony of defendant’s senior no-fault representative sufficiently identified the document as an accurate representation of the declaration page which defendant maintained electronically (see CPLR 4539 [a]; Kaliontzakis v Papadakos, 69 AD3d 803 [2010]). Furthermore, in describing defendant’s procedure for generating a declaration page, defendant’s witness satisfactorily set forth the “manner or method in which tampering or degradation of the reproduction is prevented” (CPLR 4539 [b]). Consequently, in view of the Civil Court’s improper exclusion of the declaration page, a new trial is warranted. Accordingly, the judgment is reversed and the matter is remitted to the Civil Court for a new trial.

Weston, J.P., Aliotta and Elliot, JJ., concur.


Decision Date: May 05, 2016
New Age Acupuncture, P.C. v 21st Century Ins. Co. (2016 NY Slip Op 50737(U))

Reported in New York Official Reports at New Age Acupuncture, P.C. v 21st Century Ins. Co. (2016 NY Slip Op 50737(U))

New Age Acupuncture, P.C. v 21st Century Ins. Co. (2016 NY Slip Op 50737(U)) [*1]
New Age Acupuncture, P.C. v 21st Century Ins. Co.
2016 NY Slip Op 50737(U) [51 Misc 3d 145(A)]
Decided on May 5, 2016
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 May 5, 2016

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


PRESENT: : ELLIOT, J.P., WESTON and SOLOMON, JJ.
2014-1999 K C
New Age Acupuncture, P.C., as Assignee of SEBASTIAN MONTOYA, Appellant,

against

21st Century Insurance Company, Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Katherine A. Levine, J.), entered July 23, 2014. The order, insofar as appealed from, granted the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed using CPT code 97026.

ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed using CPT code 97026 is denied.

In this action by provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint. Plaintiff appeals from so much of an order of the Civil Court as granted the branch of defendant’s motion seeking summary judgment dismissing the portion of the complaint as sought to recover for services billed using CPT code 97026.

Upon a review of the record, we find that defendant’s moving papers failed to demonstrate defendant’s prima facie entitlement to summary judgment with respect to so much of the complaint as sought to recover for services billed using CPT code 97026 (Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]; see generally Sunrise Acupuncture PC v Tri-State Consumer Ins. Co., 42 Misc 3d 151[A], 2014 NY Slip Op 50435[U] [App Term, 1st Dept 2014]).

Accordingly, the order, insofar as appealed from, is reversed and the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed using CPT code 97026 is denied.

Elliot, J.P., Weston and Solomon, JJ., concur.


Decision Date: May 05, 2016
Progressive Cas. Ins. Co. v Metro Psychological Servs., P.C. (2016 NY Slip Op 03485)

Reported in New York Official Reports at Progressive Cas. Ins. Co. v Metro Psychological Servs., P.C. (2016 NY Slip Op 03485)

Progressive Cas. Ins. Co. v Metro Psychological Servs., P.C. (2016 NY Slip Op 03485)
Progressive Cas. Ins. Co. v Metro Psychological Servs., P.C.
2016 NY Slip Op 03485 [139 AD3d 693]
May 4, 2016
Appellate Division, Second Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected through Wednesday, June 29, 2016

[*1]

 Progressive Casualty Insurance Company et al., Respondents,
v
Metro Psychological Services, P.C., Appellant.

Law Office of Melissa Betancourt, P.C., Brooklyn, NY (Frank D’Esposito of counsel), for appellant.

McCormack & Mattei, P.C., Garden City, NY (John E. McCormack and Christina Perrone of counsel), for respondents.

In an action for a judgment declaring that the plaintiffs are not obligated to pay certain no-fault insurance claims submitted by the defendant, the defendant appeals from an order of the Supreme Court, Nassau County (Parga, J.), entered May 9, 2014, which granted the plaintiffs’ motion for summary judgment on the complaint and denied its cross motion for summary judgment dismissing the complaint.

Ordered that the order is modified, on the law, by deleting the provision thereof granting the plaintiffs’ motion for summary judgment on the complaint, and substituting therefor a provision denying that motion; as so modified, the order is affirmed, with costs to the defendant.

The plaintiffs commenced this action for a judgment declaring that they are not obligated to provide insurance coverage for any of the no-fault claims submitted to them by the defendant on the ground that the defendant failed to comply with conditions precedent to reimbursement under the no-fault laws and regulations and insurance laws of this state. After the defendant interposed its answer, the plaintiffs moved for summary judgment on the complaint. The plaintiffs argued, inter alia, that the defendant failed to comply with the provision of the insurance policy which required that the defendant submit to an examination under oath (hereinafter EUO), and therefore the plaintiffs were not obligated to provide insurance coverage for the no-fault claims submitted by the defendant. The defendant cross-moved for summary judgment dismissing the complaint, arguing, in effect, that the denial of claim letters issued by the plaintiffs were defective. The Supreme Court granted the plaintiffs’ motion and denied the defendant’s cross motion. The defendant appeals.

On appeal, the defendant contends, inter alia, that the plaintiffs’ motion for summary judgment should have been denied because the plaintiffs failed to establish, prima facie, that the letters scheduling the EUOs at issue were timely and properly mailed. Generally, “proof that an item was properly mailed gives rise to a rebuttable presumption that the item was received by the addressee” (Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d 33, 46 [2013], affd 25 NY3d 498 [2015] [internal quotation marks omitted]; see Matter of Rodriguez v Wing, 251 AD2d 335 [1998]). “ ’The presumption may be created by either proof of actual mailing or proof of a standard office practice or procedure designed to ensure that items are properly addressed and mailed’ ” (New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547, 547 [2006], quoting Residential Holding Corp. v [*2]Scottsdale Ins. Co., 286 AD2d 679, 680 [2001]; see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 114 AD3d at 47). However, for the presumption to arise, the office practice must be geared so as to ensure the likelihood that the item is always properly addressed and mailed (see Nassau Ins. Co. v Murray, 46 NY2d 828 [1978]). “Denial of receipt by the insured[ ], standing alone, is insufficient to rebut the presumption” (id. at 829-830).

As the defendant correctly contends, the plaintiffs failed to establish, prima facie, that they timely and properly mailed the EUO letters to the defendant. The affirmation of the plaintiffs’ counsel contained conclusory allegations regarding his office practice and procedure, and failed to establish that the practice and procedure was designed to ensure that the EUO letters were addressed to the proper party and properly mailed (see Progressive Cas. Ins. Co. v Infinite Ortho Prods., Inc., 127 AD3d 1050, 1051-1052 [2015]; Westchester Med. Ctr. v Countrywide Ins. Co., 45 AD3d 676, 676-677 [2007]; New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547, 548 [2006]; Hospital for Joint Diseases v Nationwide Mut. Ins. Co., 284 AD2d 374, 375 [2001]).

Since the plaintiffs failed to establish their prima facie entitlement to judgment as a matter of law on the issue of the timely and proper mailing of the EUO letters, their motion for summary judgment on the complaint should have been denied, regardless of the sufficiency of the defendant’s opposition papers (see Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]; Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720, 721 [2006]).

The defendant’s cross motion for summary judgment, however, was properly denied, as the defendant failed to establish, prima facie, that the denial of claim letters issued by the plaintiffs were conclusory, vague, or otherwise defective (see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168, 1169 [2010]; Megacure Acupuncture, P.C. v Clarendon Natl. Ins. Co., 33 Misc 3d 141[A], 2011 NY Slip Op 52199[U] [App Term, 2d Dept, 11th & 13th Jud Dists 2011]). Rivera, J.P., Balkin, Barros and Connolly, JJ., concur.