April 22, 2005

Ocean Diagnostic Imaging P.C. v Utica Mut. Ins. Co. (2005 NYSlipOp 50611(U))

Headnote

The relevant facts considered by the court included a health care provider submitting a claim for no-fault benefits for medical services rendered to its assignor, and the insurance company denying the claim more than two months after receiving it. The main issue decided was whether the insurance company's requests for examinations under oath tolled the 30-day claim determination period, and whether the insurance company could assert the defense that the collision was in furtherance of an insurance fraud scheme. The court held that the insurance company's requests for examinations under oath did not toll the claim determination period, but the company could still assert the defense of insurance fraud, despite its untimely denial of the claim, as the denial was based on a "founded belief that the alleged injuries do not arise out of an insured incident." Therefore, the court affirmed the denial of the health care provider's motion for summary judgment.

Reported in New York Official Reports at Ocean Diagnostic Imaging P.C. v Utica Mut. Ins. Co. (2005 NYSlipOp 50611(U))

Ocean Diagnostic Imaging P.C. v Utica Mut. Ins. Co. (2005 NYSlipOp 50611(U)) [*1]

Ocean Diagnostic Imaging P.C. v Utica Mut. Ins. Co.

2005 NYSlipOp 50611(U)

Decided on April 22, 2005

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This opinion is uncorrected and will not be published in the printed Official Reports.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 April 22, 2005

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: April 22, 2005 SUPREME COURT OF THE STATE OF NEW YORK APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS PRESENT : PATTERSON, J.P., GOLIA and RIOS, JJ.
2004-813 K C

Ocean Diagnostic Imaging P.C. a/a/o Marie Ceasar, Appellant,
against
Utica Mutual Insurance Company, Respondent.

Appeal by plaintiff from so much of an order of the Civil Court, Kings County (R. Garson, J.), entered April 1, 2004, as denied its motion for summary judgment.

Order insofar as appealed from unanimously affirmed without costs.

In this action to recover first-party no-fault benefits for medical services rendered to its assignor, plaintiff health care provider 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]). The burden then shifted to defendant to show a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).

It is uncontroverted that defendant denied plaintiff’s claim more than two months after it received said claim. Contrary to defendant’s contention, however, its requests for examinations under oath did not toll the 30-day claim determination period inasmuch as the insurance regulations in effect at the time lacked a provision entitling an insurer to an examination under oath (see King’s Med. Supply v Kemper Auto & Home Ins. Co., 3 Misc 3d 131[A], 2004 NY Slip Op 50401[U] [App Term, 2d & 11th Jud Dists]; A.B. Med. Servs. PLLC v State Farm Mut. Auto Ins. Co., 4 Misc 3d 141[A], 2004 NY Slip Op 51031[U] [App Term, 9th & 10th Jud [*2]Dists]).

Nevertheless, defendant is not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, despite its untimely denial of the claim (see Matter of Metro Med. Diagnostics v Eagle Ins. Co., 293 AD2d 751 [2002]). We find that the affidavit of defendant’s claims representative was sufficient to demonstrate that defendant’s denial was based upon a “founded belief that the alleged
injur[ies] do[ ] not arise out of an insured incident” (Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195,199 [1997]). Consequently, an issue of fact exists and the court below properly denied plaintiff’s motion for summary judgment.
Decision Date: April 22, 2005