Maimonides Medical Center v. First United American Life Insurance

116 A.D.3d 207, 981 N.Y.S.2d 739

This text of 116 A.D.3d 207 (Maimonides Medical Center v. First United American Life Insurance) is published on Counsel Stack Legal Research, covering Appellate Division of the Supreme Court of the State of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Maimonides Medical Center v. First United American Life Insurance, 116 A.D.3d 207, 981 N.Y.S.2d 739 (N.Y. Ct. App. 2014).

Opinion

OPINION OF THE COURT

Austin, J.

Insurance Law § 3224-a, known as the Prompt Pay Law, imposes standards upon insurers for the “prompt, fair and equitable” payment of claims for health care services. The statute sets forth time frames within which an insurer must either pay a claim, notify the claimant of the reason for denying a claim, or request additional information. An insurer that fails to comply with the provisions of the Prompt Pay Law is obligated to pay the full amount of the claim, with interest. In this case of first impression for this Court, we are asked to determine whether the Prompt Pay Law affords claimants a private right of action to recover payment for health care services based on a violation of the statute, or whether enforcement of the statute is vested solely with the New York State Insurance Department. For the reasons that follow, we hold that the Prompt Pay Law affords an implied private right of action, and that the plaintiff [209]*209health care provider may thus assert claims against the defendant insurer for its alleged violation of the statute.

The plaintiff, Maimonides Medical Center (hereinafter Maimonides), a not-for-profit hospital in Brooklyn, furnished services to six patients who had supplemental Medicare insurance coverage policies, known as “Medigap” policies, with the defendant, First United American Life Insurance Company (hereinafter First United), from 2007 through 2011. The six patients assigned their benefits under their respective First United policies to Maimonides. Maimonides billed First United more than $19 million for services rendered to these six patients. In response, First United paid Maimonides slightly more than $4 million.

Maimonides commenced this action against First United to recover the balance owed for its care of the six patients on theories of breach of contract, violation of the Prompt Pay Law, and unjust enrichment. The complaint detailed the service dates and the amount of the bills issued by Maimonides to First United for each of the patients, and alleged that, despite repeated demands for payment in full, First United failed to pay the balance owed. Maimonides also alleged that First United never provided written notice, as required by the Prompt Pay Law, that it was not obligated to pay in full the amounts billed by Maimonides for services furnished to the six patients.

The Prompt Pay Law requires an insurer to pay undisputed claims within 30 days after receipt of an electronic submission or within 45 days after receipt by other means (see Insurance Law § 3224-a [a]). If a claim is disputed, the insurer is obligated to pay the undisputed portion of the claim, if there is any, and, within 30 days of receipt of the claim, notify the policyholder, covered person, or health care provider in writing of the specific reason that the insurer is not liable to pay the claim (see Insurance Law § 3224-a [b] [1]). In the alternative, the insurer may request additional information necessary to determine its potential liability with respect to payment of the claim (see Insurance Law § 3224-a [b] [2]). First United allegedly did neither. An insurer that fails to comply with the provisions of the Prompt Pay Law is obligated to pay the health care provider or the person submitting the claim the full amount of the claim, plus 12% interest per annum, to be computed from the date the claim was required to be paid (see Insurance Law § 3224-a [c] [1]). In its second, fourth, sixth, eighth, tenth, and twelfth causes of action, which alleged violation of the Prompt Pay Law, [210]*210Maimonides sought the outstanding balance due under the claims submitted on behalf of the six subject patients, plus 12% interest per annum.

Prior to answering the complaint, First United moved, inter alla, pursuant to CPLR 3211 (a) (7) to dismiss the six causes of action which alleged violation of the Prompt Pay Law. In support of its motion, First United argued that these claims failed to state a cause of action because, under the Prompt Pay Law, there is no private right of action — express or implied. It contended that the enforcement of the Prompt Pay Law is vested solely in the New York State Superintendent of Insurance (hereinafter the Superintendent), who is obligated to determine violations arising from either his or her own investigation or complaints from health care providers or policyholders. First United maintained that recognition of an implied private right of action based on the Prompt Pay Law would be inconsistent with the legislative scheme, as well as most insurance statutes, which are part of a regulatory framework that provides for administrative remedies for statutory violations. First United contended that the Prompt Pay Law only provided for the Superintendent to impose penalties for violations, including an award of 12% interest per annum.

In opposition, Maimonides contended that it had an implied right of action under the Prompt Pay Law. It maintained that this was so since (a) the Prompt Pay Law was enacted to protect health care providers such as itself, (b) the recognition of a private right of action furthered the legislative purpose of the Prompt Pay Law by assuring that claims were promptly paid by insurers, and (c) a private right of action was consistent with the legislative scheme.

In reply, First United argued that public and private avenues of enforcement are not in harmony since the enactment of the Prompt Pay Law was part of a comprehensive legislative scheme to regulate the insurance industry. It contended that the power to enforce the relevant statutes and regulations resided solely with the New York State Department of Insurance (hereinafter the Insurance Department), which is now part of the New York State Department of Financial Services (hereinafter the Financial Services Department).

The Supreme Court denied those branches of First United’s motion which were to dismiss the six causes of action which alleged violation of the Prompt Pay Law, concluding that a close reading of the statute revealed “an express legislative intent to [211]*211confer a private right of action upon the intended beneficiary patients and their providers to seek payment directly from an insurer” (Maimonides Med. Ctr. v First United Am. Life Ins. Co., 35 Misc 3d 570, 576 [2012]). First United appeals from so much of the order as denied those branches of its motion which were to dismiss the Prompt Pay Law causes of action. Although we disagree with the Supreme Court’s conclusion that the Prompt Pay Law expressly provides a private right of action, we find that such a right is implied under the statute. We thus affirm the order of the Supreme Court insofar as appealed from.

The analysis of whether the six claims predicated upon the alleged violation of the Prompt Pay Law state viable causes of action depends upon whether the Prompt Pay Law provides Maimonides with a private right of action.

Where a statute does not expressly confer a private cause of action upon those it is intended to benefit, a private party may seek relief under the statute “only if a legislative intent to create such a right of action is ‘fairly implied’ in the statutory provisions and their legislative history” (Brian Hoxie’s Painting Co. v Cato-Meridian Cent. School Dist., 76 NY2d 207, 211 [1990], citing Sheehy v Big Flats Community Day, 73 NY2d 629, 633 [1989]; see Carrier v Salvation Army, 88 NY2d 298, 302 [1996]; Burns Jackson Miller Summit & Spitzer v Lindner, 59 NY2d 314, 325 [1983]).

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Tzolis v. Wolff
884 N.E.2d 1005 (New York Court of Appeals, 2008)
Carrier v. Salvation Army
667 N.E.2d 328 (New York Court of Appeals, 1996)
Uhr v. East Greenbush Central School District
720 N.E.2d 886 (New York Court of Appeals, 1999)
Rocanova v. Equitable Life Assurance Society of United States
634 N.E.2d 940 (New York Court of Appeals, 1994)
Brian Hoxie's Painting Co. v. Cato-Meridian Central School District
556 N.E.2d 1087 (New York Court of Appeals, 1990)
Amorosi v. South Colonie Independent Central School District
880 N.E.2d 6 (New York Court of Appeals, 2007)
Cruz v. TD Bank, N.A.
2 N.E.3d 221 (New York Court of Appeals, 2013)
Burns Jackson Miller Summit & Spitzer v. Lindner
451 N.E.2d 459 (New York Court of Appeals, 1983)
Sheehy v. Big Flats Community Day, Inc.
541 N.E.2d 18 (New York Court of Appeals, 1989)
Goldberg v. Enterprise Rent-A-Car Co.
14 A.D.3d 417 (Appellate Division of the Supreme Court of New York, 2005)
AHA Sales, Inc. v. Creative Bath Products, Inc.
58 A.D.3d 6 (Appellate Division of the Supreme Court of New York, 2008)
Goldman v. Simon Property Group, Inc.
58 A.D.3d 208 (Appellate Division of the Supreme Court of New York, 2008)
Rhodes v. Herz
84 A.D.3d 1 (Appellate Division of the Supreme Court of New York, 2011)
Doe v. Roe
190 A.D.2d 463 (Appellate Division of the Supreme Court of New York, 1993)
Henry v. Isaac
214 A.D.2d 188 (Appellate Division of the Supreme Court of New York, 1995)
Klinger v. Allstate Insurance
268 A.D.2d 562 (Appellate Division of the Supreme Court of New York, 2000)
Carrube v. New York City Transit Authority
291 A.D.2d 558 (Appellate Division of the Supreme Court of New York, 2002)
Maimonides Medical Center v. First United American Life Insurance
35 Misc. 3d 570 (New York Supreme Court, 2012)

Cite This Page — Counsel Stack

Bluebook (online)
116 A.D.3d 207, 981 N.Y.S.2d 739, Counsel Stack Legal Research, https://law.counselstack.com/opinion/maimonides-medical-center-v-first-united-american-life-insurance-nyappdiv-2014.