Block v. Teachers Insurance

Order, Supreme Court, New York County (Beatrice Shainswit, J.), entered August 22, 2000, which granted defendant’s motion for summary judgment and dismissed the complaint as time barred, reversed, on the law, without costs, defendant’s motion denied, the complaint reinstated and the matter remanded for further proceedings. In granting defendant’s motion, the IAS court determined that plaintiffs cause of action accrued on January 23, 1995, the date when, at defendant’s request, she submitted to an examination by an independent medical examiner to substantiate her continued eligibility for disability benefits under defendant’s group policy. However, since there is nothing in the policy that defines such independent medical examination as part of any “Proof of Claim,” which itself is not defined in the policy, we think that, given the ambiguity in the policy, which must be construed against defendant, the appropriate date of accrual was on or about March 31, 1998, when defendant, by letter, denied plaintiffs request for reconsideration of defendant’s initial termination of her benefits on February 3, 1995. Contrary to the dissent’s statement that plaintiff waited until November 1997 to request reconsideration, by letter dated March 20, 1995 defendant acknowledged receipt of plaintiff’s February 13, 1995 request for reconsideration and that it would 299 initiate its review upon receipt of the medical evidence plaintiff indicated would be sent under separate cover. Thereafter, by letter dated January 26, 1996, defendant advised plaintiff that in order to review its decision, she would have to have her physician provide it with additional objective medical information that supported continuous total disability as defined in the policy. Clearly, plaintiff had ample reason to believe that defendant’s reconsideration of its termination of disability benefits was ongoing. Defendant ultimately stated in its March 31, 1998 letter that it had sent the relevant medical records to its medical expert for review and that, “based on the medical evidence which has been supplied to us * * * we are once again upholding our previous decision to terminate your claim for Long Term Disability Benefits.” The letter went on to advise plaintiff: “If you would like a review of our decision, [sic] A written request and objective medical information to support your opinion, should be submitted to us within sixty days of the receipt of this letter.” Significantly, for the first time in all its correspondence with plaintiff, defendant advised plaintiff of the policy’s shortened two year Statute of Limitations for an action or suit to recover under the policy. Further supporting our finding of ambiguity is defendant’s reliance upon the alternative accrual of February 28, 1997, the last day that benefits were paid under the policy. Under the circumstances presented, the accrual of plaintiff s breach of contract claims arose when her request for reconsideration was denied. Finally, although not determinative, we agree with defendant that the motion court incorrectly applied Insurance Law § 3216 (d) (1) (G) to extend the limitations period by a year. Concur — Rosenberger, J. P., Andrias and Marlow, JJ.