Total Chiropractic PC v. Mercury Cas. Ins. Co.

Recitation, as required by CPLR §2219(a) of the papers considered in review of this Motion: Papers Notice of Motion and Affidavits Annexed    SSAQQU Answering Affidavits                   RBU9WN Plaintiff’s Cross-Motion              FJSPKD Replying Affidavits Exhibits DECISION AND ORDER Upon the foregoing cited papers and after oral arguments on January 8, 2021, pursuant to CPLR §3212(g), the Decision and Order on Defendant’s Motion for Summary Judgment and Plaintiff’s Cross-Motion for Summary Judgment, is as follows: PROCEDURAL POSTURE: In this No-Fault proceeding, Mercury Casualty Insurance Company (“Defendant/Insurer”), appearing through its attorney, pursuant to CPLR §3212(a) moves for Summary Judgment and dismissal of the complaint as barred by the doctrines of collateral estoppel and res judicada. In the alternative, Defendant moves for partial Summary Judgment seeking a prima facie finding that it timely and properly denied the bills in dispute. Total Chiropractic, P.C. (“Plaintiff/Provider”), appearing through its attorney, opposes Defendant’s motion. Pursuant to CPLR §3212(a), Plaintiff cross-moves for an Order granting Summary Judgment seeking a prima facie finding that it timely and properly mailed said bills totaling $2,100.00. Plaintiff further submits that the Declaratory Judgment issued against it, was entered on default, the issues have not been litigated therefore collateral estoppel and res judicada do not apply.¹ Based on the foregoing, Defendant’s motion is GRANTED and Plaintiff’s cross-motion is DENIED. FACTUAL BACKGROUND: Plaintiff commenced the instant No-Fault action seeking payment for medical services it rendered to Assignor Santia Louis as a result of alleged injuries related to a July 10, 2015 motor vehicle accident under claim number 2015004500398710. Defendant commenced the Declaratory Judgment action against Plaintiff on October 6, 2016, in Supreme Court of the State of New York in Orange County, under Index Number EF 004083-2016 seeking an Order that Plaintiff not be entitled to payment for the claims submitted to Defendant. Specifically, Defendant alleged that the Assignor made material misrepresentations about her actual place of residence, which began with the procurement of the policy and continued until the date of motor vehicle accident. The Assignor’s misrepresentation reduced the amount of her policy premiums.² Defendant was granted its application for a Declaratory Judgment on December 5, 2016, where Orange County Supreme Court Justice Vazquez-Doles concluded “…the [Defendant] has no duty to provide any first party benefits coverage to [Assignor], and other interested parties listed as defendants,” and that Defendant “is entitled to monetary relief against [Assignor]“³. Plaintiff failed to file an answer or a motion to renew or re-argue or appeal the Orange County Declaratory Judgment action. On December 13, 2016, Defendant served the Plaintiff the Orange County Declaratory Judgment.⁴ Plaintiff commenced the instant No-Fault action on August 2, 2018 and issue was joined on September 19, 2018.⁵ POSITION OF THE PARTIES: Defendant avers its Motion for Summary Judgment should be granted in its entirety and Plaintiff’s complaint should be dismissed with prejudice. Defendant relies on the above-referenced Orange County Declaratory Judgement in support of its collateral estoppel and res judicata position since said Declaratory Judgment ordered that Mercury “has no duty to provide any first party benefits coverage to Defendant Santia Louis, and other interested parties listed as Defendants, arising out of the same July 10, 2015 motor vehicle accident as in the instant matter, given the Defendant’s misrepresentation of her place of residence was “material” as defined in Insurance Law §3105(b).” The Defendant also relies on the October 23, 2017 Decision and Order issued by Kings County Civil Court Judge Richard Montelione dismissing with prejudice a related matter bearing the caption Total Chiropractic, P.C. a/a/o Santia Louis, et. al., Index Number 073058/15, that also relied on the same Orange County Declaratory Judgment. Plaintiff avers that said Declaratory Judgment has no preclusive effect in this case because it applies only to the Assignor and not the service provider Plaintiff in this matter. Plaintiff points to Jamaica Wellness Med., P.C. v. Mercury Cas. Co. where the Appellate Term opined the “Supreme Court order in the declaratory judgment action merely awarded a default judgment to Mercury against [Plaintiff]‘s assignor, but did not declare the rights of Mercury as against [Plaintiff], the Supreme Court order cannot be considered a conclusive final determination of [Plaintiff]‘s rights and, thus, can have no preclusive effect on the no-fault action at bar.”⁶ Plaintiff also argues that Defendant failed to establish it timely and properly denied Plaintiff’s claim and is now precluded from raising the defense of the Assignor’s material misrepresentations to procure the underlying insurance policy. Plaintiff relies on the Appellate Division holding in Westchester Med. Ctr. v. GMAC Ins. Co. Online, Inc, which found that “although the defendants contend that they submitted evidence showing that the plaintiff’s assignor misrepresented his state of residence in connection with the issuance of the subject insurance policy, the defendants are precluded from asserting that defense, as a result of their untimely denial of the claim.”⁷ See also Gutierrez v. United Servs. Auto. Assn., holding that “Plaintiff correctly argues that defendant failed to demonstrate that it is not precluded from asserting its proffered defense — that the insurance policy at issue was fraudulently procured — as it failed to establish that it had timely denied plaintiff’s claim on that ground.”⁸ Any so-called global or blanket denial of claim form that does not specifically address Plaintiff’s claim is insufficient to avoid the preclusion of the defense.⁹ ANALYSIS: In deciding a motion for Summary Judgment, the Court’s role is solely to determine if any triable issues exist, not to determine the merits of any such issues. Sillman v. Twentierth Centry-Fox Film Corp., 3 NY.2d 395 (1957). Summary Judgment may only be granted if no genuine triable issue of fact is presented. See Gomes v. Courtesy Bus Co., 251 A.D.2d 625 (2nd Dep’t 1998). The movant must establish the cause of action “sufficiently to warrant the court as a matter of law in directing judgment” in the movant’s favor and must do so by evidentiary proof in admissible form. See CPLR §3212(b); Friends of Animals, Inc. v. Associated Fur Mfrs., 46 N.Y.2d 1065 (1979). “The proponent of a Summary Judgment motion must make a prima facie showing of entitlement to judgment as a matter of law, tendering sufficient evidence to eliminate any material issues of fact from the case.” Winegrad v. New York University Medical Center, 64 N.Y.2d 851, 853 (1986). Once such entitlement has been demonstrated by the movant, then the burden shifts to the party opposing the motion to demonstrate by admissible evidence that existence of a factual issue requiring a trial of the action or tender an acceptable excuse for his failure to do so. Zuckerman v. City of New York, 49 N.Y. 2d 557, 560 (1980). However, the Court of Appeals has made clear that bare allegations or conclusory assertions are insufficient to create genuine, bona fide issues of fact necessary to defeat such a motion. Rotuba Extruders, Inc. v. Ceppos, 46 N.Y. 2d 223, 231 (1978). Under New York state law, Default Judgments that have not been vacated, are final orders and can preclude Plaintiff’s claims for payment. See Lazides v. P & G Enters., 58 AD3d 607, 871 NYS2d 357 [2nd Dept 2009], revg 2007 WL 6861118 [Sup Ct, Kings County 2007]. The courts have reasoned that to hold otherwise would destroy or impair the rights or interests established by Default Judgments. See Schuylkill Fuel Corp. v. Nieberg Realty Corp., 250 NY 304, 306-307, 165 NE 456 [1929]; Great Health Care Chiropractic, P.C. v. Progressive Ins. Co., 48 Misc 3d 134[A], 18 NYS3d 579, 2015 NY Slip Op 51077[U] [App Term, 2nd Dept, 2d, 11th & 13th Jud. Dists. 2015] An order specifying the court’s Declaratory Judgment is a conclusive final determination, notwithstanding that it was entered on default. See Metro Health Prods., Inc. v. Nationwide Ins., 48 Misc 3d 85, 16 NYS3d 366 [App. Term, 2nd Dept, 2d, 11th & 13th Jud. Dists., 2015]. New York State Insurance Law and Regulations 11 NYCRR §65 (“Regulations”) provide that an insurer must pay or deny a claim for No-Fault benefits within thirty days from the receipt of the claim. See Insurance Law§5106 and Regulations §65-3. Defendant must produce legally sufficient evidence that a denial form was generated and mailed within 30-days of the receipt of the claim for No-Fault benefits, or the time was tolled by issuing a proper verification request. Jul Pol Corp. v. State Farm Fire and Casualty Company, 2003 N.Y. Slip 51153 (U) (App. Term, 2nd and 11th Jud. Distrs., July 9, 2003). The threshold issue hereis whether a default judgment that was not vacated has preclusive effects to permit the Plaintiff to collect payment for a claim submitted as first party benefits under New York’s No-Fault Insurance law. If established, this Court does not have to consider the issue of whether Plaintiff met its prima facie burden warranting payment for medical services or whether the Defendant established the bills in dispute were appropriately denied. The Court finds that the Orange County Declaratory Judgment is a final Order that names both the Assignor and the Plaintiff and clearly delineates the rights and obligations of the parties.¹⁰ The Declaratory Judgment clearly recites the relief requested by the Defendant and decrees the Defendant “has no duty to provide any first party benefits coverage to [Assignor], and other interested parties listed as defendants.”¹¹ The Plaintiff and Assignors are named Defendants on the Orange County Declaratory Judgment.¹² In its affidavits, Plaintiff failed to produce any evidence to raise a triable issue of fact regarding whether it is covered as a Defendant in the Orange County Declaratory Judgment. The Court is not persuaded by Plaintiff’s reliance on Jamaica Wellness Med P.C. v. Mercury Cas. Co., 2018 NY Slip Op 51128 (U), as its inapplicable to the instant matter. The default judgment granted in the Jamaica Wellness Medical case was only against the Assignor, as the Plaintiff provider had appeared in the action and served an Answer. The Appellate Term specifically notes that “upon review of the record, we find that, as the March 23, 2016 Supreme Court order in the declaratory judgment action merely awarded a default judgment action to Mercury against Jamaica’s assignor, but did not declare the rights of Mercury as against Jamaica.”¹³ Therefore the facts here are distinguishable given that Mercury’s Declaratory Judgment Order entered on default was specifically against both Assignor Santia Louis and Plaintiff provider Total Chiropractic P.C., who were both named in the Orange County Declaratory Judgment action and the case herein, and both failed to respond to the Orange County Declaratory Judgment action. Finally, the Appellate Division, 2nd Department held that when an accident victim assigns his or her No-Fault claim to a medical provider, pursuant to 11 NYCRR 65-3.11, the medical provider as the “assignee ‘stands in the shoes’ of an assignor and thus acquires no greater rights than its assignor.” Long Island Radiology v. Allstate Ins. Co., 36 A.D.3d 763, 830 N.Y.S.2d 192 (2nd Dept. 2007). If a certain defense may be raised by the Defendants against the injured party, it is available as against the provider who accepts the assignments of no-fault benefits. As such, a finding of material misrepresentation of an assignor would be imputed onto the health care provider who takes an assignment of benefits and assumes this risk when accepting the assignment. CONCLUSION: Accordingly, the Orange County Declaratory Judgment declared the rights and obligations of both the Plaintiff and the Assignor which found there is no coverage based on the Assignor’s material misrepresentations about her residence. The Court need not consider whether either party established their respective prima facie cases. The Defendant’s motion is GRANTED and the Plaintiff’s motion is DENIED as moot. The complaint is dismissed with prejudice. This constitutes the Decision and Order of the Court. Dated: February 8, 2021