Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co., 2012 NY Slip Op 52406(U)(App. Term 2d Dept. 2012)
I am lost on this one. I feel like I am writing a matrimonial appeal again and am in utter confusion with what the court is saying. This is how it begins:
“defendant appeals from an order of the Civil Court entered October 25, 2010 which denied defendant’s motion for summary judgment dismissing the complaint and granted plaintiff’s cross motion for summary judgment, finding that defendant’s denials were nullities because they had not been issued in duplicate”
And this how it ends:
“Defendant also submitted an affidavit by the chiropractor/acupuncturist who was to perform the IMEs which established that plaintiff’s assignor hd failed to appear for the scheduled IMEs. An affidavit executed by defendant’s litigation examiner demonstrated that denial of claim forms, which denied the claims based upon the failure of plaintiff’s assignor to appear for the IMEs, had been timely mailed to plaintiff, plaintiff’s assignor, and plaintiff’s assignor’s attorney (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16).
Insurance Department Regulations (11 NYCRR) § 65-3.8 (c) (1) requires that, upon deciding to deny a claim, “the insurer shall notify the applicant or the authorized representative on the prescribed denial of claim form, in duplicate.” Plaintiff has offered no argument as to why defendant’s mailing of each denial of claim form to plaintiff, plaintiff’s assignor and plaintiff’s assignor’s attorney, respectively, does not satisfy this requirement. Accordingly, defendant established its prima facie entitlement to judgment as a matter of law”
How does a duplicate mailing requirement get satisfied through mailing the denial to the provider, assignor and counsel for assignor? And what is weird is that this Court has previously said – in the verification context- that the letters only need to be sent to the provider if it is from him/her who information is sought. A bit confused here.
2 Responses
the plaintiff argued that the denials were void because they were not sent to the plaintiff in “duplicate”. In New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co. (32 AD3d 458, 460 [2006]), the Appellate Division, Second Department, held, in relevant part:
“Here, the defendants’ September 28, 2004, letter adequately conveyed the information mandated by the prescribed form including, but not limited to, the precise ground on which the partial denial was predicated. However, the defendants failed to establish that the letter had been issued in duplicate and approved by the Department of Insurance (see 11 NYCRR 65-3.8 [c] [1], supra). Accordingly, having failed to pay or properly deny that portion of the hospital’s claim within the statutory time frame, the defendants were precluded from interposing a defense (Presbyterian Hosp. in City of NY v Maryland Cas. Co., 90 NY2d 274, 286 [1997]; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., supra), and the Supreme Court should have granted the plaintiff’s motion for summary judgment on the second cause of action” (emphasis added).
In this case the App Term said mailing ONE to the plaintiff and ONE to the plaintiff’s attorney satisfies New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co.
The case with the Ver Requ you are referring to is different. There the plaintiff argued that ALL copies of Ver Requ sent to any provider must also be sent to that provider’s atty. The court said NO, the REG that the plaintiff was relying actually means to say that any time a Ver Requ is sent to one Person or Provider while delaying the claim of another, the claimant’s atty must be notified.
Makes sense?
That a definition is broad enough to encompass one sense of a word does not establish that word is ordinarily understood in that sense
JUSTICE SANDRA DAY O’CONNOR