Opinion
2005-72 K C.
Decided February 6, 2006.
Appeal from an order of the Civil Court of the City of New York, Kings County (Ellen Gesmer, J.), entered October 8, 2004. The order granted plaintiff's motion for summary judgment.
Order affirmed without costs.
PRESENT: PESCE, P.J., WESTON PATTERSON and BELEN, JJ
In this action to recover first-party no-fault benefits for medical services rendered its assignor, plaintiff health care provider moved for summary judgment. In opposition, defendant relied on two claim denials, dated September 23, 2002 and January 28, 2003, and a chiropractor's report of an independent medical examination (IME) which concluded that no further treatment was necessary, and alleged that requested verification had not been produced. In reply, plaintiff argued, inter alia, that as the first denial lacked most of the information an insurer is obligated to enter thereon, it amounted to no denial at all, that the purported blanket denial of coverage therein was ineffective as to claims not yet filed, that the second denial was untimely, and that the verification request, sought prior to the claims' receipt, was ineffective to toll the statutory 30-day claim determination period. The court granted the motion, and we affirm.
First, as defendant raised no issue regarding the sufficiency of plaintiff's moving papers ( see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v. Allstate Ins. Co., 5 AD3d 742; Amaze Med. Supply v. Eagle Ins. Co., 2 Misc 3d 128 [A], 2003 NY Slip Op 51701[U] [App Term, 2d 11th Jud Dists]), we need not pass on the propriety of the court's determination that plaintiff established its prima facie case. We agree that the September 23, 2002 claim denial was facially insufficient ( e.g. Nyack Hosp. v. Metropolitan Prop. Cas. Ins. Co., 16 AD3d 564, 565 [defendant's denial of claim form "even if timely, was fatally defective in that it omitted numerous items of requested information, and thus was incomplete"]; Nyack Hosp. v. State Farm Mut. Auto. Ins. Co., 11 AD3d 664, 665 [claim denial form "fatally defective in that it failed to include a number of basic items called for in the prescribed form"]; see also Summit Psychological, P.C. v. General Assur. Co., 9 Misc 3d 8, 11 [App Term, 9th 10th Jud Dists 2005]; Shtarkman v. Allstate Ins. Co., 8 Misc 3d 129 [A], 2005 NY Slip Op 51028[U] [App Term, 2d 11th Jud Dists]). Further, the denial, which asserted as the sole ground therefor the chiropractor's independent medical examination (IME), failed to allege any facts upon which the examiner based her conclusions, and while the denial states that the IME report is attached, neither plaintiff's nor defendant's copy as submitted below contains such an attachment. Thus, said denial "fail[ed] to set forth with sufficient particularity the factual basis and medical rationale for [the] denial based on the lack of medical necessity" ( A.B. Med. Servs. PLLC v. Liberty Mut. Ins. Co., 10 Misc 3d 128 [A], 2005 NY Slip Op 51902[U] [App Term, 2d 11th Jud Dists]).
Defendant's second claim denial, dated January 28, 2003, recites that on December 10, 2002, defendant received from plaintiff claims totaling the principal sum herein sought. The denial was therefore untimely, precluding its defenses, including lack of medical necessity (Insurance Law § 5106 [a]; Presbyterian Hosp. in City of N.Y. v. Maryland Cas. Co., 90 NY2d 274, 282). As to the various demands for verification which preceded the claim's receipt, they failed to toll the claim determination period ( Stephen Fogel Psychological, P.C. v. Progressive Cas. Ins. Co., 7 Misc 3d 18, 21 [App Term, 2d 11th Jud Dists 2004] ["(T)he detailed and narrowly construed verification protocols are not amenable to application at a stage prior to submission of the claim form"]). In light of the foregoing, we do not reach defendant's remaining contentions.
Pesce, P.J., Weston Patterson and Belen, JJ., concur.