New York & Presbyterian Hosp. v. Country-Wide Ins. Co.
| Decision Date | 13 October 2011 |
| Citation | 2011 N.Y. Slip Op. 07149,958 N.E.2d 88,934 N.Y.S.2d 54,17 N.Y.3d 586 |
| Parties | NEW YORK AND PRESBYTERIAN HOSPITAL, as Assignee of Joaquin Benitez, Respondent, v. COUNTRY–WIDE INSURANCE COMPANY, Appellant. |
| Court | New York Court of Appeals Court of Appeals |
OPINION TEXT STARTS HERE
Thomas Torto, New York City, and Jaffe & Koumourdas, LLP, for appellant.
Joseph Henig, P.C., Bellmore (Joseph Henig and Gregory Henig of counsel), for respondent.
The question before the Court is whether a health care services provider, as assignee of a person injured in a motor vehicle accident, can recover no-fault benefits by timely submitting the required proof of claim after the 30–day period for providing written notice of the accident has expired. We hold it cannot.
On July 19, 2008, Joaquin Benitez was injured in a traffic accident which took place in Manhattan, and treated at New York and Presbyterian Hospital (Presbyterian) from that date through July 26, 2008. On the date of Benitez's discharge, he and Presbyterian executed an assignment of no-fault benefits form under which he assigned to Presbyterian “all rights[,] privileges and remedies to payment for health care services provided by [Presbyterian] to which [Benitez is] entitled under Article 51 (the No–Fault statute) of the Insurance Law.” Benitez and Presbyterian also executed a completed N.Y.S. Form NF–5 (i.e., a hospital facility form). Neither Benitez nor Presbyterian provided the required written notice of accident to his no-fault insurer, Country–Wide Insurance Company (Country–Wide), within 30 days of the accident as required by the New York insurance regulations (11 NYCRR 65–1.1).
On August 25, 2008, Presbyterian, as assignee of Benitez, billed Country–Wide (i.e., sought no-fault benefits) for the sum of $48,697.63. In billing Country–Wide, Presbyterian submitted a number of documents, including the required proof of claim (the NF–5 form). Country–Wide received the bill and other documents on August 28, 2008, 40 days after the accident. Country–Wide denied Presbyterian's claim on the ground it had not received timely notice of the accident under 11 NYCRR 65–1.1(d), which requires an “eligible insured person” to give written notice to the insurer “in no event more than 30 days after the date of the accident.”
Presbyterian brought this action against Country–Wide to compel payment of no-fault benefits in the amount of its bill, plus statutory interest and attorney's fees, alleging it had provided timely notice and proof of claim under 11 NYCRR 65–1.1, which requires an insured person's assignee to submit written proof of claim no later than 45 days after the date health care services are rendered. Presbyterian and Country–Wide each moved for summary judgment.
Supreme Court granted Presbyterian summary judgment, ruling that the hospital satisfied its notice obligation by timely submitting the proof of claim ( Wyckoff Hgts. Med. Ctr. v. Country Wide Ins. Co., 2009 N.Y. Slip Op. 33263 [U], 2009 WL 8486286 [2009] ). Citing 11 NYCRR 65–3.3(d), the Appellate Division affirmed (71 A.D.3d 1009, 896 N.Y.S.2d 691 [2d Dept.2010] ), stating, “[c]ontrary to the insurer's contention, the hospital's submission of a completed hospital facility form ... within 45 days after services were rendered satisfied the written notice requirement set forth in 11 NYCRR 65–1.1” ( id. at 1010, 896 N.Y.S.2d 691). This Court granted Country–Wide leave to appeal and we now reverse.
Country–Wide argues that the Appellate Division decision eviscerates the 30–day written notice of accident requirement and that the aforementioned regulations do not contain any language which provides that submission of a proof of claim for health care services within 45 days excuses the failure to give the threshold notice of accident within 30 days of the accident. In response, Presbyterian construes the stated no-fault regulations as exempting health care providers from the 30–day notice of accident requirement. In Presbyterian's view, its filing of the hospital facility form within 45 days of the date services were rendered constitutes both “proof of claim” and timely “notice of accident.” For the reasons that follow, we agree with Country–Wide's position.
The primary goals of New York's no-fault automobile insurance system are “to ensure prompt compensation for losses incurred by accident victims without regard to fault or negligence, to reduce the burden on the courts and to provide substantial premium savings to New York motorists ( matter of medicaL socy. of state oF ny. v. Serio, 100 N.y.2d 854, 860, 768 N.Y.S.2d 423, 800 N.E.2d 728 [2003] ). In furtherance of these objectives, “the Superintendent of Insurance has adopted regulations implementing the No–Fault Law (Insurance Law art 51), including circumscribed time frames for claim procedures ” ( Hospital for Joint Diseases v. Travelers Prop. Cas. Ins. Co., 9 N.Y.3d 312, 317, 849 N.Y.S.2d 473, 879 N.E.2d 1291 [2007] [emphasis added] ).
11 NYCRR 65–1.1(d), the mandatory personal injury protection endorsement for motor vehicle liability insurance policies, provides:
“ Conditions
“ Action Against [Insurance] Company. No action shall lie against the Company unless, as a condition precedent thereto, there shall have been full compliance with the terms of this coverage.
“ Notice. In the event of an accident, written notice setting forth details sufficient to identify the eligible injured person, along with reasonably obtainable information regarding the time, place and circumstances of the accident, shall be given by, or on behalf of, each eligible injured person, to the Company, or any of the Company's authorized agents, as soon as reasonably practicable, but in no event more than 30 days after the date of the accident ...
“ Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the case of a claim for health service expenses, the eligible injured person or that person's assignee or representative [e.g., a health care services provider] shall submit written proof of claim to the Company, including full particulars of the nature and extent of the injuries and treatment received and contemplated, as soon as reasonably practicable but, in no event later than 45 days after the date services are rendered ” (emphasis added).
In addition, 11 NYCRR 65–3.3(d) states:
“ The written notice required by ... the mandatory and additional personal injury protection endorsement(s) shall be deemed to be satisfied by the insurer's receipt of a completed prescribed application for motor vehicle no-fault benefits (N.Y.S. Form N–F 2) forwarded to the applicant pursuant to subdivision 65–3.4(b) of this subpart or by the insurer's receipt of a completed hospital facility form (N.Y.S. Form N–F 5) ” (emphasis added).
The “notice of accident” and “proof of claim” under 11 NYCRR 65–1.1 are independent conditions precedent to a no-fault insurer's liability ( see Hospital for Joint Diseases, 9 N.Y.3d at 317, 849 N.Y.S.2d 473, 879 N.E.2d 1291 [ ). By ruling that the notice of accident condition was satisfied based on the plain language of 11 NYCRR 65–3.3(d), the Appellate Division disregarded the separate and distinct nature and purpose of these requirements. Even more troubling, such a construction effectively reads the 30–day written notice of accident requirement out of the no-fault regulations. But nothing in 11 NYCRR 65–3.3(d) explicitly dispenses with the 30–day notice of accident requirement. Rather, 11 NYCRR 65–3.3(d) merely provides that a NF–5 form may constitute the written notice required under the notice of accident provision.
In other words, these regulations (read alone or in tandem) cannot be interpreted to mean that a hospital/assignee's timely submission of a proof of claim for health services within 45 days of discharge of the injured person excuses the insured/assignor's failure to give the threshold notice of accident within 30 days of the accident, or that health care service providers are exempt from the written...
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