A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51033(U))

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 January 13, 2005. The order denied plaintiffs’ motion for summary judgment.

Order reversed without costs, plaintiffs’ motion for summary judgment granted and matter remanded to the court below for the calculation of statutory interest and attorney’s fees.

In this action to recover first-party no-fault benefits for medical services rendered to their assignor, plaintiffs established their prima facie entitlement to summary judgment by proof that they submitted claims, 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]; 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]). The burden then shifted to defendant to show a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).

A review of the record indicates that, in opposition to plaintiffs’ motion for summary judgment, defendant solely relied upon a fraud defense alleging that the claims were based on a non-covered event. We note that defendant is not precluded from asserting the defense that the alleged injuries do not arise out of a covered accident (see Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]). However, the documentation submitted by defendant in opposition to plaintiff’s motion, consisting of the affirmation of defendant’s attorney and examinations under oath testimony of several persons involved in the accident, does not show [*2]that the accident was a non-covered event. The inconsistencies between the testimonies do not 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., 90 NY2d at 199). Consequently, defendant failed to demonstrate the existence of a triable issue of fact as to whether there was a lack of coverage (see id.; Zuckerman v City of New York, 49 NY2d 557 [1980]).

Accordingly, the order of the court below is reversed, plaintiffs’ motion for summary judgment is granted and matter remanded for the calculation of statutory interest and attorney’s fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

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

Golia, J., dissents in a separate memorandum.

Golia, J., dissents and votes to affirm the order denying plaintiff’s motion for summary judgment in the following memorandum:

Contrary to the holding of the majority, I find that defendant presented sufficient facts and circumstances to establish that its 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]).

The supporting papers established certain inconsistencies in the testimonies of the occupants of the subject car. Said papers also disclosed the facts that each of the occupants had several prior claims and that one of the prior claims involved the same two individuals being injured together in another automobile accident.

The confluence of circumstances certainly constitute a “founded belief” that the “accident” may not be a valid covered event.

As correctly stated by the majority, the defendant is not precluded from asserting the defense that the alleged injuries do not arise out of a covered accident (Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d at 199).

Further, the D.A.V. Chiropractic claim for $303.30 was properly and timely denied due to lack of medical necessity based upon a “negative” IME report. The majority acknowledges the propriety and timeliness of the denial but believes summary judgment is warranted in favor of the plaintiff because the report annexed to the motion papers was an unsworn copy of the report.

For the reasons set forth, in detail, in my dissent in Ocean Diagnostic Imaging v Lancer Ins. Co. (6 Misc 3d 62 [2004]), an unsworn medical report when submitted in opposition to a motion for summary judgment is sufficient to raise a triable issue of fact.
Decision Date: May 19, 2006