Zwanger & Pesiri Radiology Group, LLP v Mapfre Ins. Co.
Annotate this CaseDecided on June 14, 2017
District Court of Suffolk County, Third District
Zwanger & Pesiri Radiology Group, LLP, a/a/o Jorge Rodriguez, Plaintiff,
against
Mapfre Insurance Company, Defendant.
HUCV 1227-16
James F. Matthews, J.
Upon the following papers numbered 1 to 15 read on this motion by defendant for an order granting summary judgment of dismissal ; by Notice of Motion /Order to Show Cause and supporting papers 1,2,9 ; Notice of Cross Motion and supporting papers ; Answering Affidavits and supporting papers 10,12 ; Replying Affidavits and supporting papers 13,15; Filed papers; Other exhibits: 3-8,11,14 ; (and after hearing counsel in support of and opposed to the motion), it is,
ORDERED that the motion by defendant for summary judgment dismissing plaintiff's complaint pursuant to CPLR 3212, is denied.
Defendant moves by summary judgment for dismissal of plaintiff's complaint which seeks to recover first-party no-fault benefits for medical services rendered to plaintiff's assignor on 02/24/15 in the total amount of $878.67 as the result of an automobile accident of 12/05/14.
The grounds for dismissal are the failure of plaintiff to fully comply with defendant's 3rd request for additional verification dated 05/07/15, by providing "a copy of the decision-making report from the referring doctor demonstrating the medical necessity and/or need for the MRI(s)." In addition, defendant asserts plaintiff failed to provide "documentation identifying the relationship between each individual involved in the rendering of services and the professional corporation, including the manner in which the person is compensated [ie: W-2, 1099)." Also, plaintiff failed to provide verification of documents "that establishes the licensure, certification or credentials for each individual involved in the rendering of the services for which payment is sought"; the name and model number of the MRI machine used on the above date[s] of service"; [*2]and "the completed NF-3 Form with original signature[non-stamped]").[FN1] Defendant contends that the above stated verification requests remain outstanding to date, though defendant acknowledges receipt on 04/20/15 of a "partial response" containing certain items previously requested.
In support of the motion, defendant asserts the first verification request was sent on 03/18/15 within 15 business days of receipt of plaintiff's claim on 03/04/15. Upon non-compliance, a second verification request was sent on 04/20/15. After 120 days elapsed without receipt of the requested verification, defendant denied the claim by mailing a NF-10 Denial of Claim form dated 09/17/15 with an Explanation of Review ("EOR") stating inter alia "that your claim has been denied as you have failed to submit the requested verification of additional relevant information under your control of possession, or written proof providing reasonable justification for the failure to comply, within 120 calendar days of the initial request."
In opposition to the motion, plaintiff asserts defendant failed to demonstrate by admissible evidence, that the verification requests were timely and properly mailed to plaintiff. Plaintiff contends the affidavits submitted in support of defendant's motion, have not provided a foundation for admission of its business records, a necessary part of demonstrating defendant's office practice and procedures. Plaintiff further asserts defendant has not shown "good reasons" for demanding the verifications which would toll the time from which defendant had to pay or deny the claims.
No-fault regulations mandate that a written proof of claim for health service expenses are overdue if not paid or denied by the insurer within 30 calendar days (see Insurance Law §5106[a]; 11 NYCRR §65-3.8[a][1]). An insurer may toll the 30 day period by requesting additional verification of the claim within 15 business days from its receipt of the claim (see 11 NYCRR 65-3.5[b]). If the insurer has not received verification from the plaintiff within 30 days of the initial request, the insurer may send a follow-up verification request by phone or mail within 10 calendar days (see 11 NYCRR 65-3.6[b]). An insurer may not issue a denial of claim form (NF-10) prior to its receipt of verification of all relevant information requested by the insurer (see Insurance Law §5106[a]; 11 NYCRR §65-3.5[c]). However, an insurer may deny the claim after 120 calendar days if plaintiff does not provide all of the requested verification under its control or possession, or written proof providing reasonable justification for its failure to comply (see 11 NYCRR §65-3.5[o], for all claims submitted after 4/1/13). Also, an insurer's "non-substantive, technical or immaterial defect or omission, as well as an insurer's failure to comply with a prescribed time frame" shall not "negate an applicant's obligation to comply with the request or notice" (see 11 NYCRR §65-3.5[p], for all claims submitted after 4/1/13).
Here, the Court determines that defendant has failed to make a prima facie showing of entitlement to judgment as a matter of law with proof in admissible form sufficient to establish the lack of any material issues of fact (see Alvarez v Prospect Hospital, 68 NY2d 320, 324 [1986]; Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]; Zuckerman v City of New York, 49 NY2d 557, 562 [1980]); see also Manhattan Medical v State Farm Mut. Ins. Co., 20 Misc 3d 1144[A][Civ. Ct. Richmond Cty. 2008]).
Defendant's sole Affidavit of its No-Fault Litigation Supervisor, is insufficient to establish the timeliness and propriety of the mailing of its verification request, follow-up [*3]verification requests, and the NF-10 denial of claim. The affidavit's statements are conclusory and based upon hearsay, and fail to sufficiently demonstrate defendant's standard office practice and procedures used to ensure the proper mailing of its verification requests and denials (see St. Vincent's Hosp. of Richmond v Government Employees Ins. Co., 50 AD3d 1123 [2nd Dept 2008]; Ortho-Med Surgical Supply, Inc. v MVAIC, 28 Misc 3d 139[A][App Term 2nd, 11th & 13th Jud Dists 2010]; Delta Diagnostic Radiology, P.C. v Chubb Group of Insurance, 17 Misc 3d 16, 18 [App Term 2nd & 11th Jud Dists 2007]). The Court notes the lack of an affidavit from a claims representative and/or a mailroom employee, who would be familiar with defendant's office practice and procedures for mailing verification requests and denials, especially as it applied in the instant matter.
As a result, defendant has failed to create a presumption of timely and proper mailing (see S & M Supply Inc. v GEICO, 2003 NY Slip Op. 51192[U][App Term, 2nd & 11th Jud. Dists. 2003]; Harbor Medical & Diagnostics P.C. v Allstate Ins. Co., 11 Misc 3d 1063[A][Civ Ct, New York City 2006]).
Moreover, defendant claims "a copy of the decision-making report from the referring doctor demonstrating the medical necessity and/or need for the MRI(s)" has not been provided to date. However, defendant's own evidence demonstrates that plaintiff provided a Physician's Letter of Medical Necessity dated 02/16/15 to defendant with its letter dated 04/15/15 (see defendant's Exhibit "C" and plaintiff's Exhibit "1"). As a result, defendant has failed to demonstrate a prima facie case.
In addition, defendant has failed to demonstrate that it informed "the applicant AND its attorney of the reason why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested." Defendant's prima facie proof fails to show defendant informed the applicant and his attorney, in compliance with 11 NYCRR §65-3.6(b).
Accordingly, the motion by defendant for summary judgment dismissing plaintiff's action against it pursuant to CPLR 3212, is denied.
It is not necessary for the Court to reach any remaining contentions.
The foregoing constitutes the decision and order of this Court.
Dated: June 14, 2017
Hon. James F. Matthews
J.D.C. Footnotes
Footnote 1: The language for the additional verification requests is taken from defendant's Explanation of Benefits, attached as exhibit B).
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