Hernandez v Merchants Mut. Ins. Co., 2022 NY Slip Op 04156 (2d Dept. 2022)
I went through the papers and I have zero understanding why this went as far as it did.
(1) “The defendant answered the complaint and the plaintiff later moved for summary judgment in the principal sum of $44,573.86, representing unpaid first-party no-fault benefits under the insurance policy. The defendant opposed the motion. The Supreme Court granted the plaintiff’s motion and issued a judgment in favor of the plaintiff in the principal sum of $44,573.86. The defendant appeals.”
(2) “A plaintiff makes a prima facie showing of entitlement to judgment as a matter of law by submitting evidence that the prescribed statutory billing forms were mailed and received, and that payment of no-fault benefits was overdue (see Insurance Law § 5106[a]; 11 NYCRR 65-3.8[c]; Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498, 501; A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779, 780; New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547, 547).”
(3) “In support of his motion, the plaintiff submitted, inter alia, the disputed claims, the defendant’s form denials, the affidavit of his surgeon, Richard Peress, and the affidavit of Christine Taylor, assistant director of patient accounts for Phelps Memorial Hospital (hereinafter the hospital).”
(4) “The plaintiff demonstrated, prima facie, that the prescribed statutory billing forms relative to the medical services provided by Peress were mailed and received, and that the defendant failed to pay or validly deny the claims within the permissible 30 days (see Insurance Law § 5102[a][1]; Global Liberty Ins. Co. v W. Joseph Gorum, M.D., P.C., 143 AD3d 768; New York & Presbyt. Hosp. v Selective Ins. Co. of Am., 43 AD3d 1019; Hobby v CNA Ins. Co., 267 AD2d 1084; see also DeGiorgio v Racanelli, 136 AD3d 734; Geffner v North Shore Univ. Hosp., 57 AD3d 839). In opposition, the defendant failed to submit evidence in admissible form sufficient to raise a triable issue of fact as to whether the claimed benefits were properly denied on the ground of lack of medical justification (see 11 NYCRR 65-3.8[b][4]).”
(5) “Contrary to the defendant’s contention, the plaintiff had standing to pursue his claims for no-fault benefits (see Allstate Ins. Co. v Kapeleris, 183 AD3d 626).”
I can take a lot from this case. (1) Standard prima facie appears to be back on motion and at trial; (2) The Geffner rule now applies to PIP – funny I argued this at the App Term and I was turned down; (3) Having assumed personal liability for the hospital bill, Plaintiff has standing to bring this action.
I would say this case on medical necessity cases has the potential to make being an insurance carrier in surgery cases that much more difficult.
