Inwood Hill Med. P.C. v. Allstate Ins. Co., 2004 NY Slip Op 50565(U) (NY 6/18/2004)
| Decision Date | 18 June 2004 |
| Docket Number | 43154/03. |
| Citation | 2004 NY Slip Op 50565(U) |
| Parties | INWOOD HILL MEDICAL P.C., BRONX NEURODIAGNOSTICS P.C., A/A/O JOSE RINCON, Plaintiffs, v. ALLSTATE INSURANCE COMPANY, Defendant. |
| Court | New York Court of Appeals Court of Appeals |
Inwood Hill Medical P.C. and Bronx Neurodiagnostics P.C., as assignees of Jose Rincon, Plaintiffs.
Plaintiffs represented by: Amos Weinberg, Esq., Great Neck, NY.
Allstate Insurance Company, Defendant.
Defendant represented by: Stern & Montana LLP, New York, NY.
In this action to recover first-party no-fault benefits, plaintiffs Inwood Hill Medical P.C. ("IHM" or "assignee") and Bronx Neurodiagnostics P.C. ("BN" or "assignee") as assignees of Jose Rincon ("Rincon" or "assignor") move for an order pursuant to CPLR §3212 granting plaintiffs summary judgment against defendant Allstate Insurance Company ("Allstate" or "defendant") in the sum of $8,418.49. Defendant opposes the motion.
Rincon was allegedly in a motor vehicle accident on April 11, 2002. He allegedly suffered personal injuries and was treated by health care providers IHM and BN. The next day, Rincon assigned to IHM and BN his right to recover benefits from Allstate for health care services rendered to him. (See, Exhibit "C" to the Motion). Plaintiffs then mailed the executed assignment of benefits forms and an application for motor vehicle no-fault benefits ("NF-2") to Allstate. Between June 20, 2002 and October 16, 2002, IHM and BN mailed several claim forms denominated as "Verification of Treatment By Attending Physicians or Other Provider of Health Service" ("NF-3" or "claim form") to Allstate. (See, Exhibits "D" & "E" to the Motion).
By letter dated July 18, 2002, Allstate via its counsel sent Rincon a notice to appear for an Examination Under Oath ("EUO") on August 23, 2002 to verify his claim for no-fault benefits. Thereafter, by letter dated August 22, 2002, Allstate and Rincon agreed to adjourn the EUO from August 23 to September 16, 2002. (See, Exhibit "G" to the Opposition papers). Allstate conducted Rincon's EUO on September 16, 2002. Allstate also conducted EUO's of Rincon's co-claimants, David Villones (Allstate's policy holder) and Floyd Spencer on August 22, 2002 and September 16, 2002, respectively. (See, Exhibits "C," "D," and "E" to the Opposition papers).
Allstate conceded that it received IHM's and BN's claim forms and it issued its denials as follows:
Date of Claim Date Received Date of Denial Claim/Bill Amount
June 18, 2002 June 25, 2002 October 8, 2002 $ 154.30
June 18, 2002 June 25, 2002 October 8, 2002 $ 80.02
June 18, 2002 June 25, 2002 October 8, 2002 $ 1,560.09
June 18, 2002 June 25, 2002 October 8, 2002 $ 2,163.20
June 19, 2002 June 21, 2002 October 8, 2002 $ 265.82
July 2, 2002 July 8, 2002 October 8, 2002 $ 245.81
July 2, 2002 July 8, 2002 October 8, 2002 $ 642.96
July 8, 2002 July 22, 2002 September 18, 2002 $ 2,619.20
July 10, 2002 July 17, 2002 October 8, 2002 $ 132.91
October 2, 2002 October 18, 2002 October 30, 2002 $ 554.18
$ 8,418.49
(See, Exhibits "D" & "E" to the Motion and Exhibit "F" to the Opposition papers).
Specifically, Allstate denied the bulk of plaintiffs' claim forms by Denial of Claim Forms ("NF-10" or "denials") dated October 8, 2002, stating that "No-Fault benefits are denied based on EUO (Examination Under Oath) of the Claimant and Failure to Establish proof of claim." With respect to a $2,619.20 claim form dated July 8, 2002, Allstate denied it on September 18, 2002 for an additional reason "based on [an unproduced] peer review by Dr. Joseph Cole."
As a result of nonpayment of first-party no-fault benefits, this action ensued by service of a summons and complaint. (See, Exhibit "A" to the Motion). Allstate interposed an answer with several affirmative defenses asserting, inter alia, a lack of coverage under the applicable insurance policy. (See, Exhibit "B" to Opposition papers, Answer at ¶ 11).
The movant has the initial burden of proving entitlement to summary judgment. Winegrad v. New York University Medical Center, 64 NY2d 851, 487 NYS2d 316 (1985). Once such proof has been offered, in order to defend the summary judgment motion, the opposing party must "show facts sufficient to require a trial of any issue of fact." CPLR § 3212(b); Alvarez v. Prospect Hospital, 68 NY2d 320, 508 NYS2d 923 (1986); Zuckerman v. City of New York, 49 NY2d 557, 427 NYS2d 595 (1980); Friends of Animals, Inc. v. Associated Fur Mfrs., 46 NY2d 1065, 416 NYS2d 790 (1979); Freedman v. Chemical Construction Corp., 43 NY2d 260, 401 NYS2d 176 (1977); Spearmon v. Times Square Stores Corp., 96 AD2d 552, 465 NYS2d 230 (2d Dept 1983). "It is incumbent upon a [litigant] who opposes a motion for summary judgment to assemble, lay bare and reveal [his, her, or its] proof, in order to show that the matters set up in [the pleadings] are real and are capable of being established upon a trial." Spearmon, 96 AD2d at 553 (quoting Di Sabato v. Soffes, 9 AD2d 297, 301, 193 NYS2d 184, 189 [1st Dept 1959]). If the opposing party fails to submit evidentiary facts to controvert the facts set forth in the movant's papers, the movant's facts may be deemed admitted and summary judgment granted since no triable issue of fact exists. Kuehne & Nagel, Inc. v. F. W. Baiden, 36 NY2d 539, 369 NYS2d 667 (1975). In addition, an affidavit or affirmation by an attorney or individual who does not have personal knowledge of the facts is insufficient in support or opposition to the motion as it lacks probative value. Wehringer v. Helmsley Spear, 91 AD2d 585 (1st Dept 1982), affd 59 NY2d 688, 463 NYS2d 417 (1983).
Approximately thirty years ago, the Legislature enacted sweeping changes to our inadequate tort system of reparations for personal injuries suffered in automobile accidents. This program under Title 18 of the Insurance Law was titled "Comprehensive Automobile Insurance Reparations Act." (L. 1973, ch. 13, effective February 1, 1974, former Insurance Law § 670, et seq). This legislation is commonly referred to as the No-Fault Law because it provides a plan for compensation of victims of motor vehicle accidents for economic losses without regard to fault or negligence. Montgomery v. Daniels, 38 NY2d 41, 378 NYS2d 1 (1975); Overly v. Bangs Ambulance, Inc., 96 NY2d 295, 727 NYS2d 378 (2001).
The noble and stated intent of the No-Fault Law was to create a new and improved insurance reparations system:
[W]hich assures that every auto accident victim will be compensated for substantially all of his economic loss, promptly and without regard to fault; [and] will eliminate the vast majority of auto accident negligence suits, thereby freeing our courts for more important tasks. (Governor's Memorandum of Approval, 1973 N.Y. Legis. Ann. 298). (Emphasis added, quotation marks omitted)
Granger v. Urda, 44 NY2d 91, 98, 404 NYS2d 319, 322 (1978). A lynch-pin of the No-Fault Law was the prompt payment of victim's claims under the so-called "30-day rule" as first-party benefits were "overdue if not paid within thirty-days after the claimant supplies proof of the fact and the amount of loss sustained." Former Insurance Law § 675(1); Montgomery v. Daniels, 38 NY2d 41, 378 NYS2d 1 (1975).
Effective September 1, 1984, the No-Fault Law was re-codified without substantial change from the "Comprehensive Automobile Insurance Reparations Act" to the "Comprehensive Motor Vehicle Insurance Reparations Act" under Article 51 of the Insurance Law. (L. 1984, ch. 367 & ch. 805).
For more than thirty years, the Superintendent of Insurance promulgated regulations implementing the No-Fault Law, which were adopted as Regulation 68 and codified at 11 NYCRR part 65. Matter of Medical Society of the State of N.Y. v. Serio, 100 NY2d 854, 768 NYS2d 423 (2003) ("Medical Society II"). In 1999, in an effort to combat abuse of the no-fault laws, the Superintendent proposed an amended Regulation 68. The amended regulation was successfully challenged in the courts. Matter of Medical Society of the State of N.Y., Inc. v. Levin, 185 Misc 2d 536 (Sup Ct, N.Y. County 2000), affd 280 AD2d 309 (1st Dept 2001) ("Medical Society I"). However, while the appeal in that case was pending, the Superintendent reinitiated the rule-making process and promulgated another revised Regulation 68, which was also challenged. In Medical Society II, the Court of Appeals upheld the Superintendent's authority to promulgate the challenged regulations as being fully consistent with Article 51 of the Insurance Law.
Among the most significant changes adopted in the revised regulations was a reduction in the time frames applicable to the filing of notices and proofs of claim. This was based on the Superintendent's determination that much of the abuse was associated with the lengthy time frames within which claims could be presented to insurers. Medical Society II, 100 NY2d at 862, 768 NYS2d at 427. The Superintendent also concluded that the shorter time frames would better effectuate the legislative purpose of providing prompt compensation "as the loss is incurred" pursuant to Insurance Law § 5106(a). Id.
The revised regulations reduced the time limit for filing a notice of claim from ninety (90) to thirty (30) days. 11 NYCRR §§ 65-1.1; 65-2.4(b). The revised regulations also reduced the time in which to submit proof of loss due to medical treatment from one hundred eighty (180) to forty-five (45) days, and proof of work loss from "as soon as reasonably practicable" to ninety (90) days. 11 NYCRR §§ 65-1.1; 65-2.4(c). In addition, the revised regulations also increased the time limit for the insurer to seek...
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