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 June 1, 2005. The order denied plaintiff’s motion for summary judgment.

Order 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. [*2]

Plaintiff commenced this action to recover first-party no-fault benefits for medical services rendered to its assignor. Thereafter, plaintiff moved for summary judgment, which motion defendant opposed. The court below denied said motion by order entered June 1, 2005 and this appeal ensued.

At the outset we find that the letters defendant asserts are verification requests for plaintiff’s $494.37, $359.35 and $815.36 claims are insufficient to act as such and, therefore, did not toll the statutory time period in which defendant had to pay or deny these claims (see e.g. Melbourne Med., P.C. v Utica Mut. Ins. Co., 4 Misc 3d 92 [App Term, 2d & 11th Jud Dists 2004]). Consequently, defendant’s denials as to these claims were untimely and it is precluded from raising the defenses proffered herein (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]). It is noted that defendant paid $565.70 on plaintiff’s $815.36 claim.

There is no merit to plaintiff’s contention that the defense of lack of medical necessity is precluded as to its $1,972.08 and $1,573.24 claims because defendant failed to provide it with a copy of the peer review report. We note that defendant failed to establish that it sent a copy of the peer review report within the 30-day claim denial period. Although the regulations set forth that plaintiff may request a copy of the peer review report (see 11 NYCRR 65-3.8 [b] [4], formerly 11 NYCRR 65.15 [g] [2] [iv]), they provide no sanctions for an insurer’s failure to do so. Nevertheless, the lack of medical necessity defense is precluded on another ground. To preserve the defense of lack of medical necessity, defendant’s denial of claim forms must assert, with the requisite specificity, the necessary facts and medical rationale to establish such defense (Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]), thereby satisfying the NF-10 form’s requirement that the basis of any denial be “fully and explicitly” set forth (see A.B. Med. Servs. PLLC v Nationwide Mut. Ins. Co., 7 Misc 3d 132[A], 2005 NY Slip Op 50605[U] [App Term, 2d & 11th Jud Dists]; Park Neurological Servs. P.C. v Geico Ins., 4 Misc 3d 95, 96 [App Term, 9th and 10th Jud Dists 2004]). Herein, the denials were factually insufficient and thus, while timely, did not avoid preclusion (see A.B. Med. Servs. PLLC v Utica Mut. Ins. Co., 10 Misc 3d 50, 53 [App Term, 2d & 11th Jud Dists 2005]). Moreover, the affirmed peer review report defendant submitted in opposition to plaintiff’s motion for summary judgment (the contents of which, contrary to plaintiff’s contention, established a triable issue as to the medical necessity of the services rendered) does not remedy the factual insufficiencies of the denials (see A.B. Med. Servs. PLLC v Liberty Mut. Ins. Co., 10 Misc 3d 128[A], 2005 NY Slip Op 51902[U] [App Term, 2d & 11th Jud Dists]).

In view of the foregoing, plaintiff’s motion for summary judgment is granted, and the matter is remanded to the court below for the calculation of statutory interest and an [*3]
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 with 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.

In this regard, I note my dissent in A.B. Med. Servs. PLLC v Liberty Mut. Ins. Co. (10 Misc 3d 128[A], 2005 NY Slip Op 51902[U] [App Term, 2d & 1th Jud Dists]), and in further support of my argument, I cite 11 NYCRR 65-3.8 (b) (4) which states: [*4]

“If the specific reason for a denial of a no-fault claim…is a…peer review report…the insurer shall release a copy of that report…upon the written request of any of these parties.” (emphasis added)

To hold as the majority does, in my opinion, would usurp the role of the Legislature. It would require defendant to produce the peer review report within 30 days despite the fact that the regulations do not require that the report be produced at all, unless requested in writing by the plaintiff, a burden the rules did not impose upon the defendant.
Decision Date: July 12, 2006

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 (Eileen Nadelson, J.), entered March 18, 2005. The order denied plaintiff’s motion for summary judgment.

Order affirmed without costs.

In this action to recover first-party no-fault benefits for medical supplies furnished to its assignor, plaintiff established a prima facie entitlement to summary judgment by proof that it submitted claims, setting forth the fact and the amounts of the losses 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]; A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86 [App Term, 2d & 11th Jud
Dists 2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]).

Defendant timely denied the claims on the ground of lack of medical necessity based upon a peer review report. The peer reviewer set forth a “factual basis and medical rationale” (Park Neurological Servs. P.C. v GEICO Ins., 4 Misc 3d 95, 97 [App Term, 9th & 10th Jud Dists 2004]) for his conclusion that there was no medical necessity for the supplies furnished based on the documentation provided to him. This was sufficient to raise a triable issue of the supplies’ medical necessity. We note that contrary to plaintiff’s contention, under the facts presented the [*2]reviewer’s mere reference to unavailable reports and notes does not require the inference that the reviewer considered the information in his possession insufficient to permit a medical necessity determination and that recourse to the verification process was necessary to amplify the record. Accordingly, plaintiff’s motion for summary judgment was properly denied.

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

Golia, J., concurs in a separate memorandum.

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

While I agree with the ultimate disposition in the decision reached by the majority, I wish to emphasize that I am constrained to 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 12, 2006

—[*1]

In an action to recover no-fault benefits under an insurance contract brought by motion for summary judgment in lieu of complaint pursuant to CPLR 3213, the plaintiff appeals, as limited by her brief, from so much of an order of the Supreme Court, Nassau County (Brennan, J.), dated August 10, 2005, as denied her motion for summary judgment in lieu of complaint.

Ordered that the order is affirmed insofar as appealed from, with costs.

Because the plaintiff’s action was not based upon an instrument for the payment of money only, it was improperly commenced by motion for summary judgment in lieu of complaint (see CPLR 3213; New York Cent. Mut. Fire Ins. Co. v Danaher, 290 AD2d 783, 784 n 3 [2002]; cf. Hellert v Travelers Ins. Co., 52 AD2d 751 [1976]). Nonetheless, since the issues in dispute were fully submitted by the parties, the Supreme Court properly disposed of the motion on the merits (see Schulz v Barrows, 94 NY2d 624, 628 [2000]; New York Cent. Mut. Fire Ins. Co. v Danaher, supra; see also CPLR 103 [c]; Miller v North Shore Towers Assoc., 119 Misc 2d 644 [1983]).

With respect to the merits, the plaintiff failed to establish her prima facie entitlement to judgment as a matter of law in connection with her cause of action alleging that the defendant insurer is collaterally estopped from rejecting her claim for no-fault benefits. In order to invoke collateral estoppel against the defendant, the plaintiff must demonstrate that a pending issue was [*2]raised, that it was necessarily decided and material in a prior action, and that the party to be estopped had a full and fair opportunity to litigate the issue in the earlier action (see Bansbach v Zinn, 1 NY3d 1, 10 [2003]; Pinnacle Consultants v Leucadia Natl. Corp., 94 NY2d 426, 431-432 [2000]; Matter of Kleiger-Brown v Brown, 306 AD2d 482, 483 [2003]; Airco Alloys Div. v Niagara Mohawk Power Corp., 76 AD2d 68, 81-82 [1980]). Here, the underlying liability action was settled, and the issue of whether the accident in which the plaintiff was injured arose from the use and operation of the insured vehicle was never raised or adjudicated. The defendant is thus not estopped from disclaiming an obligation to pay no-fault benefits to the plaintiff on that ground, particularly where the categories of occurrences covered under the liability provisions of the relevant policy are broader than those covered under the no-fault provisions, and there is no evidence in the record that the defendant, by its conduct, made any actual or implied promises that it would provide no-fault coverage (see Walsh v Prudential Ins. Co. of Am., 101 AD2d 988 [1984], affd 64 NY2d 1053 [1985]).

In addition, the plaintiff failed to sustain her burden of establishing, as a matter of law, that her accident, which occurred when she slipped and fell on an icy sidewalk while attempting to walk around a parked vehicle owned by the defendant’s insured, arose from the use and operation of that vehicle (see Matter of Transcontinental Ins. Co. v Hampton, 10 Misc 3d 1056[A], 2005 NY Slip Op 51988[U] [2004]; Pavone v Aetna Cas. & Sur. Co., 91 Misc 2d 658, 661 [1977]; see generally Walton v Lumbermens Mut. Cas. Co., 88 NY2d 211, 215 [1996]; Matter of New York Cent. Mut. Fire Ins. Co. [Hayden—Allstate Ins. Co.], 209 AD2d 927).

The parties’ remaining contentions are either academic or without merit. Santucci, J.P., Spolzino, Lifson and Covello, JJ., concur.

—[*1]

In an action to recover no-fault medical payments, the plaintiffs appeal from so much of an order of the Supreme Court, Nassau County (McCarty, J.), dated September 30, 2005, as denied that branch of their motion which was for summary judgment on their first cause of action to recover payments for medical services rendered by the plaintiff New York and Presbyterian Hospital, and granted that branch of the defendant’s cross motion which was for summary judgment dismissing the first cause of action.

Ordered that the appeal by the plaintiff Mount Vernon Hospital is dismissed, without costs or disbursements, as that plaintiff is not aggrieved by the order appealed from (see CPLR 5511); and it is further,

Ordered that the order is modified, on the law, by deleting the provision thereof granting that branch of the defendant’s cross motion which was for summary judgment dismissing the first cause of action and substituting therefor a provision denying that branch of the cross motion; as so modified, the order is affirmed insofar as appealed from by the plaintiff New York and Presbyterian Hospital, without costs or disbursements, and the first cause of action is reinstated.

Pursuant to the statutory and regulatory framework governing the payment of no-fault automobile benefits, insurance companies are required to either pay or deny a claim for benefits within 30 days of receipt of the claim (see Insurance Law § 5106 [a]; 11 NYCRR 65-3.8 [c]). [*2]However, the 30-day period may be extended where the insurer makes a request for additional information within 15 business days of its receipt of the claim (see 11 NYCRR 65-3.5 [b]; Nyack Hosp. v General Motors Acceptance Corp., 27 AD3d 96, 100 [2005]; Hospital for Joint Diseases v ELRAC, Inc., 11 AD3d 432, 434 [2004]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., 5 AD3d 568, 569-570 [2004]), and an insurer is not obligated to pay or deny a claim until all demanded verification is provided (see Nyack Hosp. v General Motors Acceptance Corp., supra at 100-101; Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492, 493 [2005], lv denied 7 NY3d 704 [2006]).

The plaintiff New York and Presbyterian Hospital (hereinafter the plaintiff) made a prima facie showing that it was entitled to judgment as a matter of law on its first cause of action by submitting evidence that the prescribed statutory billing forms had been mailed and received, and that the defendant had failed to either pay or deny the claim within the requisite 30-day period (see Nyack Hosp. v General Motors Acceptance Corp., supra at 100; New York & Presbyt. Hosp. v AIU Ins. Co., 20 AD3d 515, 516 [2005]; New York & Presbyt. Hosp. v Progressive Cas. Ins. Co., supra at 570). However, in opposition to the motion, the defendant established that it had made a timely request for additional information and that it timely denied the claim within 30 days of receipt of the hospital records it had requested to verify the claim. Accordingly, the Supreme Court properly denied that branch of the plaintiffs’ motion which was for summary judgment on the first cause of action.

However, the Supreme Court should have denied that branch of the defendant’s cross motion which was for summary judgment dismissing the first cause of action. Although the defendant established that its denial of the subject claim was timely, it failed to submit sufficient evidentiary proof, in admissible form, to make a prima facie showing that it properly denied the claim upon the ground that the medical treatment provided was unrelated to the accident (see New York & Presbyt. Hosp. v AIU Ins. Co., supra; Hospital for Joint Diseases v Hertz Corp., 9 AD3d 392 [2004]; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 8 AD3d 250 [2004]; Mount Sinai Hosp. v Triboro Coach, 263 AD2d 11, 20 [1999]). Crane, J.P., Ritter, Krausman and Skelos, JJ., concur.

—[*1]

In an action to recover no-fault insurance benefits, the defendants appeal from an order of the Supreme Court, Nassau County (Bucaria, J.), dated September 7, 2005, which denied their motion to vacate a clerk’s judgment of the Supreme Court, Nassau County, entered December 8, 2004, upon their failure to appear or answer the complaint, to quash an information subpoena dated March 28, 2005, and to vacate an order of the same court dated May 26, 2005 directing them to comply with the information subpoena.

Ordered that the order is reversed, on the law and as a matter of discretion, with costs, the motion is granted, the clerk’s judgment entered December 8, 2004 is vacated, the information subpoena dated March 28, 2005 is quashed, and the order dated May 26, 2005 is vacated.

“A [defendant] seeking to vacate a default judgment pursuant to CPLR 5015 (a) (1) ‘must demonstrate a reasonable excuse for its delay in appearing and answering the complaint and a meritorious defense to the action’ ” (New York & Presbyt. Hosp. v American Home Assur. Co., 28 AD3d 442 [2006], quoting Eugene Di Lorenzo, Inc. v A.C. Dutton Lbr. Co., 67 NY2d 138, 141 [1986]). The defendants established both a reasonable excuse for their failure to timely appear and answer the complaint and potentially meritorious defenses, namely, the failure of the plaintiff New York University Hospital Rusk Institute to comply with the defendants’ demands for verification of the [*2]claim (see 11 NYCRR 65-3.8 [a] [1]; Mount Sinai Hosp. v Allstate Ins. Co., 25 AD3d 673, 674 [2006]; Nyack Hosp. v General Motors Acceptance Corp., 27 AD3d 96 [2005]) and the alleged exhaustion of the policy limits through payment of prior claims (see Mount Sinai v Allstate Ins. Co., 28 AD3d 727 [2006]; New York & Presbyt. Hosp. v Allstate Ins. Co., 12 AD3d 579 [2004]).

Accordingly, in view of the strong public policy that actions be resolved on their merits, the relatively brief delay involved, the defendants’ lack of wilfulness, and the absence of prejudice to the plaintiff, the Supreme Court improvidently exercised its discretion in denying the defendants’ motion, inter alia, to vacate the December 8, 2004, judgment (see New York & Presbyt. Hosp. v American Home Assur. Co., supra; New York & Presbyt. Hosp. v Auto One Ins. Co., 28 AD3d 441 [2006]; New York & Presbyt. Hosp. v Travelers Prop. Cas. Ins. Co., 27 AD3d 708 [2006]; Hospital for Joint Diseases v Dollar Rent A Car, 25 AD3d 534 [2006]). Miller, J.P., Adams, Goldstein and Covello, JJ., concur.

—[*1]

In a proposed class action by individual insureds or their assignees, inter alia, in effect, to recover payments for acupuncture treatments, the plaintiff appeals from an order of the Supreme Court, Nassau County (Warshawsky, J.), entered January 12, 2005, which, among other things, granted that branch of the defendant’s motion which was to dismiss the complaint pursuant to CPLR 3211 (a) (7).

Ordered that the order is affirmed, with costs.

The Supreme Court properly dismissed the complaint for failure to state a cause of action (see CPLR 3211 [a] [7]). The plaintiff’s claims are based on the erroneous proposition that New York Insurance Department regulation 68 (11 NYCRR part 65) requires the defendant to use only physicians licensed as acupuncturists to conduct independent medical examinations of patients who have received acupuncture treatment. The regulation contains no such requirement (see 11 NYCRR 65-1.1). Furthermore, contrary to the plaintiff’s contentions, no license or certification is required for a physician conducting an independent medical examination of a patient who has received acupuncture treatment, and such a physician is not engaged in the practice of acupuncture (see Education Law §§ 6521, 8211 [1] [a]; Savarese v Allstate Ins. Co., 287 AD2d 492 [2001]). [*2]

In light of this determination, the parties’ remaining contentions need not be reached. Schmidt, J.P., Santucci, Luciano and Rivera, JJ., concur.

—[*1]

In an action, inter alia, to recover no-fault benefits pursuant to a policy of automobile insurance, the plaintiff appeals from an order of the Supreme Court, Queens County (Schulman, J.), dated July 14, 2005, which denied her motion, in effect, for summary judgment, and granted the defendant’s cross motion to dismiss the action pursuant to CPLR 3211 (a) (5).

Ordered that the order is affirmed, without costs or disbursements.

The doctrine of collateral estoppel bars a party from “relitigating in a subsequent action or proceeding an issue clearly raised in a prior action or proceeding and decided against that party” (Ryan v New York Tel. Co., 62 NY2d 494, 500 [1984]). To invoke the doctrine, the identical issue must have been decided in the prior action or proceeding, and be decisive of the present action, and the party to be precluded from relitigating the issue must have had a full and fair opportunity to contest the prior determination (see D’Arata v New York Cent. Mut. Fire Ins. Co., 76 NY2d 659, 664 [1990]; Matter of Robert v O’Meara, 28 AD3d 567 [2006]).

Contrary to the plaintiff’s contention, the Supreme Court properly denied her motion, in effect, for summary judgment and granted the defendant’s cross motion to dismiss the action pursuant to CPLR 3211 (a) (5) on the ground that it was barred by a prior arbitration award. The defendant demonstrated that the issues raised in the prior arbitration proceeding, in which the [*2]plaintiff challenged the denial on August 8, 2000, of her claim for further no-fault benefits, were identical to and decisive of her present cause of action. In opposition to the cross motion, the plaintiff failed to sustain her burden of demonstrating that she did not have a full and fair opportunity to litigate issues relating to the August 8, 2000 denial of benefits at the prior arbitration proceeding. Accordingly, the court properly gave collateral estoppel effect to the arbitrator’s determination (see Clemens v Apple, 65 NY2d 746 [1985]; Lobel v Allstate Ins. Co., 269 AD2d 502 [2000]; Barnett v Ives, 265 AD2d 865 [1999]). Ritter, J.P., Krausman, Lifson and Lunn, JJ., concur.

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 (Bernice Daun Siegal, J.), entered May 26, 2005. The order, insofar as appealed from, denied plaintiff’s cross motion for summary judgment.

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

In this action to recover first-party no-fault benefits for health care services rendered to its assignor, 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]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]).

In denying plaintiff’s cross motion for summary judgment, the court below referred to the allegedly defective NF-3 form which contains an unreadable marking in the provider’s signature space, an allegedly defective assignment and an allegedly defective supporting affidavit by someone without personal knowledge of the facts. However, these deficiencies were waived because the defendant failed to timely seek verification of the assignment or the NF-3 form (A.B. [*2]Med. Servs. PLLC v Prudential Prop. & Cas. Ins. Co., 11 Misc 3d 137[A], 2006 NY Slip Op 50504[U] [App Term, 2d & 11th Jud Dists]).

In opposition to plaintiff’s cross motion for summary judgment, the defendant conceded that it had received plaintiff’s claim form and indicated the date of receipt on its denial of claim form. This adequately established that plaintiff sent and defendant received said claim (Capio Med., P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 129[A], 2005 NY Slip Op 50526[U] [App Term, 2d & 11th Jud Dists]). Defendant made the conclusory allegation, by one without personal knowledge of the facts, that it had sent several requests for independent medical examinations (IMEs) and that plaintiff’s assignor failed to appear. Since defendant failed to describe the standard office practice or procedures it used to ensure that such requests were properly addressed and mailed (see New York & Presbyt. Hosp. v Allstate Ins. Co., ___ AD3d ___, 2006 NY Slip Op 03558; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]), defendant failed to create a triable issue of fact (Fair Price Med. Supply Corp. v General Assur. Co., 6 Misc 3d 137[A], 2005 NY Slip Op 50256[U] [App Term, 2d & 11th Jud Dists]).

Accordingly, plaintiff’s cross motion for summary judgment should have been granted and the matter is remanded for the calculation of statutory interest and an assessment of attorney’s fees pursuant to Insurance Law § 5106 and the regulations promulgated thereunder.

Rios and Belen, JJ., concur.

Golia, J.P., concurs in a separate memorandum.

Golia, J.P., concurs with 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 7, 2006

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 (Howard G. Lane, J.), entered August 17, 2004. The order, insofar as appealed from, granted plaintiff’s motion for partial summary judgment as to its ninth cause of action and denied defendant’s cross motion for partial summary judgment as to said cause of action.

Order, insofar as appealed from, affirmed without costs.

Plaintiff commenced this action to recover assigned first-party no-fault benefits for health services rendered to its assignor. Plaintiff moved for partial summary judgment as to its first, fifth, seventh and ninth causes of action, and defendant cross-moved for partial summary judgment as to plaintiff’s first and ninth causes of action. The order, insofar as appealed from, granted plaintiff’s motion for partial summary judgment as to its ninth cause of action ($1,360.48 claim of assignor Isabel Gonzalez) and denied defendant’s cross motion for partial summary judgment as to said cause of action.

Plaintiff established its prima facie entitlement to partial summary judgment by proof that it submitted a claim, setting forth the fact and the amount of the loss sustained, and that payment [*2]of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). Despite defendant’s untimely denial of plaintiff’s claim for the sum of $1,360.48, defendant was not precluded from asserting the defense of lack of coverage (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]; Hospital for Joint Diseases v Allstate Ins. Co., 21 AD3d 348 [2005]; Westchester County Med. Ctr. v Allstate Ins. Co., 283 AD2d 488 [2001]). In support of its cross motion for summary judgment, defendant contended that the assignor, Isabel Gonzalez, was not an “eligible
injured person” (11 NYCRR 65-1.1 [d]) since she did not “regularly reside[]” (11 NYCRR 65-1.1[g]) with the insured, Sarito Gonzalez, and, as such, was not a relative of Mr. Gonzalez entitled to coverage under his insurance policy. We note that the Mandatory Personal Injury Protection Endorsement, as set forth in 11 NYCRR 65-1.1 (g), defines a relative as “a spouse, child or other person related to the named insured by blood, marriage or adoption (including a ward or foster child), who regularly resides in the insured’s household, including any such person who regularly resides in the household, but is temporarily living elsewhere.”

Defendant’s assertion, both in the affirmation of counsel and in the affidavit of its litigation examiner, that Isabel Gonzalez did not reside with the insured, was conclusory in nature and unsupported by competent evidence (see Alvarez v Prospect Hosp., 68 NY2d 320 [1986]) and therefore, was insufficient to demonstrate a “founded belief that the alleged injur[ies] do[] not arise out of an insured incident” (Central Gen. Hosp., 90 NY2d 195, 199 [1997]). Accordingly, defendant failed to demonstrate the existence of a triable issue of fact as to whether there was a lack of coverage, and similarly failed to establish its entitlement to summary judgment as a matter of law (see Zuckerman v City of New York, 49 NY2d 557 [1980]). In view of the foregoing, the lower court properly granted [*3]
plaintiff’s motion for partial summary judgment as to its ninth cause of action and denied defendant’s cross motion for partial summary judgment as to said cause of action.
Rios and Belen, JJ., concur.

Golia, J.P., concurs in part and dissents in part in a separate memorandum.

PSYCH. & MASSAGE THERAPY ASSOC., PLLC
Assignee of GREGORY PRZYBOROUWSKI, HECTOR MORALES
SONIA GUARDADO, DICSIANA REYES and ISABEL GONZALEZ,

Respondent,

-against-

PROGRESSIVE CASUALTY INS. CO.,

Appellant.

Golia, J.P., concurs in part and dissents in part and votes to modify the order, insofar as appealed from, by providing that plaintiff’s motion for partial summary judgment as to its ninth cause of action is denied in the following memorandum:

I agree with the majority that “…defendant was not precluded from asserting the defense of lack of coverage…” even though such defense was not raised in a “timely” denial.

I, however, do not agree with the majority in their holding that the issue raised by the defendant “was insufficient to demonstrate a “founded belief that the alleged injur[ies] do[ ] not arise out of an insured incident” because the affidavits by the defendant were conclusory and unsupported by competent evidence. In point of fact, the plaintiff’s own submitted documents list the residence of its assignor Isabel Gonzalez to be at 342 Wyona Street in Brooklyn, New York which is not the residence of the insured.

This fact alone raises a “founded belief” that the plaintiff’s assignor was not an eligible insured entitled to receive no-fault benefits, certainly sufficient to warrant a denial of plaintiff’s motion for summary judgment.
Decision Date: July 6, 2006

—[*1]

In an action to recover no-fault benefits under an insurance contract, the defendant appeals from a judgment of the Supreme Court, Nassau County (Mahon, J.), entered January 20, 2005, which, after a nonjury trial, and upon denying the defendant’s application to dismiss the complaint on the ground of lack of standing, is in favor of the plaintiffs and against it in the total sum of $33,452.77.

Ordered that the judgment is reversed, on the law, with costs, the motion is granted, and the complaint is dismissed.

The defendant correctly contends that the plaintiff hospitals lacked standing. The proof adduced at trial included unsigned assignment of benefit forms (see Leon v Martinez, 84 NY2d 83 [1994]). Schmidt, J.P., Adams, Luciano and Lifson, JJ., concur.