Health East Ambulatory Surgical Center, etc. v. Country-Wide Insurance Company
Attorneys and Parties
Brief Summary
New York no-fault insurance (Personal Injury Protection (PIP)) reimbursement dispute involving evidentiary use of judicial admissions from motion papers and the insurer’s burden to prove verification requests that toll the 30-day payment period.
After a bench trial, the Civil Court admitted the insurer’s own summary judgment motion papers as a party admission establishing receipt of the claim, found the claim overdue because the insurer did not pay or deny within 30 days, and awarded damages to the provider.
The Appellate Term’s order that had reversed the Civil Court’s judgment.
The motion papers contained a judicial admission of receipt admissible without a sponsoring witness under Guide to NY Evid rule 8.04 [admission by a party opponent is not hearsay]. Assertions in the same papers that verification requests were sent were not admitted as evidence in chief, were not offered under the rule of completeness, were not preserved, and were not shown admissible as business records. Plaintiff made a prima facie case (Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498), defendant conceded it neither paid nor denied within 30 days, and defendant failed to carry its burden to prove timely verification requests.
Background
Health East, a medical provider, sought no-fault (PIP) reimbursement from Country-Wide for services to its assignor. At the nonjury trial, the provider introduced Country-Wide’s prior summary judgment motion papers, in which Country-Wide admitted receiving the provider’s claim. Country-Wide argued that it sent verification requests six days after receipt, but those assertions appeared only in affidavits within the motion papers and were not admitted into evidence at trial, and no business-record foundation was offered.
Lower Court Decision
The Civil Court admitted the insurer’s motion papers as a party admission establishing receipt of the claim, found the claim overdue because the insurer did not pay or deny within 30 days, rejected the unproven verification defense, and entered judgment for the provider.
Appellate Division Reversal
The Appellate Division unanimously reversed the Appellate Term and reinstated the Civil Court’s judgment, holding that the trial court properly admitted the insurer’s judicial admission of receipt (no witness required) and properly declined to admit the affidavits’ verification assertions as evidence in chief; the insurer failed to preserve any completeness objection and did not establish admissibility as business records. Because the insurer conceded it did not pay or deny within 30 days and failed to prove verification mailing, the claim was overdue.
Legal Significance
Confirms that an insurer’s statements in motion papers can be used at trial as party admissions and that affidavits in motion practice are not evidence in chief absent a proper evidentiary foundation. Clarifies that to toll the 30-day no-fault payment period, an insurer bears the burden to prove that verification requests were sent with admissible evidence; failure to do so renders the claim overdue.
A provider may establish its prima facie no-fault case with the insurer’s judicial admission of claim receipt; unless the insurer proves timely verification requests with admissible evidence, its failure to pay or deny within 30 days makes the claim overdue and warrants judgment for the provider.