Star Medical Services, P.C. v. Allstate Insurance

5 Misc. 3d 785, 2004 NY Slip Op 24410, 786 N.Y.S.2d 286, 2004 N.Y. Misc. LEXIS 1943
CourtCivil Court of the City of New York
DecidedOctober 25, 2004
StatusPublished

This text of 5 Misc. 3d 785 (Star Medical Services, P.C. v. Allstate Insurance) is published on Counsel Stack Legal Research, covering Civil Court of the City of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Star Medical Services, P.C. v. Allstate Insurance, 5 Misc. 3d 785, 2004 NY Slip Op 24410, 786 N.Y.S.2d 286, 2004 N.Y. Misc. LEXIS 1943 (N.Y. Super. Ct. 2004).

Opinion

OPINION OF THE COURT

Eileen N. Nadelson, J.

This action arises pursuant to the provisions of New York’s No-Fault Insurance Law.

The assignments of benefits that provide the basis of this claim present two discrete issues to be decided by this court. The alleged accident occurred on March 18, 2003, when the car driven by the son of the insured collided with another car. The assignors are the son and his passenger; the insured himself was not in the car nor involved in the accident. The insured’s policy covers accidents occurring while the son is driving the vehicle.

The claims for first-party benefits were submitted by plaintiff medical provider in a timely fashion. After the claims were submitted, defendant insurer requested additional verification in the form of an examination under oath (EUO) from the driver assignor. The request for the EUO was sent to the driver and the attorney representing the driver in a separate action. The address used to send the request to the driver was incorrect, and the request was never received by this assignor, although it was received by his attorney. It is noted that defendant did have the driver’s correct address, but left a significant portion of the address off the envelope. The driver assignor did not appear for the EUO. The subsequent follow-up request was also mailed to the same erroneous address, and the driver did not appear for the rescheduled EUO.

Meanwhile, defendant conducted EUOs of the passenger assignor and the insured. The passenger stated that she was picked up by the driver around 8:00 a.m., which was their usual custom, and that the accident occurred shortly thereafter. She further stated that she was removed from the vehicle by the fire department’s EMS team when they arrived on the scene. The police also were summoned.

The insured stated that he and the driver live at the same address and work at the same facility. He said that on the morn[787]*787ing in question he left for work at around 6:00 a.m., which was his customary practice. He further claimed that his son, according to his belief, usually leaves for work at 7:00 a.m., and arrives at work at around 7:30 a.m., but that he and his son do not work in the same area and he does not actually see his son arrive.

The insured said that he was called about the accident by the passenger, and arrived at the scene between 10:00 and 10:30 a.m., at which time he saw the passenger standing outside the car. He said he did not believe that she had been in the car.

The claims were ultimately denied by defendant insurer. The denial of benefits for the driver assignor’s treatment was dated August 8, 2003, the claim having been received on May 15, 2003; the denial of benefits for the passenger assignor’s treatment was dated August 20, 2003, the claim having been received on May 16, 2003.

Defendant stated that the denial of benefits for the driver assignor was based on his failing to attend scheduled examinations under oath, and the denial of benefits for the passenger assignor was based on defendant’s determination that the injuries complained of did not result from the alleged accident.

Plaintiff has moved for summary judgment, asserting that the denial of benefits for the driver assignor’s treatments was not received within the statutorily mandated 30 days after receipt of the claims (11 NYCRR 65-3.5, 65-3.8 [a]), and that the denial of benefits for the passenger assignor’s treatments is based on unsubstantiated hypotheses. Defendant maintains that its requests for verification of the claim tolled that statutory period pursuant to 11 NYCRR 65-3.5, and that the two conflicting EUOs of the passenger and the insured raise triable issues of fraud in presenting the claim.

The first issue required to be determined by this court is whether a request for an examination under oath to an injured party’s attorney is sufficient notification to the injured party under New York’s No-Fault Law and regulations? This is an issue of first impression under the regulations.

The regulations promulgated under New York’s No-Fault Law, appearing under part 65 of title 11 of the New York Code, Rules and Regulations, prescribe the manner in which requests for verification must be made. However, the regulations only deal specifically with time limits for making requests and scheduling EUOs; only tangentially do they indicate how notice is to be sent.

[788]*78811 NYCRR 65-3.5 (b) states that requests for verification “need not be made [in] any prescribed [manner] or . . . form.” Section 65-3.5 (e) states, in pertinent part, that the “insurer shall inform the applicant at the time the examination is scheduled that the applicant will be reimbursed for any loss of earnings and reasonable transportation expenses . . . .”

11 NYCRR 65-3.6 (b) states:

“[I]f any requested verifications [sic] has not been supplied to the insurer 30 calendar days after the original request, the insurer shall, within 10 calendar days, follow up with the party from whom the verification was requested ... At the same time the insurer shall inform the applicant and such person’s attorney of the reason(s) why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested.” (Emphasis added.)

A legally valid basis for denying a first-party benefit claim would be the provider’s assignor failing to comply with requests for verification. (See generally, Lopedote v General Assur. Co., 4 Misc 3d 1001 [A], 2004 NY Slip Op 50593[U] [Kings County 2004].) However, the sine qua non of any legal request for information is that the party required to provide such information be given adequate and appropriate notice. (See generally, BHNJ Realty Corp. v Rivera, 144 Misc 2d 241 [NY County 1989].)

Neither the No-Fault Insurance Law nor the regulations promulgated thereunder specify the manner in which a request or notice be given. Therefore, in deciding whether notice to an assignor’s attorney, who is not representing the medical provider claimant, is sufficient notice to the assignor of the request for verification, the court must look to other statutes’ notice requirements to insure that the mandates of due process are met.

Section 308 (2) of the CPLR, concerning service of process, states that if a person is not personally served, service may be effectuated by serving a person of suitable age and discretion at the dwelling, place of business or abode of the person to be served and mailing a copy of the pleadings to that person’s last known address. Service may also be perfected by affixing a copy of the pleadings to the door of the dwelling of the person to be served and mailing a copy óf the pleadings to that address. These are dual requirements, and both serving the suitable person or affixing the papers and mailing the pleadings must be [789]*789completed before service is deemed satisfied. If the pleadings are mailed to the wrong address, service is deemed incomplete. (Schurr v Fillebrown, 146 AD2d 623 [2d Dept 1989].) Further, under section 312-a of the CPLR, personal service may be effectuated by mail, with proof of mailing and acknowledgment of receipt. However, in all instances, the mailing must be made to the person’s correct last known address. (See generally, Zaretski v Tutunjian, 133 AD2d 928 [3d Dept 1987]; Smith Carpet v Walter Arnold, Inc., 94 AD2d 643 [1st Dept 1983].)

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

Related

Carpet v. Walter Arnold, Inc.
94 A.D.2d 643 (Appellate Division of the Supreme Court of New York, 1983)
Zaretski v. Tutunjian
133 A.D.2d 928 (Appellate Division of the Supreme Court of New York, 1987)
Schurr v. Fillebrown
146 A.D.2d 623 (Appellate Division of the Supreme Court of New York, 1989)
Broman v. Stern
172 A.D.2d 475 (Appellate Division of the Supreme Court of New York, 1991)
A.B. Medical Services PLLC v. Eagle Insurance
3 Misc. 3d 8 (Appellate Terms of the Supreme Court of New York, 2003)
Palumbo v. Estate of Clark
94 Misc. 2d 1 (Civil Court of the City of New York, 1978)
BHNJ Realty Corp. v. Rivera
144 Misc. 2d 241 (Civil Court of the City of New York, 1989)

Cite This Page — Counsel Stack

Bluebook (online)
5 Misc. 3d 785, 2004 NY Slip Op 24410, 786 N.Y.S.2d 286, 2004 N.Y. Misc. LEXIS 1943, Counsel Stack Legal Research, https://law.counselstack.com/opinion/star-medical-services-pc-v-allstate-insurance-nycivct-2004.