St. Barnabas Hosp. v Allstate Ins. Co., 2009 NY Slip Op 07824 (App. Div., 2nd, 2009)
“A proper denial of [a] claim [for no-fault benefits] must include the information called for in the prescribed denial of claim form (see 11 NYCRR 65-3.4[c][11]) and must promptly apprise the claimant with a high degree of specificity of the ground or grounds on which the disclaimer is predicated’” (Nyack Hosp. v State Farm Mut. Auto Ins. Co., 11 AD3d 664, 664, quoting General Acc. Ins. Group v Cirucci, 46 NY2d 862, 864). However, a timely denial of a no-fault insurance medical claim alone does not avoid preclusion where said denial is factually insufficient, conclusory, vague, or otherwise involves a defense which has no merit as a matter of law (see Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d 564, 565).
The defendant insurer, Allstate Insurance Company (hereinafter Allstate), issued a timely denial of claim within 30 days of its receipt of the completed hospital facility form (NYS Form N-F 5) from the plaintiff St. Barnabas Hospital, as assignee of Patrick Bateman (hereinafter the plaintiff) (see 11 NYCRR 65-3.5[g], 65-3.8[c]). Contrary to Allstate’s contention, however, the Supreme Court properly determined that the denial of claim, which incorrectly stated the amount of the claim and gave an invalid reason for the denial (see 11 NYCRR 65-3.3[d], 65-3.5[g]; see also Westchester Med. Ctr. v Lincoln [*2]Gen. Ins. Co., 60 AD3d 1045, 1046; Nyack Hosp. v Encompass Ins. Co., 23 AD3d 535, 536), was fatally defective (see Nyack Hosp. v Metropolitan Prop. & Cas. Ins. Co., 16 AD3d at 565; Nyack Hosp. v State Farm Mut. Auto. Ins. Co., 11 AD3d at 665; Presbyterian Hosp. in City of N.Y. v Maryland Cas. Co., 226 AD2d 613, 614). Thus, Allstate failed to demonstrate the existence of a meritorious defense (see CPLR 5015[a][1]).
A.M. Med. Servs., P.C. v Avis Rent A Car, 2009 NY Slip Op 52177(U) (App. Term, 2nd, 2009)
In order to vacate the order granting plaintiff’s unopposed motion for summary judgment and the judgment entered pursuant thereto, defendant was required to establish both a reasonable excuse for its default and a meritorious defense (see CPLR 5015 [a] [1]; Eugene Di Lorenzo, Inc. v Dutton Lbr. Co., 67 NY2d 138, 141 [1986]). The affidavits submitted by defendant in support of its motion suffice to establish that defendant had a reasonable excuse for its failure to oppose plaintiff’s motion for summary judgment.
Defendant also demonstrated that it has a meritorious defense and raised a triable issue of fact. The affidavit submitted by defendant sufficiently established that the denial of claim forms were timely mailed in accordance with defendant’s standard office practice and procedure (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Furthermore, defendant submitted two affirmed peer review reports, each explaining why the services billed for were not medically necessary (see A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).