Reported in New York Official Reports at VS Care Acupuncture v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50164(U))
against
State Farm Mutual Automobile Ins. Co. Defendant-Respondent.
Plaintiff appeals from an order of the Civil Court of the City of New York, New York County (Robert R. Reed, J.), entered September 30, 2013, which granted defendant’s motion for summary judgment dismissing the complaint.
Per Curiam.
Order (Robert R. Reed, J.), entered September 30, 2013, modified by reinstating plaintiff’s claim for first-party no-fault benefits billed under CPT codes 97039 and 97026; as modified, order affirmed, without costs.
Defendant’s documentary submissions established prima facie that it timely and properly denied plaintiff’s no-fault claims billed under CPT codes 97810, 97811 and 99203 on the ground that the amounts charged were in excess of the fees fixed by the applicable workers’ compensation fee schedule (see Akita Med. Acupuncture, P.C. v Clarendon Ins. Co., 41 Misc 3d 134[A], 2013 NY Slip Op 51860[U][App Term, 1st Dept 2013]; Great Wall Acupuncture v Geico Ins. Co., 16 Misc 3d 23 [App Term, 2d & 11th Jud Dists 2007]). In opposition, plaintiff failed to raise a triable issue as to the efficacy of defendant’s mailing of the denial forms or the calculation of the fees. Contrary to plaintiff’s contention, defendant’s April 12, 2010 denial of plaintiff’s claim in the amount of $2,690 was timely, since the last day of the 30 calendar days within which defendant was required to pay or deny the claim (see 11 NYCRR 65-3.8[c]) fell on Saturday, April 10, 2010 (see General Construction Law § 20).
Triable issues remain, however, in connection with plaintiff’s claims billed under CPT codes 97039 (moxibustion) and 97026 (infrared treatment). The position taken by defendant’s affiant, a certified medical coder, that the above-mentioned services, although “within the scope of practice of an acupuncturist, . . cannot be considered for reimbursement” because the procedure codes billed under were listed in the workers’ compensation physical medicine fee schedule, is unpersuasive. Inasmuch as the superintendent of insurance has not adopted or established a fee schedule for reimbursement of acupuncture services performed by a licensed acupuncturist, an insurer may consider the “charges permissible for similar procedures under schedules already [*2]adopted or established by the superintendent” (11 NYCRR 68.5[b]) for purposes of determining the appropriate reimbursement rate (see Forrest Chen Acupuncture Servs., P.C. v Geico Ins. Co., 54 AD3d 996 [2008]).
Plaintiff’s remaining arguments are either unpreserved or lacking in merit.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concurI concurI concur
Decision Date: February 25, 2015
Reported in New York Official Reports at Daimler Chrysler Ins. Co. v New York Cent. Mut. Fire Ins. Co. (2015 NY Slip Op 01538)
| Daimler Chrysler Ins. Co. v New York Cent. Mut. Fire Ins. Co. |
| 2015 NY Slip Op 01538 [125 AD3d 518] |
| February 19, 2015 |
| Appellate Division, First Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| Daimler Chrysler Insurance Company,
Appellant, v New York Central Mutual Fire Insurance Co., Respondent. |
Buckley Law Group, P.A., New York (Erdal Turnacioglu of counsel), for appellant.
Boeggeman George & Corde, P.C., White Plains (Richard G. Corde of counsel), for respondent.
Order, Supreme Court, New York County (Milton A. Tingling, J.), entered April 12, 2013, which denied plaintiff’s motion for summary judgment on its claim for defense costs expended in the underlying personal injury action, and granted defendant’s cross motion for summary judgment dismissing the complaint, unanimously affirmed, with costs.
The underlying personal injury action was discontinued by stipulation, to which plaintiff’s insured was a signatory, agreeing that all cross claims between the defendants in that action were “discontinued and waived.” The stipulation contained no reservation of any insurer’s subrogation rights (see Weinberg v Transamerica Ins. Co., 62 NY2d 379, 381-382 [1984]; Ziegler v Raskin, 100 AD2d 814 [1st Dept 1984], appeal dismissed 65 NY2d 925 [1985]). Thus, plaintiff, as subrogee of its insured, standing in its insured’s shoes and having no greater rights than its insured has, may not assert a subrogation claim against defendant (see Progressive Ins. Co. v Sheri Torah, Inc., 44 AD3d 837, 838 [2d Dept 2007]).
Plaintiff’s claim is also time-barred, because plaintiff is seeking common-law subrogation relief, and the statute of limitations on the underlying personal injury cause of action (three years) commenced to run as of the date of the accident (see General Construction Law § 20; Vigilant Ins. Co. of Am. v Housing Auth. of City of El Paso, Tex., 87 NY2d 36, 43 [1995]; CPLR 214 [5]; cf. Matter of Motor Veh. Acc. Indem. Corp. v Aetna Cas. & Sur. Co., 89 NY2d 214, 221 [1996] [subrogation rights created by no-fault statute commenced on date benefits were paid]).
Although defendant informed plaintiff six months before the limitations period expired that the lessee had failed to name plaintiff’s insured as an additional insured on his personal automobile insurance policy and that plaintiff’s insured was afforded coverage under the policy as a loss payee only, plaintiff did not assert a breach of contract claim against the lessee, or bring a declaratory judgment action against defendant or a subrogation action until well after the time to do so had expired (see Allstate Ins. Co. v Stein, 1 NY3d 416, 423 [2004]).
Thus, even if plaintiff were, as it contends, an additional insured solely by operation of [*2]the terms of the policy issued by defendant, and without reference to the terms of the lease, it could not assert a subrogation claim because its time to do so has expired. Concur—Friedman, J.P., Sweeny, Andrias, Moskowitz and DeGrasse, JJ.
Reported in New York Official Reports at Five Boro Med. Equip., Inc. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 51888(U))
against
New York Central Mutual Fire Insurance Company Defendant-Appellant.
Defendant, as limited by its briefs, appeals from so much of an order of the Civil Court of the City of New York, New York County (Andrea Masley, J.), dated May 22, 2013, as denied, in part, its motion for summary judgment dismissing the complaint.
Per Curiam.
Order (Andrea Masley, J.), dated May 22, 2013, insofar as appealed from, modified by granting defendant’s motion for summary judgment dismissing plaintiff’s claims seeking no-fault first-party benefits in the aggregate amount of $1,710.05; as modified, order affirmed, with $10 costs to defendant-appellant.
The defendant-insurer made a prima facie showing of entitlement to summary judgment dismissing plaintiff’s no-fault claims in the total sum of $ 1,710.75, for medical supplies provided to plaintiff’s assignor on June 2, 2011 and June 22, 2011, by establishing its proper and timely mailing of the denial of claim forms at issue herein (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2d Dept 2008]), and submitting a sworn peer review report which set forth a sufficient factual basis and medical rationale for the stated conclusion that the medical supplies provided to the assignor were not medically necessary (see Triangle R. Inc. v New York Cent. Mut. Fire Ins. Co., 32 Misc 3d 143[A], 2011 NY Slip Op 51663[U] [App Term, 1st Dept 2011]). Plaintiff’s opposing submission, consisting of an attorney’s affirmation unaccompanied by any medical evidence or other competent proof, was insufficient to raise a triable issue (see Munoz v Hollingsworth, 18 AD3d 278, 279 [2005]; CPT Med. Servs., P.C. v NY Cent. Mut. Fire Ins. Co., 18 Misc 3d 87 [2007]). Plaintiff’s objections to the peer review doctor’s qualifications “go to the weight and not the admissibility of her opinion” (Solano v Ronak Med. Care, 114 AD3d 592 [2014]).
We sustain so much of the order under review as denied defendant’s motion for summary judgement dismissing plaintiff’s claim of $1,080 for medical supplies provided to plaintiff’s assignor on June 27, 2011, since defendant’s own moving papers tend to indicate that this claim was not timely denied (see Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d [*2]312, 317 [2007]; Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195 [1997]; Country-Wide Ins. Co. v Zabloski, 257 AD2d 506 [1990]).
Plaintiff’s remaining arguments are either unpreserved for appellate review or without merit.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concur I concur
Decision Date: December 31, 2014
Reported in New York Official Reports at Cortland Med. Supply, Inc. v 21st Century Centennial Ins. Co. (2014 NY Slip Op 51886(U))
| Cortland Med. Supply, Inc. v 21st Century Centennial Ins. Co. |
| 2014 NY Slip Op 51886(U) [46 Misc 3d 136(A)] |
| Decided on December 31, 2014 |
| Appellate Term, First 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 December 31, 2014
PRESENT: Lowe, III, P.J., Schoenfeld, Hunter, Jr., JJ.
570781/14
against
21st Century Centennial Ins. Co. Defendant-Respondent.
Plaintiff appeals from an order of the Civil Court of the City of New York, New York County (Jennifer G. Schecter, J.), entered September 18, 2013, which granted defendant’s motion for summary judgment dismissing the complaint.
Per Curiam.
Order (Jennifer G. Schecter, J.), entered September 18, 2013, affirmed with $10 costs.
The defendant-insurer made a prima facie showing of entitlement to judgment as a matter of law by demonstrating that it timely and properly denied plaintiff’s claim for no-fault first-party benefits, through the affidavits of employees of its mailing center and of the entity which administers its no-fault claims, detailing their respective office mailing procedures, accompanied by a certificate of mailing (see Nassau Ins. Co. v Murray, 46 NY2d 828, 829 [1978]; Badio v Liberty Mut. Fire Ins. Co., 12 AD3d 229,330 [2004]), and the peer review report of its orthopedic doctor, which set forth a sufficient factual basis and medical rationale for her stated conclusion that the medical supplies provided by plaintiff to its assignor were not medically necessary (see Triangle R. Inc. v New York Cent. Mut. Fire Ins. Co., 32 Misc 3d 143[A], 2011 NY Slip Op 51663[U] [App Term, 1st Dept 2011]). Plaintiff’s opposition, consisting of an attorney’s affirmation unaccompanied by any medical evidence or other competent proof, was insufficient to raise a triable issue as to medical necessity (see Munoz v Hollingsworth, 18 AD3d 278, 279 [2005]; CPT Med. Servs., P.C. v NY Cent. Mut. Fire Ins. Co., 18 Misc 3d 87 [2007]).
Plaintiff’s remaining contentions are either unpreserved for appellate review or without merit.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concur I concur
Decision Date: December 31, 2014
Reported in New York Official Reports at SMB Med., P.C. v State Farm Mut. Ins. Co. (2014 NY Slip Op 51853(U))
| SMB Med., P.C. v State Farm Mut. Ins. Co. |
| 2014 NY Slip Op 51853(U) [46 Misc 3d 133(A)] |
| Decided on December 30, 2014 |
| Appellate Term, First 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 December 30, 2014
PRESENT: Lowe, III, P.J., Schoenfeld, Hunter, Jr., JJ.
570655/14
against
State Farm Mutual Insurance Company, Defendant-Appellant.
Defendant appeals from so much of an order of the Civil Court of the City of New York, Bronx County (Elizabeth A. Taylor, J.), entered July 3, 2013, as denied, in part, its motion for summary judgment dismissing the complaint.
Per Curiam.
Order (Elizabeth A. Taylor, J.), entered July 3, 2013, insofar as appealed from, reversed, with $10 costs, and defendant’s motion for summary judgment dismissing the complaint is granted in its entirety. The Clerk is directed to enter judgment accordingly.
The defendant-insurer made a prima facie showing of entitlement to summary judgment dismissing the plaintiff-provider’s claim for first-party no-fault benefits in the amount of $662.89, by establishing that it timely and properly mailed the notices for independent medical examinations (IMEs) to plaintiff’s assignor and his counsel, and that the assignor failed to appear (see American Tr. Ins. Co. v Lucas, 111 AD3d 423 [2013]; American Tr. Ins. Co. v Solorzano, 108 AD3d 449 [2013]). Contrary to plaintiff’s central argument, defendant submitted competent evidence of the assignor’s nonappearance in the form of an affirmation of the scheduled examining physician and a sworn affidavit of an employee of defendant’s third-party IME scheduler attesting to the affiants’ personal knowledge of their office practices and policies when an assignor fails to appear for a scheduled IME (see American Tr. Ins. Co. v Lucas, 111 AD3d at 424).
In opposition, plaintiff did not specifically deny the assignor’s nonappearance or otherwise raise a triable issue with respect thereto, or as to the mailing or reasonableness of the underlying notices (see Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559, 560 [2011], lv denied 17 NY3d 705 [2011]).
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concur I concur
Decision Date: December 30, 2014
Reported in New York Official Reports at Allstate Ins. Co. v Pierre (2014 NY Slip Op 08921)
| Allstate Ins. Co. v Pierre |
| 2014 NY Slip Op 08921 [123 AD3d 618] |
| December 23, 2014 |
| Appellate Division, First Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| Allstate Insurance Company,
Respondent, v Jean Eddy Pierre et al., Defendants, and Adelaida Laga PT et al., Appellants. |
The Rybak Firm, PLLC, Brooklyn (Damin J. Toell of counsel), for appellants.
Freiberg, Peck & Kang, LLP, Armonk (Yilo J. Kang of counsel), for respondent.
Order, Supreme Court, Bronx County (Alison Y. Tuitt, J.), entered July 18, 2013, which granted plaintiff insurer’s motion for summary judgment declaring that defendants-appellants are not entitled to no-fault benefits, unanimously modified, on the law, solely to declare that defendants-appellants are not entitled to no-fault benefits, and otherwise affirmed, without costs.
Plaintiff established that defendants are not entitled to no-fault benefits because their assignors failed to appear at scheduled examinations under oath (EUOs). This Court in Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC (82 AD3d 559 [1st Dept 2011], lv denied 17 NY3d 705 [2011]) held that the failure to submit to requested independent medical examinations (IMEs) constitutes a breach of a condition precedent to coverage under a no-fault policy and voids coverage regardless of the timeliness of the denial of coverage (id. at 560). Although the instant case involves the failure to appear at EUOs, and not IMEs, this Court’s holding in Unitrin applies to EUOs (see e.g. Interboro Ins. Co. v Perez, 112 AD3d 483, 483 [1st Dept 2013]; Seacoast Med., P.C. v Praetorian Ins. Co., 38 Misc 3d 127[A], 2012 NY Slip Op 52354[U] [App Term, 1st Dept 2012]; Interboro Ins. Co. v Clennon, 113 AD3d 596, 597 [2d Dept 2014]). Defendants do not dispute that their assignors failed to appear at their first EUOs, and plaintiff established, through admissible evidence, that the assignors failed to appear at their second EUOs (see Arco Med. NY, P.C. v Metropolitan Cas. Ins. Co., 41 Misc 3d 140[A], 2013 NY Slip Op 52001[U], *2 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]; Quality Psychological Servs., P.C. v Interboro Mut. Indem. Ins. Co., 36 Misc 3d 146[A], 2012 NY Slip Op 51628[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]). Plaintiff also established that the statements on the record were business records (see e.g. People v Cratsley, 86 NY2d 81, 90-91 [1995]; One Step Up, Ltd. v Webster Bus. Credit Corp., 87 AD3d 1, 11-12 [1st Dept 2011]). Although plaintiff was required to show (and did show) that the assignors each failed to appeared at two EUOs (see DVS Chiropractic, P.C. v Interboro Ins. Co., 36 Misc 3d 138[A], 2012 NY Slip Op 51443[U], *2 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012]), plaintiff was not required to demonstrate that the assignors’ nonappearances were willful (see Unitrin, 82 AD3d at 561).
[*2] Defendants’ argument that plaintiff failed to establish that it had mailed the EUO notices to the assignors’ correct addresses is unpreserved (see e.g. Ta-Chotani v Doubleclick, Inc., 276 AD2d 313, 313 [1st Dept 2000]) and unavailing (see American Tr. Ins. Co. v Leon, 112 AD3d 441, 442 [1st Dept 2013]). Similarly, their argument that plaintiff waived the defense of the assignors’ nonappearance because plaintiff did not establish that it ever denied defendants’ claims is unpreserved (see 276 AD2d at 313). In any event, the argument is unavailing, as defendants’ own verified answer alleged that plaintiff had denied their claims.
Defendants failed to show that summary judgment is premature due to outstanding discovery (see Interboro, 113 AD3d at 597).
We modify the court’s order solely to make a declaration in plaintiff’s favor (see Maurizzio v Lumbermens Mut. Cas. Co., 73 NY2d 951, 954 [1989]; see also QBE Ins. Corp. v Jinx-Proof Inc., 102 AD3d 508, 510 [1st Dept 2013]).
We have considered defendants’ remaining arguments and find them unavailing. Concur—Tom, J.P., Friedman, Renwick, Manzanet-Daniels and Kapnick, JJ.
Reported in New York Official Reports at Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. (2014 NY Slip Op 51766(U))
| Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. |
| 2014 NY Slip Op 51766(U) [46 Misc 3d 126(A)] |
| Decided on December 17, 2014 |
| Appellate Term, First 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 December 17, 2014
PRESENT: Lowe, III, P.J., Shulman, Hunter, Jr., JJ.
570325/14
against
21 Century Advantage Ins. Co. Defendant-Respondent.
Plaintiff, as limited by its brief, appeals from so much of an order of the Civil Court of the City of New York, New York County,(Jennifer G. Schecter, J.), dated July 16, 2013, as granted defendant’s motion for summary judgment dismissing plaintiff’s no-fault claim in the amount of $355.
Per Curiam.
Order (Jennifer G. Schecter, J.), dated July 16, 2013, insofar as appealed from, reversed, with $10 costs, and plaintiff’s claim for first-party no-fault benefits in the amount of $355 reinstated.
Defendant’s motion for summary judgment dismissing plaintiff’s first-party no-fault claim seeking payment of $355 – stemming from acupuncture services rendered by plaintiff on December 1, 2009, December 10, 2009 and January 7, 2010 – should have been denied. Defendant failed to demonstrate, prima facie, that its denials were properly mailed (see Country-Wide Ins. Co. v Zabloski, 257 AD2d 506 [1999]). In this regard, the affidavit submitted by an employee of Farmers Insurance Exchange, defendant’s claims administrator, failed to adequately describe its office mailing procedures (see Matter of Lumbermens Mut. Cas. Co. [Collins], 135 AD2d 373, 375 [1987]), merely stating that items placed in its “mail bin” are picked up by a nonparty entity – Pitney Bowes Services, Inc. (“Pitney Bowes”) – which brings the items on a daily basis to the post office. The affiant professed no personal knowledge of, nor did she attempt to describe, the procedures utilized by Pitney Bowes to assure timely and proper delivery. Nor were these deficiencies remedied by defendant’s submission in its reply papers below of an affidavit from a Pitney Bowes representative (see Batista v Santiago, 25 AD3d 326 [2006]).
Moreover, even beyond defendant’s shortcomings in proof concerning the mailing issue, the report of defendant’s peer review acupuncturist failed to set forth sufficient facts or medical rationale for his stated conclusion that further acupuncture treatment of plaintiff’s assignor was not medically necessary. That the assignor may have subjectively reported during the course of the peer review examination that she “feels worse” after three months of acupuncture treatment did not, by itself and without any objective medical explanation by the peer reviewer, eliminate [*2]all triable issues regarding the medical necessity of continued acupuncture treatment.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concurI concurI concur
Decision Date: December 17, 2014
Reported in New York Official Reports at Medcare Supply, Inc. v Farmers New Century Ins. Co. (2014 NY Slip Op 51752(U))
| Medcare Supply, Inc. v Farmers New Century Ins. Co. |
| 2014 NY Slip Op 51752(U) [45 Misc 3d 135(A)] |
| Decided on December 15, 2014 |
| Appellate Term, First 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 December 15, 2014
PRESENT: Lowe, III, Shulman, Hunter, Jr., JJ.
570173/14
against
Farmers New Century Ins. Co. Defendant-Respondent.
Plaintiff appeals from an order of the Civil Court of the City of New York, New York County (Jennifer G. Schecter, J.), entered April 15, 2013, which granted defendant’s motion for summary judgment dismissing the complaint.
Per Curiam.
Order (Jennifer G. Schecter, J.), entered April 15, 2013, reversed, with $10 costs, motion denied and complaint reinstated.
The action, seeking recovery of first-party no-fault benefits, is not ripe for summary dismissal. The defendant insurer failed to establish, prima facie, that it did not timely receive the plaintiff provider’s no-fault claim. In this regard, defendant relied on the affidavit of a claims representative employed in the Hicksville, New York office of non-party Farmers Insurance Exchange (“Exchange”), the entity which “administers claims” on defendant’s behalf. Although the affiant averred that there was no record of the underlying no-fault claim in his office’s paper and computer files, he professed no personal knowledge of the practice and procedures put in place by defendant in connection with the handling of no-fault claims sent to its Oklahoma City office, the designated mailing address for the submission of such claims (see Westchester Med. Ctr. v Philadelphia Indem. Ins. Co., 69 AD3d 613, 614 [2010]).
In any event, plaintiff, in opposition, raised a triable issue as to the mailing of the claim by producing a stamped mailing certificate tending to support its assertion that it timely mailed the no-fault claim to defendant at its designated Oklahoma City address (see LMK Psychological Servs., P.C. v Liberty Mut. Ins. Co., 30 AD3d 727 [2006]; Badio v Liberty Mut. Fire Ins. Co., 12 AD3d 229 [2004]).
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concurI concur.
Decision Date: December 15, 2014
Reported in New York Official Reports at NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U))
| NJ/NY Pain Mgt. v Allstate Ins. Co. |
| 2014 NY Slip Op 51569(U) [45 Misc 3d 130(A)] |
| Decided on November 3, 2014 |
| Appellate Term, First 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 November 3, 2014
PRESENT: Schoenfeld, J.P., Shulman, Ling-Cohan, JJ.
570565/14
against
Allstate Insurance Company, Defendant-Appellant.
Defendant, as limited by its brief, appeals from so much of an order of the Civil Court of the City of New York, New York County (Ann E. O’Shea, J.), dated October 17, 2011, as granted plaintiffs’ cross motion for summary judgment on the complaint.
Per Curiam.
Order (Ann E. O’Shea, J.), dated October 17, 2011, affirmed, with $10 costs.
Plaintiffs-providers established prima facie their entitlement to judgment as a matter of law by demonstrating that the necessary billing documents were mailed to and received by defendant-insurer and that payment of the no-fault benefits was overdue (see Insurance Law § 5106[a]; 11 NYCRR 65-3.8 [a][1]; Countrywide Ins. Co. v 563 Grand Med., P.C., 50 AD3d 313 [2008]).
In opposition, defendant failed to raise a triable issue. Although defendant showed that it timely denied the claim on the ground of medical necessity, it failed to submit the IME report upon which its denial was based or any other evidentiary proof to support its defense of medical necessity (see Vista Surgical Supplies, Inc. v Travelers Ins. Co., 50 AD3d 778 [2008]; Mollins v Allstate Ins. Co., 20 Misc 3d 141[A], 2008 NY Slip Op 51616[U][App Term, 1st Dept 2008]; cf. NYU-Hospital for Joint Diseases v Esurance Ins. Co., 84 AD3d 1190 [2011]). In the absence of “evidentiary facts” showing that a “bona fide” issue exists (see Rotuba Extruders v Ceppos, 46 NY2d 223, 231 [1979]) as to the medical necessity of the services here at issue, plaintiff’s cross motion for summary judgment was properly granted.
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concur I concur
Decision Date: November 03, 2014
Reported in New York Official Reports at Urban Well Acupuncture, P.C. v American Commerce Ins. Co. (2014 NY Slip Op 51520(U))
| Urban Well Acupuncture, P.C. v American Commerce Ins. Co. |
| 2014 NY Slip Op 51520(U) [45 Misc 3d 128(A)] |
| Decided on October 22, 2014 |
| Appellate Term, First 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 October 22, 2014
PRESENT: Schoenfeld, J.P., Shulman, Ling-Cohan, JJ.
570167/14
against
American Commerce Ins. Co. Defendant-Respondent.
Plaintiff appeals from an order of the Civil Court of the City of New York, New York County (James E. d’Auguste, J.), entered February 27, 2013, which granted defendant’s motion for summary judgment dismissing the complaint.
Per Curiam.
Order (James E. d’Auguste, J.), entered February 27, 2013, reversed, with $10 costs, motion denied, and complaint reinstated.
The action, seeking recovery of first-party no-fault benefits, is not ripe for summary dismissal since defendant “failed to . . . establish that the denial of claim form was in fact mailed to the plaintiff” (Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d 564, 564-565 [2005]; see Mercury Cas. Co. v Encare, Inc., 90 AD3d 475 [2011]). The affidavit submitted by the defendant insurer to establish proof of mailing – identifying the affiant as a “mailroom representative” of a nonparty to this action, State-Wide Insurance Company (“State-Wide”) – neither stated that the affiant actually mailed the claim denial to plaintiff nor, so far as appears, described defendant’s mailing office practice and procedures (see New York and Presbyterian Hospital v Allstate Ins. Co., 29 AD3d 547 [2006]), as opposed to those generally followed by State-Wide. Conspicuously absent from defendant’s moving submission was any allegation or showing that a jural relationship existed between defendant and State-Wide. Given these shortcomings in defendant’s proof, we have no occasion to consider whether defendant’s purported mailing of the claim denial to the individual treating acupuncturist rather than the employing professional corporation was proper (see 11 NYCRR 65-3.8[c])
THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concurI concur
Decision Date: October 22, 2014