Damadian MRI In Elmhurst v. Liberty Mut. Ins. Co., 2003 NY Slip Op 51700(U) (NY 12/24/2003), 2002-999 S C.

• Decision Date: 24 December 2003
• Docket Number: 2002-999 S C.
• Citation: 2003 NY Slip Op 51700(U)
• Parties: DAMADIAN MRI IN ELMHURST, P.C., as assignee of STACEY JONES, Respondent, v. LIBERTY MUTUAL INSURANCE COMPANY, Appellant.
• Court: New York Court of Appeals Court of Appeals

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2003 NY Slip Op 51700(U)

DAMADIAN MRI IN ELMHURST, P.C., as assignee of STACEY JONES, Respondent, v. LIBERTY MUTUAL INSURANCE COMPANY, Appellant.

2002-999 S C.

Appellate Term of the Supreme Court of New York, Second Department.

Decided December 24, 2003.

Appeal by defendant from an order of the District Court, Suffolk County (P. Barton, J.), entered on June 11, 2002, which granted plaintiffs motion for summary judgment in the principal sum of $879.73.

Order unanimously affirmed without costs.

PRESENT: DOYLE, P.J., WINICK and SKELOS, JJ.

In this action to recover $879.73 in first-party no-fault benefits, for medical services provided to its assignor, plaintiff moved for summary judgment. The motion papers establish that after plaintiff submitted its proof of claim, i.e., the completed statutory forms (11 NYCRR 65-3.3 [d]; 65-3.5 [a]), defendant failed to pay or deny the claim within 30 days of receipt of the requested verification (11 NYCRR 65-3.8 [a] [1]) and failed otherwise to set forth any other basis for denial of the claim within 30 days of receipt (Insurance Law § 5106; 11 NYCRR 65-3.8 [c]). Consequently, defendant is precluded, with certain exceptions not relevant here, from interposing a defense [11 NYCRR 65-3.8 [b] [4]; Central Gen. Hosp. v. Chubb Group of Ins. Co., 90 NY2d 195, 199 [1997]; New York & Presbyt. Hosp. v. American Tr. Ins. Co., 287 AD2d 699, 701 [2001]; Mount Sinai Hosp. v. Triboro Coach, 263 AD2d 11, 17 [1999]).

In opposition to the motion for summary judgment, defendant challenged the treatment's medical necessity, arguing that because no-fault compensation is available only for medically necessary treatment (e.g. Insurance Law § 5102 [a] [1]), on summary judgment, plaintiff must prove the treatment's medical necessity by proof in admissible form even if defendant is precluded from controverting said proof. Plaintiff contends that its properly completed claim form establishes its prima facie case for the recovery of no-fault benefits in summary judgment, and we agree.

In furtherance of the legislative mandate "to encourage prompt payment of claims, to discourage investigation by insurers and to penalize delays" (Dermatossian v. New York City Tr. Auth., 67 NY2d 219, 225 [1986]), the Insurance Department regulations provide that the "written notice [of claim] required by section 65-2.4. . . shall be deemed to be satisfied by the insurer's receipt of a completed prescribed application for motor vehicle no-fault benefits" (11 NYCRR 65-3.3 [d]), that is, the approved claim forms or their functional equivalent (11 NYCRR 65-3.5 [g]). Because such submissions suffice to place the burden on the insurer to timely interpose its objections, with the requisite supporting allegations where necessary, or be precluded thereafter from asserting those objections or defenses, including the claim that the treatment was medically unnecessary, the clear implication is that a properly completed claim form, which suffices on its face to establish the "particulars of the nature and extent of the injuries and treatment received and contemplated" (11 NYCRR 65-1.1), and the "proof of the fact and amount of loss sustained" (Insurance Law § 5106 [a]), is all that is necessary at the claim stage to establish the treatment's medical necessity (Insurance Law § 5102 [a] [1]; see Dermatossian v. New York City Tr. Auth., 67 NY2d at 224 ["to receive payment (a claimant) need only file a 'proof of claim' (which ) the insurers are obliged to honor. . . promptly or suffer the statutory penalties"]).

While under the facts presented we are only called upon to decide whether a proper proof of claim establishes a prima facie case on a provider's motion for summary judgment where the insurer is precluded from raising the defense of lack of medical necessity, courts have declined to distinguish a proper proof of claim under the insurance regulations from the quantum of proof necessary to prevail on a motion for summary judgment in an ensuing action on the claim whether or not the defendant was precluded (Presbyterian Hosp. in City of N.Y. v. Maryland Cas. Co., 226 AD2d 613, 614 [1996]; Interboro Gen. Hosp. v. Allcity Ins. Co., 149 AD2d 569, 570 [1989]; see S & M Supply Inc. v. Geico Ins., NYLJ, July 17, 2003 [App Term, 2d & 11th Jud Dists] ["(P)laintiff establishes its prima facie entitlement to summary judgment. . . by showing that it submitted a complete proof of claim"]; Choicenet Chiropractic P.C. v. Allstate Ins. Co., NYLJ, Mar. 7, 2003 [App Term, 2d & 11th Jud Dists] ["Plaintiff established a prima facie case (for summary judgment) by the submission of statutory forms for proof of claim and the amount of the loss."]; Liberty Queens Med. P.C. v. Liberty Mut. Ins. Co., NYLJ, Nov. 4, 2002 [App Term, 2d & 11th Jud Dists] [same]; Park Health Ctr. v. Prudential Prop. & Cas. Ins. Co., NYLJ, Dec. 14, 2001 [App Term, 2d & 11th Jud Dists] [same]; Sehgal v. Royal Ins. Co. of Am., NYLJ, Apr. 15, 1999 [App Term, 9th & 10th Jud Dists]; accord Vinings Spinal Diagnostic, P.C. v. Liberty Mut. Ins. Co., 186 Misc 2d 287, 291 [Dist Ct, Nassau County 2000]). Indeed, to hold otherwise would undermine the clear legislative mandate to facilitate the prompt and efficient resolution of first-party no-fault claims, many of which involve small sums for medical supplies, by imposing on the provider the unwarranted burden to obtain the necessary affidavits or other proof extrinsic to the forms to establish medical necessity. Thus, we reaffirm our holding that a provider's proof of a properly-completed claim makes out a prima facie case upon its motion...