New York & Presbyterian Hospital v. Allstate Insurance

194 Misc. 2d 384, 749 N.Y.S.2d 700, 2002 N.Y. Misc. LEXIS 1330
CourtNew York Supreme Court
DecidedOctober 18, 2002
StatusPublished

This text of 194 Misc. 2d 384 (New York & Presbyterian Hospital v. Allstate Insurance) is published on Counsel Stack Legal Research, covering New York Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
New York & Presbyterian Hospital v. Allstate Insurance, 194 Misc. 2d 384, 749 N.Y.S.2d 700, 2002 N.Y. Misc. LEXIS 1330 (N.Y. Super. Ct. 2002).

Opinion

OPINION OF THE COURT

Ira J. Raab, J.

[385]*385The Facts

On October 19, 1998, defendant insurance company issued an automobile insurance policy containing a New York no-fault endorsement to Norberto Feliciano, who was treated at plaintiff hospital from October 19, 1998 through October 23, 1998, for burn injuries sustained in the accident.

This action was commenced in Nassau County Supreme Court and was then removed to the Nassau County District Court under CPLR 325 (d), and assigned to this Justice, who was then a Nassau County District Court Judge.

After a framed issue hearing before this Judge in the District Court on a motion and cross motion for summary judgment, it was determined that the insured executed an assignment of benefits to plaintiff; that on June 25, 1999, plaintiff mailed to defendant, by certified mail, return receipt requested, an $8,419.37 claim for medical services; that on June 30, 1999, the claim was received by defendant’s agent; that the defendant failed to deny or pay the claim within 30 days after receipt of the claim; and that the defendant failed to request verification of information within 10 days of receipt of the claim.

Stipulation as to the Facts

On January 2, 2001, the case was transferred back to the Supreme Court after this Judge was elevated to the Supreme Court. At the trial in the Supreme Court, the parties stipulated to the following relevant facts: Norberto Feliciano was working under the hood of his unoccupied parked van when the carburetor exploded. The burn injuries that Mr. Feliciano received were a direct result of the exploding carburetor. He was treated at plaintiff hospital for these bums. The hospital’s billing company, Hospital Receivables Corporation, prepared the hospital facility form (N-F5), which is a no-fault form that a hospital may submit to verify hospital treatment, as well as satisfying the requirement of submitting an application for no-fault benefits.

[386]*386Claims of the Parties

Defendant raises a defense that the personal injury caused by the exploding carburetor while the plaintiffs assignor was working under the hood of the parked and unoccupied van did not arise out of “the use and operation of’ the motor vehicle. (Sando v Firemen’s Ins. Co. of Newark, N.J., 79 AD2d 774 [3d Dept 1980]; Insurance Law § 5102 [b], |j].) Thus, claims the defendant, the event was not covered by the statute or the insurance policy.

Plaintiff claims that even though the event may not have been covered by the statute and the insurance policy, nevertheless, the defendant is precluded from raising such a defense because the defendant did not deny or pay the claim within 30 days after the receipt of the claim.

Stipulation as the Issue of Law

The parties stipulated that the court will determine if the defendant’s failure to pay or deny the claim within 30 calendar days after receipt of the claim precludes the defendant from raising a defense of noncoverage of the event. The parties further stipulated that if there is preclusion, judgment will be entered in favor of the plaintiff for the amount of the claim, and if there is no preclusion, judgment will be entered in favor of the defendant.

The Statute

Insurance Law § 5106 (a) requires that a no-fault insurer either pay or deny a no-fault first-party benefits claim submitted to it within 30 calendar days of the receipt of such claim. Payment of first-party benefits and additional first-party benefits shall be made as the loss is incurred. Such benefits are overdue if not paid within 30 calendar days after the claimant supplied proof of the fact and amount of loss sustained. If proof is not supplied as to the entire claim, the amount which is supported by proof is overdue if not paid within 30 calendar days after such proof is supplied. Alternatively, 11 NYCRR 65.15 (d) (1) permits the insurer to request verification of information within 10 business days of receipt of the claim. Failing to exercise either option precludes an insurer from raising defenses to the claim, except the defense of noncoverage. Defendant insurance company asserts such a noncoverage defense.

Discussion

In St. Clare’s Hosp. v Allcity Ins. Co. (201 AD2d 718 [2d Dept 1994]), the Court said that it is incumbent upon the [387]*387insurer to pay or deny the claim and set forth its defenses within 30 days of receipt of the claim as required by Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3).

In Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co. (90 NY2d 274 [1997]), the Court of Appeals, in a case involving a policy “exclusion,” upheld a lower court ruling stating that an insurer may be precluded from interposing an intoxication exclusion defense for failure to deny a no-fault benefits claim within 30 days of receipt as required by Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3). The Court held that an insurer is precluded from raising such an affirmative defense to a no-fault first-party benefits assignee’s claim where the insurer neither paid nor denied the claim within 30 days of receipt of the claim, nor sought to effectively extend the 30-day requirement by requesting verification in prescribed fashion.

In New York Presbyt. Hosp. v Empire Ins. Co. (295 AD2d 325 [2d Dept 2002]), coverage was denied because the injury arose out of an event that was not covered by the policy. In that case, the motor vehicle policy stated that “Coverage was not afforded to any person operating a motor vehicle while in an intoxicated condition or while his/her ability to operate such vehicle is impaired by the use of a drug.” The Court ruled that because the defendants failed to reject the claim of the plaintiff for payment of no-fault benefits within 30 days as prescribed by Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3), the defendants are precluded from disclaiming coverage. It further ruled that 11 NYCRR 65.15 (g) (5) does not extend the 30-day limit.

In Katz v Allstate Ins. Co. (96 AD2d 930 [2d Dept 1983]), the Court held that an insurer is not required under Insurance Law § 167 (8) to give notice of disclaimer, where at the time of accident the insured’s automobile had been stolen and was being operated by a thief without knowledge or consent of the insured, and plaintiff was aware from the inception that the vehicle had been stolen and was being operated by a thief. The Court stated (at 931):

“The policy clearly never contemplated any coverage while the vehicle was in the hands of a thief. Contrary to plaintiffs’ contention, this is not a situation where both the driver and the vehicle were covered, but there was no insurance 6 “by reason of exclusion” ’; rather, there is no insurance protection here by ‘ “lack of inclusion” ’, and written notice was, therefore, not required” (citing Zappone, [388]*388infra).

In Zappone v Home Ins. Co.

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Related

Presbyterian Hospital v. Maryland Casualty Co.
683 N.E.2d 1 (New York Court of Appeals, 1997)
Central General Hospital v. Chubb Group of Insurance Companies
681 N.E.2d 413 (New York Court of Appeals, 1997)
Zappone v. Home Insurance
432 N.E.2d 783 (New York Court of Appeals, 1982)
Sando v. Firemen's Insurance
79 A.D.2d 774 (Appellate Division of the Supreme Court of New York, 1980)
Katz v. Allstate Insurance
96 A.D.2d 930 (Appellate Division of the Supreme Court of New York, 1983)
St. Clare's Hospital v. Allcity Insurance
201 A.D.2d 718 (Appellate Division of the Supreme Court of New York, 1994)
Presbyterian Hospital v. Atlanta Casualty Co.
210 A.D.2d 210 (Appellate Division of the Supreme Court of New York, 1994)
New York & Presbyterian Hospital v. Empire Insurance
295 A.D.2d 325 (Appellate Division of the Supreme Court of New York, 2002)

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Bluebook (online)
194 Misc. 2d 384, 749 N.Y.S.2d 700, 2002 N.Y. Misc. LEXIS 1330, Counsel Stack Legal Research, https://law.counselstack.com/opinion/new-york-presbyterian-hospital-v-allstate-insurance-nysupct-2002.