Opinion
Index No. CV-750591-18/KI
08-09-2022
Life Equipment, Inc AAO Keandre Black, Plaintiff(s), v. Mid-Century Ins Co, Defendant(s).
Attorney for Plaintiff: Zachary Whiting, Esq. Law Office of Zara Javakov Esq., P.C. Attorney for Defendant: William Ross Van Tuyl, Esq. Law Offices of Buratti Rothenberg & Burns
Unpublished Opinion
Attorney for Plaintiff: Zachary Whiting, Esq. Law Office of Zara Javakov Esq., P.C.
Attorney for Defendant: William Ross Van Tuyl, Esq. Law Offices of Buratti Rothenberg & Burns
Ellen E. Edwards, J.
Recitation, as required by CPLR 2219(a), of the papers considered in the review of this motion:
Papers Numbered
Notice of Motion and Affidavits /Affirmations annexed SLIVKW; VK0TOY
Answering Affidavits/ Affirmations PINFJE; WANWVP
Reply Affidavits/ Affirmations
Memoranda of Law
Other
In this action seeking to recover assigned first-party no-fault benefits, defendant moves for summary judgment on ground that plaintiff's assignor failed to appear for Independent Medical Examinations ("IMEs"). Plaintiff opposes the defendant's motion and cross moves for summary judgment in its favor. The following bill is at issue:
Date of ServiceBill AmountDate Bill ReceivedIME
Scheduling Letters sentIME
DateDate Denied
5/17/18
to 6/6/18$1049.796/12/185/18/18;
6/14/18;
7/25/186/12/1;
7/10/1;
8/14/188/22/18;
9/20/18
Upon the forgoing cited papers, and after oral argument, the Decision/Order on defendant's motion for summary judgment and plaintiff's cross motion is as follows:
On a motion for summary judgment, the moving party must make a prima facie showing of entitlement to judgment as a matter of law, tendering sufficient evidence to demonstrate the absence of any material issues of fact. If the moving party produces the required evidence, the burden shifts to the nonmoving party to establish the existence of material issues of fact which require a trial of the action. (Xiang Fu He v. Troon Mgt., Inc., 34 N.Y.3d 167, 175 (2019) (internal citations and quotation marks omitted)).
A. Defendant's Motion for Summary Judgment
I. IME No-Show
An assignor's appearance at an IME "is a condition precedent to the insurer's liability on the policy." (Stephen Fogel Psychological, P.C. v. Progressive Cas. Ins. Co., 35 A.D.3d 720, 722 (2d Dept. 2006)). "Consequently, an insurer may deny a claim retroactively to the date of loss for a claimant's failure to attend IMEs 'when, and as often as, the [insurer] may reasonably require.'" (Id. at 722, citing 11 NYCRR 65-1.1).
To meet its prima facie burden, the defendant must establish that: (1) it properly mailed scheduling letters for IMEs to plaintiff's assignor; (2) the IME was timely scheduled; (3) the assignor failed to appear at the initial IME and the rescheduled follow-up IME; and (4) defendant timely denied the claim on that ground. (Motionpro Physical Therapy v. Hereford Ins. Co., 58 Misc.3d 159 (A) (App Term 2018)).
Here, the defendant contends that it issued proper and timely denials based on the assignor's failure to appear for three scheduled IMEs. Defendant submitted the affidavit of its claims representative, Christopher Stewart to explain why defendant requested the IMEs. (See defendant's exhibit D, Stewart aff). Stewart attested that defendant requested an IME after receiving notice that plaintiff's assignor was involved in an accident on March 22, 2018. (Id. at 14). Thereafter, defendant requested a third-party company, ExamWorks, Inc. to schedule an initial IME on June 12, 2018 at 2:15pm. (Id. at 15). ExamWorks, Inc. also rescheduled follow-up IMEs for July 10, 2018 at 1:00 pm and August 14, 2018 at 1:00 pm. ((Id.).
"Generally, proof that an item was properly mailed gives rise to a rebuttable presumption that the item was received by the addressee." (Viviane Etienne Med. Care, P.C. v. Country-Wide Ins. Co., 114 A.D.3d 33, 46 (2d Dept 2013)). "The presumption may be created by either proof of actual mailing or proof of a standard office practice or procedure designed to ensure that items are properly addressed and mailed." (New York and Presbyt. Hosp. v. Allstate Ins. Co., 29 A.D.3d 547 (2d Dept 2006) quoting Residential Holding Corp. v. Scottsdale Ins. Co., 286 A.D.2d 679, 680 (2d Dept 2001). To the extent that proof of mailing is based upon a standard office practice or procedure, the burden is on the insurer to present an affidavit of an employee who personally mailed the items, or an employee with personal knowledge of the office's mailing practices and procedures. (Quality Psychological Services, P.C. v. Hartford Ins. Co., 38 Misc.3d 1210(A) (Civ Ct 2013)). This individual "must describe those practices or procedural in detail, explicitly denoting the manner in which she/he acquired the knowledge of such procedures or practices, and how a personal review of the file indicates that those procedures or practices were adhered to with respect to the processing of that particular claim." (Id.)
Here, defendant relies on the affidavit of Georgianna Michios, a litigation manager at ExamWorks Inc. to establish proof of timely mailing of the IME scheduling letters. (See defendant's exhibit I, Michios aff). The Court finds that defendant's submission of Michios' affidavit is insufficient to establish that the IME scheduling letters were timely and properly mailed. The Court agrees with plaintiff that the affidavit is conclusory. Michios merely states that an employee places the scheduling letters in a properly addressed envelope and mails the letter via regular mail and/ or certified mail. (Id. at 5). This affidavit fails to explicitly state ExamWorks, Inc. practices and procedures for mailing the scheduling letters.
Further, defendant's submission of the three delivery confirmation receipt is also insufficient to prove that the IME scheduling letters were timely and properly mailed. (See defendant's exhibit G, IME Scheduling Letters). The Appellate Division, Second Department found that defendant's submission of a certified mail receipt and "Track & confirm" printout were insufficient where there was no evidence presented that the item purportedly mailed to the plaintiff was mailed under the proffered certified receipt number. (New York and Presbyt. Hosp., 29 A.D.3d 547). Here, the three delivery confirmation receipts submitted by the defendant state that the items were delivered on May 23, 2016, June 18, 2018 and July 27, 2018, respectively. However, there was no evidence presented that the items purportedly mailed to the plaintiff were mailed under the proffered certified receipt number listed on each delivery confirmation receipt. Thus, the defendant failed to establish timely mailing of the IME scheduling letters.
Even if defendant had demonstrated timely mailing of the scheduling letters, defendant did not establish that plaintiff's assignor failed to appear at the IMEs. Here, defendant submitted the affidavit of John Ioozzio, a licensed chiropractor and acupuncturist. (See defendant's exhibit H, Iozzio aff). The basis of Ioozzio's information is his personal knowledge of his office policy, and review of the physical file and computer records. (Id. at 3). Ioozzio's business practice is to make a notation in the file, if the individual fails to appear. (Id. at 4). Ioozzio stated that he personally recorded each of Keandre Black's nonappearance at the scheduled IMEs. (Id. at 6,8,10). However,
"it is the business record itself, not the foundational affidavit, that serves as proof of the matter asserted. Accordingly, [e]vidence of the contents of business records is admissible only where the records themselves are introduced. Without their introduction, a witness's testimony as to the contents of the records is inadmissible hearsay.'" (Longevity Med. Supply, Inc. v. Progressive Ins. Co., 68 Misc.3d 748, 753 (Civ Ct 2020) quoting Bank of New York Mellon v. Gordon, 171 A.D.3d 197, 205-06 (2d Dept. 2019)).
Here, Ioozzio did not submit any business records evidencing the assignor's nonappearance.
Further, Ioozzio stated that he was present at each scheduled IME. According to Ioozio, the assignor failed to appear for the initial IME on June 12, 2018, and rescheduled follow-up IMEs on July 10, 2018 and August 14, 2018. (See Iozzio aff Ioozzio at6,8,10). Iozzio neither stated how and whether he would have been able to identify the insured, or that no one appeared at the office at the time of each scheduled IME. (Longevity Medical Supply, Inc., 68 Misc.3d at 748). Therefore, the court agrees with plaintiff that Ioozzio's affidavit lacked personal knowledge regarding the assignor's nonappearance.
Thus, defendant failed to establish that plaintiff's assignor failed to appear at the IMEs on June 12, 2018, July 10, 2018 and August 14, 2018.
II. Timeliness of the Denial of Claim Forms
"[A]n insurer must either pay or deny a claim for motor vehicle no-fault benefits, in whole or in part, within 30 days after an applicant's proof of claim is received. An insurer can extend the 30-day period within which to pay or deny a claim by making a timely demand for further verification of the claim." (Infinity Health Prods., Ltd. v. Eveready Ins. Co., 67 A.D.3d 862, 864 (2d Dept. 2009) [internal citations omitted]).
Defendant contends that on June 12, 2018 it received a bill from plaintiff for the dates of service on May 17, 2018 through June 6, 2018. The bill was in the amount of $1049.79. According to defendant, after plaintiff's assignor failed to appear for IMEs on June 12, 2018 and August 14, 2018, a general denial form dated August 22, 2018 was mailed to plaintiff on August 23, 2022. This denial falls within the 30-days period. Also, another denial of claim form dated September 20, 2018 was mailed to plaintiff on September 21, 2018.
To establish proper mailing, defendant submits the affidavit of Carlton Lewis, a mailing manager, and certificates of mailing report. (See defendant's exhibit E, Lewis aff; defendant's exhibit C, Denials). According to Lewis, the items were either generated and mailed from mailing centers in Chino, California or Caledonia, Michigan. (Lewis aff 3). Lewis further stated that both denials were delivered to the U.S. Post Office, and there were no notations on the certificate of mailing reports that either denial was delayed or there were any malfunctions. (Id. at9,10,15). Lewis' affidavit and certificates of mailing reports establish proof of mailing of the denial claims forms on August 23, 2022 and September 21, 2018, in accordance with a standard office procedure. (Residential Holding Corp. v. Scottsdale Ins. Co., 286 A.D.2d 679 (2d Dept. 2001); Ortho-Med Surgical Supply, Inc. v. Progressive Cas. Ins. Co., 27 Misc.3d 141 (A) (App Term 2010)).
Contrary to plaintiff's arguments, Lewis demonstrated personal knowledge of the mailing procedures. Lewis was employed as the mailing manager at both the Caledonia and Chin mailing centers (Curtin aff 1). Also, he is responsible for ensuring that the standard mailing practices and procedures are followed. (Id. at 2). Further, Lewis' affidavit properly laid the foundation for the admission of the denial of claim forms and certificates of mailing reports as business records.
Thus, defendant timely issued denial of claim forms for the dates of service on May 17, 2018 through June 6, 2018. However, as discussed above, defendant did not establish that plaintiff's assignor failed to appear at the IMEs on May 23, 2016, June 18, 2018 and July 27, 2018.
Accordingly, defendant's motion for summary judgment is granted to the extent it established that it timely denied plaintiff's claim.
B. Plaintiff's Cross-Motion for Summary Judgment
A no-fault provider establishes its prima facie entitlement to summary judgment by (1) proof of the submission to the defendant of a claim form; (2) proof of the fact and the amount of the loss sustained; and (3) proof either that the defendant had failed to pay or deny the claim within the requisite 30-days period, or that the defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law. (See Insurance Law § 5106(a)); Westchester Med. Ctr. v. Nationwide Mut. Ins. Co., 78 A.D.3d 1168 (2010); see also New York & Presbyt. Hosp. v. Allstate Ins. Co., 31 A.D.3d 512 (2006)). Once plaintiff meets its prima facie burden, the burden shifts to defendant to raise a triable issue fact. (See Alvarez v. Prospect Hosp., 68 N.Y.2d 320 (1986)).
To establish proper mailing, plaintiff submits the affidavit of its owner, Albert Khaimov to describe its's standard office and procedures for generating and mailing bills. (See plaintiff's exhibit C, Khaimov aff). Khaimov stated that he created a bill in the amount of $1049.79 for the dates of service on May 17, 2018 through June 6, 2018. (Id. at 20). However, he does not state when the bill was mailed to defendant. The court may, in its discretion, rely on defendant's documentary submissions to establish defendant's receipt of plaintiff's claims. (Devonshire Surgical Facility v. GEICO, 16 Misc.3d 130 (A) (App Term 2007)). Here, defendant's claim representative affidavit established receipt of plaintiff's bill on June 12, 2018. (Stewart aff 18). Further, any deficiencies in plaintiff's proof of mailing were cured by defendant's submission of the denial of claim forms in defendant's motion papers, which admitted receipt of plaintiff's bills. (Bob Acupuncture, P.C. v. New York Cent. Mut. Fire Ins. Co., 53 Misc.3d 135 (A) (App Term 2016); see Oleg Barshay, DC, P.C. v. State Farm Ins. Co., 14 Misc.3d 74 (App Term 2006); Longevity Med. Supply, Inc., 68 Misc.3d at 758). Therefore, defendant's claim representative affidavit and denial of claims forms established receipt of plaintiff's claim. Further, Khaimov stated that the bill was neither paid nor denied within the 30-days period. (Khaimov aff 20).
Defendant proved that it timely denied plaintiff's claim by timely mailing denial of claim forms. However, as discussed above, defendant did not establish that plaintiff's assignor failed to appear at duly scheduled IMEs. Therefore, the issue that is presented here is whether the timely denials warrant denial of plaintiff's cross motion for summary judgment in its favor, even though the evidence of the grounds of the denials was insufficient. The court in Longevity Med. Supply, Inc. v. Progressive Ins. Co discussed how two Appellate Term, Second Department decisions reached opposite results on this issue. (See Longevity Med. Supply, Inc., 68 Misc.3d at 759-60. The court discussed that,
[In Rockaway Med. and Diagnostic, P.C. v. Country-Wide Ins. Co., 29 Misc.3d 136 (A) (App Term 2010)], once the plaintiff met its prima facie burden, the Appellate Term required the defendant not only to come forward with evidence that the denial was timely, but also to lay bare the evidence of the grounds of the denial, which had to be sufficient to establish the grounds. [Three years later in Shara Acupuncture, P.C. v. Allstate Ins. Co., 41 Misc.3d 129 (A) (App Term 2013), once the plaintiff met its prima facie burden that the claims were neither paid nor denied within the 30-day period after defendant's receipt of the bill, the Appellate Term required the insurer only to come forward with evidence that the denial was timely to defeat the plaintiff's motion for summary judgment. Put differently, once the insurer came forward with evidence that the denial was timely, the burden in Shara Acupuncture, P.C. appears to shift back to the plaintiff to establish the denial was conclusory, vague or without merit as a matter of law to be entitled to summary judgment. (Longevity Med. Supply, Inc., 68 Misc.3d at 760) (internal citations omitted.)
Shara Acupuncture, P.C. controls here. As discussed above, the plaintiff's prima facie burden can be established in two ways: (1) proof that the defendant had failed to pay or deny the claim within the requisite 30-days period, or (2) proof that the defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law. (Ave T MPC Corp. v. Auto One Ins. Co., 32 Misc.3d 128 (A) (App Term 2011)). If plaintiff cannot meet its prima facie burden under the first method because defendant submitted evidence of a timely denial, then the court should consider whether plaintiff met the prima facie burden under the second method. (Longevity Med. Supply, Inc., 68 Misc.3d at 760 citing Longevity Med. Supply, Inc. v. Glob. Liberty Ins. Co., 67 Misc.3d 135 (A) (App Term 2020)).
Here, the plaintiff's prima facie burden was based solely on proof that the claims were neither paid nor denied within the 30-days period. However, the defendant established that it timely denied plaintiff's bill. Because plaintiff had not demonstrated that the denials were conclusory, vague, or without merit as a matter of law, plaintiff is not entitled to judgment in its favor.
Thus, plaintiff's cross motion for summary judgment is granted to the extent that it established timely submission of the bill to defendant, and that it remains unpaid.
C. Conclusion
Plaintiff met its prima facie case by establishing timely mailing of the bill to defendant, and that it remains unpaid. Defendant met its prima facie case by establishing timely denial.
Accordingly, the defendant's motion for summary judgment is granted to the extent it established that it timely denied plaintiff's bill. The plaintiff's cross motion for summary judgment is granted to the extent it established timely submission of the claim to defendant, and the bill remains unpaid. The issue left for trial is defendant's IME no-show defense.
This constitutes the decision and order of the court.