March 15, 2007

SZ Med., P.C. v Trumbull Ins. Co. (2007 NY Slip Op 50499(U))

Headnote

The relevant facts considered by the court were that the plaintiffs had submitted claims for first-party no-fault benefits for health care services provided to their assignor, and that payment of these benefits was overdue. The main issue decided was whether the defendant could demonstrate the existence of a triable issue of fact regarding the timely denial of the claims based on fraudulent billing. The holding of the case was that the defendant failed to submit adequate proof that it mailed timely verification requests, which would have extended the 30-day claim determination period, and as a result, the denials were untimely. The defendant was precluded from raising most defenses, including its defense of fraudulent billing, and the order granting plaintiffs' motion for summary judgment was affirmed.

Reported in New York Official Reports at SZ Med., P.C. v Trumbull Ins. Co. (2007 NY Slip Op 50499(U))

SZ Med., P.C. v Trumbull Ins. Co. (2007 NY Slip Op 50499(U)) [*1]

SZ Med., P.C. v Trumbull Ins. Co.

2007 NY Slip Op 50499(U) [15 Misc 3d 126(A)]

Decided on March 15, 2007

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This opinion is uncorrected and will not be published in the printed Official Reports.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 March 15, 2007

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : RUDOLPH, P.J., TANENBAUM and LaCAVA, JJ
2005-948 N C.

SZ Medical, P.C., JH Chiropractic, P.C. and New Wave Oriental Acupuncture, P.C. a/a/o Michael Boyce, Respondents,
against
Trumbull Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, Third District (Anna R. Anzalone, J.), dated March 18, 2005. The order granted plaintiffs’ motion for summary judgment.

Order affirmed without costs.

In this action to recover assigned first-party no-fault benefits for health care services provided to plaintiffs’ assignor, plaintiffs established their prima facie entitlement to summary judgment by proof that they 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]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). As a result, the burden shifted to defendant to demonstrate the existence of a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320 [1986]).

Defendant asserts, inter alia, that it timely denied plaintiffs’ claims based on fraudulent billing. However, the denial of claim forms are dated February 17, 2004 and indicate that plaintiffs’ twelve claims were received by defendant between October 13, 2003 and December 13, 2003. Although defendant claimed to have mailed timely verification requests, which would extend the 30-day claim determination period (11 NYCRR 65-3.5, 65-3.8 [a] [1]), it failed to submit adequate proof that it did so (see New York & Prebyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2006]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]). Thus, defendant’s time to deny the claims was not tolled, the denials were untimely and defendant was [*2]precluded from raising most defenses as a result of its untimely denials (see Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 90 NY2d 274, 282 [1997]), including its defense of fraudulent billing (see Presbyterian Hosp. in City of N.Y., 90 NY2d at 285; Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]; Careplus Med. Supply Inc. v State-Wide Ins. Co., 11 Misc 3d 29 [App Term, 2d & 11th Jud Dists 2005]). Accordingly, the order granting plaintiffs’ motion for summary judgment is affirmed.

Rudolph, P.J., Tanenbaum and LaCava, JJ., concur.