the no-fault
App. Term, 2nd Dept.
Vincent Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co., 32 Misc 3d 143(A) (App. Term, 2nd, 11th & 13th Jud. Dists. 2011)
In support of its cross motion, defendant submitted an affidavit of an employee of Allegiance which sufficiently established that the IME requests had been timely mailed in accordance with Allegiance's standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant also submitted an affidavit of the chiropractor/acupuncturist who was to perform the IMEs, which was sufficient to establish that plaintiff's assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). In addition, an affidavit executed by defendant's litigation examiner demonstrated that the claim denial forms, which denied the claims based on plaintiff's assignor's nonappearance at the IMEs, had been timely mailed pursuant to defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16). Since an assignor's appearance at an IME "is a condition precedent to the insurer's liability on the policy" (Stephen Fogel Psychological, P.C., 35 AD3d at 722; see also Insurance Department Regulations [11 NYCRR] § 65-1.1), defendant properly denied plaintiff's claims based upon the assignor's failure to satisfy a condition precedent to coverage and, thus, was not precluded from raising such issue (see Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045 [2d Dept 2009]). Accordingly, defendant's cross motion for summary judgment dismissing the complaint should have been granted. In light of our determination, we need not reach the remaining contentions raised on appeal.
PSW Chiropractic Care, P.C. v Maryland Cas. Co., 2011 NY Slip Op 51719(U) (App. Term, 2nd, 11th & 13th Jud. Dists. 2011)
At the nonjury trial of this action by a provider to recover assigned first-party no-fault benefits, the sole issue was the medical necessity of chiropractic treatment rendered to plaintiff's assignor. Defendant's expert medical witness, who had performed two independent medical examinations of plaintiff's assignor on defendant's behalf, testified that the chiropractic treatment at issue was not medically necessary. In a decision after trial, the Civil Court found in favor of plaintiff in the principal sum of $4,246.20. Defendant appeals from the decision. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5520 [c]).
The decision of a fact-finding court should not be disturbed upon appeal unless it is obvious that the court's conclusions could not be reached under any fair interpretation of the evidence (see Claridge Gardens v Menotti, 160 AD2d 544 [1990]). The determination of a trier of fact as to issues of credibility is given substantial deference, as a trial court's opportunity to observe and evaluate the testimony and demeanor of witnesses affords it a better perspective from which to assess their credibility (see Vizzari v State of New York, 184 AD2d 564 [1992]; Kincade v Kincade, 178 AD2d 510 [1991]).
In the present case, the record supports the determination of the Civil Court, based upon its assessment of the credibility of defendant's witness and the proof
adduced at trial, that defendant failed to satisfy its burden of proving that the disputed chiropractic services were not medically necessary. As we find no basis to disturb the Civil Court's findings, the judgment is affirmed.
Steinhardt, J.P., and Rios, J., concur.
Golia, J., dissents in a separate memorandum.
Golia, J., dissents and votes to reverse the judgment and direct the entry of judgment in favor of defendant dismissing the complaint, in the following memorandum:
In my opinion, the Civil Court's finding that defendant failed to demonstrate that the disputed services were not medically necessary was erroneous. The mandatory personal injury protection endorsement, as set forth in the no-fault regulations, requires insurers to reimburse an eligible injured person, or his or her assignee, for necessary expenses for medical services rendered "on account of personal injures caused by an accident arising out of the use or operation of a motor vehicle" (Insurance Department Regulations [11 NYCRR] § 65-1.1). In a trial of the present case, plaintiff's prima facie case consisted entirely of stipulated facts. No witness was called to the stand. The disputed medical services for which plaintiff now seeks recovery at this trial are for treatments that were provided after June 18, 2003.
Defendant, upon presentation of its case, produced the testimony of its doctor, who had performed two independent medical examinations of plaintiff's assignor. The doctor testified that the assignor's physical condition had returned to its pre-accident status. The doctor further testified that, as of the date of his second examination, June 18, 2003, there was no need for any further chiropractic treatment.
Inasmuch as there is no testimony contradicting defendant's doctor's testimony elicited by plaintiff at trial, credibility is not at issue. Consequently, the trial court's conclusion cannot be reached under any fair interpretation of the evidence before it. I question the majority's reliance on giving deference to the determination of the trier of fact as to a witness's credibility, when plaintiff's case was entered without the benefit of actual testimony of any witnesses. As such, I give credit to defendant's doctor's testimony and find that the condition being treated did not arise out of an insured incident and was not exacerbated by an insured incident.
Consequently, defendant should not be held liable for plaintiff's chiropractic treatment of the assignor herein (see Central General Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]).
Accordingly, I would reverse the judgment appealed from and direct that judgment be entered in favor of defendant dismissing the complaint.
EBM Med. Health Care, P.C. v Amica Mut. Ins. Co., 2011 NY Slip Op 51720(U) (App. Term, 2nd, 11th & 13th Jud. Dists. 2011)
A defendant moving for dismissal on statute of limitations grounds bears the initial burden of establishing, prima facie, that the time in which to sue has expired (see 6D
Farm Corp. v Carr, 63 AD3d 903 [2009]; Island ADC, Inc. v Baldassano Architectural Group, P.C., 49 AD3d 815 [2008]). The time within which an action must be commenced is computed "from the time the cause of action accrued to the time the claim is interposed" (CPLR 203 [a]). In this case, the claim was interposed when the summons and complaint were filed on June 27, 2007 (CCA 400). As the six-year statute of limitations for contract actions applies to the claims involved herein (CPLR 213 [2]; see Mandarino v Travelers Prop. Cas. Ins. Co., 37 AD3d 775 [2007]), the statute of limitations bars any claim that accrued prior to June 27, 2001.
In the no-fault context, a cause of action accrues when payment of no-fault benefits becomes "overdue" (see Insurance Law § 5106 [a]; see also Benson v Boston Old Colony Ins. Co., 134 AD2d 214 [1987]; New Era Acupuncture, P.C. v MVAIC, 18 Misc 3d 139[A], 2008 NY Slip Op 50353[U] [App Term, 2d & 11th Jud Dists 2008]). In this case, benefits became overdue 30 days after defendant's receipt of proof of the claim (see Insurance Law § 5106 [a]; former Insurance Department Regulations [11 NYCRR] § 65.15 [g], now Insurance Department Regulations [11 NYCRR] § 65-3.8; Aetna Life & Cas. Co. v Nelson, 67 NY2d 169, 175 [1986]). The complaint alleges that a claim form in the amount of $1,707.97 was submitted to defendant on June 6, 2001. In considering a motion to dismiss a complaint as barred by the statute of limitations, the court must take the factual allegations of the complaint as true, and must resolve all inferences in favor of the plaintiff (see Island ADC, Inc., 49 AD3d 815). We note that defendant's dismissal motion was based upon an allegation that defendant had received a bill for $1,467.95 on April 3, 2001, and that this bill, along with a bill for $240.02, are the bills which are the subject of this action. However, defendant failed to demonstrate that these two bills, one of which it claims to have received on April 3, 2001, are the subject of this action, where the complaint alleges that one bill for $1,707.97 was submitted on June 6, 2001.
As the earliest date defendant could have received the $1,707.97 bill was June 6, 2001 and the earliest date that benefits could have become overdue with respect to this bill was July 7, 2001, we find that defendant failed to meet its burden of establishing, prima facie, that the time in which to sue has expired.
LVOV Acupuncture, P.C. v Geico Ins. Co., 2011 NY Slip Op 51721(U) (App. Term, 2nd, 11th & 13th Jud. Dists. 2011)
We find that the workers' compensation fee schedule, which is required by law (see Workers' Compensation Law § 13) and incorporated by reference into the Insurance Department Regulations (see 11 NYCRR 68.1 [a]), is "of sufficient authenticity and reliability that it may be given judicial notice" (Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co., 61 AD3d 13, 20 [2009]; see also CPLR 4511 [b]). Defendant demonstrated that it had fully paid plaintiff for the services billed under codes 97810 and 97811 in accordance with the Official New York Workers' Compensation Chiropractic Fee Schedule (see Great Wall Acupuncture, P.C. v GEICO Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]). Since plaintiff did not object to the fee schedule amount set forth by the defense, nor contest the timely denial of the claims, so much of defendant's motion as sought summary judgment dismissing the complaint as to these claims is granted.
Defendant did not proffer any evidence or argument to warrant the dismissal of plaintiff's claim of $160.56 for the initial acupuncture visit on September 2, 2005, billed under fee schedule treatment code 99204 (cf. Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). Accordingly, we do not disturb so much of the order appealed from as granted the branch of plaintiff's motion seeking summary judgment as to this claim, and which denied defendant's cross motion insofar as it sought summary judgment dismissing the complaint as to this claim.
In light of the foregoing, the order is modified by providing that plaintiff's motion for summary judgment is granted only to the extent of awarding plaintiff summary judgment in the sum of $160.56 for the initial acupuncture visit on September 2, 2005 and is otherwise denied, and by further providing that defendant's cross motion for summary judgment is granted only to the extent of awarding summary judgment dismissing the remaining claims.
Radiology Today, P.C. v Progressive Ins. Co., 2011 NY Slip Op 51724(U)(App. Term, 2nd, 11th & 13th Jud. Dists. 2011)
The nonjury trial of this action by a provider to recover assigned first-party no-fault benefits was limited, pursuant to CPLR 3212 (g), to the issue of the medical necessity of the billed-for services. Before defendant called any witnesses, the Civil Court precluded the admission of defendant's peer review report into evidence, precluded the testimony of defendant's expert witness and granted plaintiff's motion for a directed verdict. Defendant appeals from the judgment that was subsequently entered.
Defendant's expert medical witness, who was not the expert who had prepared the peer review report upon which defendant's denial of the subject claim was based, should have been permitted to testify (see Psychology YM, P.C. v Geico Gen. Ins. Co., 32 Misc 3d 130[A], 2011 NY Slip Op 51316[U] [App Term, 2d, 11th & 13th Jud Dists 2011]; Dilon Med. Supply Corp. v New York Cent. Mut. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52454[U] [App Term, 2d & 11th Jud Dists 2007]). Under the circumstances presented, we do not reach the question of whether the peer review report could have been entered into evidence.
D & R Med. Supply v American Tr. Ins. Co., 2011 NY Slip Op 51727(U) (App. Term, 2nd, 11th & 13th Jud. Dists. 2011)
It is undisputed that defendant timely mailed its request and follow-up request for verification to plaintiff (see Insurance Department Regulations [11 NYCRR] § 65-3.5 [b]; § 65-3.6 [b]; St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). The record establishes that plaintiff's responses to defendant's verification requests failed to provide the information which defendant had requested, in that plaintiff merely stated that the supplies at issue had been provided pursuant to a doctor's prescription and did not advise defendant of the name of the doctor who had issued the prescription or where the doctor was located so that defendant could try to obtain the requested information from the prescribing doctor (see Urban Radiology, P.C. v Tri-State Consumer Ins. Co., 27 Misc 3d 140[A], 2010 NY Slip Op 50987[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Consequently, defendant's cross motion for summary judgment dismissing the complaint as premature should have been granted, as defendant's time to pay or deny the claim had not begun to run (see Insurance Department Regulations [11 NYCRR] § 65-3.8 [a]; Hospital for Joint Diseases v New York Cent. Mut. Fire Ins. Co., 44 AD3d 903 [2007]; Central Suffolk Hosp. v New York Cent. Mut. Ins. Co., 24 AD3d 492 [2005]; Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533 [2004]). In light of the foregoing, we reach no other issue.
Pesce, P.J., and Weston, J., concur.
Steinhardt, J., dissents in a separate memorandum.
Steinhardt, J., dissents and votes to affirm the order in the following memorandum:
Although I am in agreement with my learned colleagues regarding the timeliness of the mailings of defendant's request and follow-up request for verification, I disagree with the outcome arrived at by the majority. The information sought by defendant from plaintiff, i.e., 1) an initial report from the referring physician and 2) a letter of medical necessity from the referring physician, were never within plaintiff supply company's possession. In clear and concise language, it so advised defendant. Defendant neither revised its verification request nor paid the claim. Based on the outlined scenario, in the majority's view, the time for defendant to pay or deny the claim would never begin to run and the claim would be premature forever. In my opinion, plaintiff responded to defendant's request and follow-up request in a timely manner and defendant neither paid nor denied the claim that forms the subject matter of plaintiff's complaint within 30 days. Consequently, plaintiff is entitled to summary judgment in its favor.
Turnpike Med., P.C. v MVAIC, 2011 NY Slip Op 51717(U) (App. Term, 2nd, 11th & 13th Jud. Dists. 2011)
On appeal, defendant contends that plaintiff was not entitled to summary judgment because plaintiff's assignor was not a qualified person since he failed to provide defendant with written proof of lack of insurance. This argument lacks merit because plaintiff's assignor's status as a qualified person is not dependent upon defendant's receipt of these documents (see Insurance Law § 5202 [b]; Liberty Orthopedics, PLLC v MVAIC, 20 Misc 3d 136[A], 2008 NY Slip Op 51533[U] [App Term, 2d & 11th Jud Dists 2008]). As plaintiff established its prima facie entitlement to judgment as a matter of law (see New York Hosp. Med. Ctr. of Queens v Motor Veh. Acc. Indem. Corp., 12 AD3d 429 [2004]), and as defendant's remaining contentions are raised for the first time on appeal and are not properly before this court (see Terranova v Waheed Brokerage, Inc., 78 AD3d 1040 [2010]; Pierre v Lieber, 37 AD3d 572, 573 [2007]; Gouldborne v Approved Ambulance & Oxygen Serv., 2 AD3d 113, 114 [2003]; Ta-Chotani v Doubleclick, Inc., 276 AD2d 313 [2000]; Gordon v Hong, 126 AD2d 514 [1987]), the judgment is affirmed.
Weston, J.P., and Rios, J., concur.
Golia, J., concurs in a separate memorandum.
Golia, J., concurs with the result only in the following memorandum:
I am constrained to agree with the majority with regard to the issue of what constitutes a plaintiff's prima facie case in a no-fault action brought against the Motor Vehicle Accident Indemnification Corporation (MVAIC) in view of the Appellate Division's ruling in New York Hosp. Med. Ctr. of Queens v Motor Veh. Acc. Indem. Corp. (12 AD3d 429 [2004]; see also Matter of MVAIC v Interboro Med. Care & Diagnostic PC, 73 AD3d 667 [2010] ["the burden is on MVAIC to prove its lack-of-coverage defense"]).
I nevertheless disagree with the characterization of plaintiff as a "qualified" injured party.
Although defendant MVAIC does assert that it is entitled to receive proof of a "lack of insurance," its opposition to the underlying motion in the Civil Court was predicated upon plaintiff's failure to establish its prima facie case. In order to establish its case, plaintiff must, in my opinion, first establish, as a condition precedent, that it was entitled to collect no-fault benefits from MVAIC. That is, that there is no "private" insurance available. That was not done here.
The Insurance Law, coupled with the Insurance Department No-Fault Regulations, creates a somewhat complex statutory and definitional scheme. Nevertheless, its purpose was to achieve a logical and fair result. That purpose, in cases involving MVAIC, is to provide that an individual who is injured in an automobile accident and who did not violate the mandatory-insurance law will receive no-fault benefits. Providing, that is, that there is no "private" insurance company responsible for covering the loss. This is the last line of protection for individuals who are injured by someone who has violated the financial responsibility requirements of the Insurance Law. The Law also covers those injured in a "hit and run" accident. In the normal course of events, benefits are paid by a "private" insurance carrier which bears responsibility to the "covered" individual. However, if, and only if, there is no responsible "private" insurance carrier, then the "injured" individual is eligible to receive no-fault benefits from MVAIC.
MVAIC was created for the sole purpose of providing insurance coverage where there otherwise would be none. Consequently, unlike any other "private" carrier, if a claimant is seeking payment from MVAIC, that claimant must establish that it is eligible to receive payments from MVAIC in the first instance. Again, the claimant must establish prima facie, as a condition precedent, that there is no "private" insurance carrier responsible for his injuries. This fact is an immutable truth. MVAIC should not be required to raise the issue, as would be the case where the defendant is a "private" carrier. Therefore, this plaintiff should be required to plead and then prove the unavailability of any "private" insurance according to the Insurance Law. That is the requirement of any condition precedent and that requirement is supported by well- settled authority (see Katz v City of New York, 87 NY2d 241 [1995]).
In the case at bar, plaintiff did not even attempt to prove this condition precedent despite the fact that plaintiff, in its original complaint, did plead, "That at the time of the accident there was no existing insurance policy containing benefits as defined by 11 NYCRR 65.15 (K) (IV) under the New York State No Fault Law." Plaintiff here knew what was legally required of it and did plead this fact, but failed to prove it.
Accordingly, were it not for the constraint of the appellate authority to the contrary, I would hold that plaintiff failed to establish its prima facie case and would deny its motion.
Radiology Imaging of Queens v Progressive Ins., 2011 NY Slip Op 51860(U)
In support of its motion for summary judgment, defendant established that a denial of claim form, which denied the claim at issue on the ground of lack of medical necessity, was timely mailed in accordance with its standard office practices andprocedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant also submitted, among other things, an affirmed peer review report, which set forth a factual basis and medical rationale for the doctor's opinion that there was a lack of medical necessity for the rendered service. Consequently, defendant established its prima facie entitlement to summary judgment (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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]). Accordingly, defendant's unopposed motion for summary judgment dismissing the complaint should have been granted.
Padova Physical Rehab. Medicine, P.C. v Praetorian Ins. Co., 2011 NY Slip Op 51862(U)
In support of its motion, defendant submitted an affidavit of a manager employed by the independent medical review service retained by defendant to schedule and conduct IMEs, which sufficiently established that the IME notices had been timely mailed in accordance with that service's standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Inc. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant also submitted affirmations by the medical professionals who were retained to perform the IMEs, which affirmations were sufficient to establish that plaintiff's assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). In addition, an affidavit by defendant's examiner demonstrated the timely mailing of the claim denial forms, based on the assignor's nonappearance at the IMEs, pursuant to defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16). Since an assignor's appearance at an IME "is a condition precedent to the insurer's liability on the policy" (Stephen Fogel Psychological, P.C., 35 AD3d at 722; see also Insurance Department Regulations [11 NYCRR] § 65-1.1), defendant properly denied plaintiff's claims based upon the assignor's failure to satisfy a condition precedent to coverage and, thus, was not precluded from raising such issue (see Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045 [2d Dept 2009]; but see Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559 [1st Dept 2011]).
New York Hosp. Med. Ctr. of Queens v Statewide Ins. Co., 2011 NY Slip Op 51863(U) (App. Term, 9th & 10th Jud. Dists., 2011)
A no-fault provider establishes its prima facie entitlement to summary judgment by proof of the submission to the defendant of a claim form, proof of the fact and the amount of the loss sustained, and proof either that the defendant failed to pay or deny the claim within the requisite 30-day period, or that the defendant 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 AD3d 1168 [2010]; see also New York & Presbyt. Hosp. v Allstate Ins. Co., 31 AD3d 512 [2006]). In order for a claim form to constitute prima facie proof of the fact and the amount of the loss sustained, the affidavit submitted by a plaintiff in support of its motion for summary judgment must lay a sufficient foundation to establish that the claim form annexed thereto is admissible under the business records exception to the hearsay rule, which allows a document to be used as proof of the "act, transaction, occurrence or event" recorded in the document (CPLR 4518 [a]; see Matter of Carothers v GEICO Indem. Co., 79 AD3d 864 [2010]; Art of Healing Medicine, P.C. v Travelers Home & Mar. Ins. Co., 55 AD3d 644 [2008]; Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 31 Misc 3d 21 [App Term, 2d, 11th & 13th Jud Dists 2011]; King's Med. Supply, Inc. v Hereford Ins. Co., 5 Misc 3d 55 [App Term, 9th & 10th Jud Dists 2004]).
In the case at bar, plaintiff's submission of a third-party affidavit failed to demonstrate that the NF-5 hospital facility form or the UB04, which was incorporated by reference into the NF-5 and which listed the services provided by the hospital, was plaintiff's business record and therefore admissible as proof that, for example, those services were rendered (see Matter of Carothers, 79 AD3d 864; King's Med. Supply, Inc., 5 Misc 3d 55). Accordingly, the order is affirmed.
MSSA Corp. v American Tr. Ins. Co., 2011 NY Slip Op 51864(U)
In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The Civil Court found, pursuant to CPLR 3212 (g), that plaintiff had established its prima facie case, that defendant had demonstrated that it had timely denied plaintiff's claim and that the sole issue for trial was the medical necessity of the supplies provided to plaintiff's assignor. Defendant appeals from so much of the order as denied its cross motion for summary judgment dismissing the complaint.
In support of its cross motion, defendant submitted, among other things, an affirmed peer review report, which set forth a factual basis and medical rationale for the doctor's determination that there was a lack of medical necessity for the medical supplies at issue. Defendant's showing that the supplies were not medically necessary was unrebutted by plaintiff.
In light of the foregoing, and the Civil Court's CPLR 3212 (g) finding that defendant "established the issue of timely denials," a finding which plaintiff does not dispute, defendant's cross motion for summary judgment dismissing the complaint should have been granted (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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]).
AIM Acupuncture, P.C. v Encompass Ins., 2011 NY Slip Op 51874(U)
For the reasons stated in AIM Acupuncture, P.C. as Assignee of Alexander Kerron v Encompass Ins. (___ Misc 3d ___, 2011 NY Slip Op _____ [Appeal No. 2009-1018 Q C], decided herewith), the judgment is affirmed.
Pesce, P.J., and Rios, J., concur.
Steinhardt, J., dissents in a separate memorandum.
Steinhardt, J., dissents and votes to reverse the judgment, vacate the order entered March 25, 2009 and deny plaintiff's motion for summary judgment in the following memorandum:
For the reasons stated in my dissent in AIM Acupuncture, P.C. as Assignee of Alexander Kerron v Encompass Ins. (___ Misc 3d ___, 2011 NY Slip Op _____ [Appeal No. 2009-1018 Q C], decided herewith), I vote to reverse the judgment, vacate the order entered March 25, 2009 and deny plaintiff's motion for summary judgment.
Stracar Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co., 2011 NY Slip Op 51875(U)
CPLR 3101 (a) directs "full disclosure of all matter material and necessary in the prosecution or defense of an action, regardless of the burden of proof." Pursuant to CPLR 3124, the court may grant an order compelling discovery and "a trial court is given broad discretion to oversee the discovery process" (Maiorino v City of New York, 39 AD3d 601, 601 [2007], quoting Castillo v Henry Schein, Inc., 259 AD2d 651, 652 [1999]; see also Gillen v Utica First Ins. Co., 41 AD3d 647 [2007]). Absent an improvident exercise of that discretion, the court's determination will not be disturbed on appeal (see Matter of US Pioneer Elecs. Corp. [Nikko Elec. Corp. of Amer.], 47 NY2d 914, 916 [1979]; Gillen v Utica First Ins. Co., 41 AD3d 647). Upon a review of the record, we find that the Civil Court did not improvidently exercise its discretion. Accordingly, the order, insofar as appealed from, is affirmed.
Mosad Med., P.C. v Praetorian Ins. Co, 2011 NY Slip Op 51876(U)
In support of its cross motion, defendant submitted, among other things, an affirmed peer review report, which set forth a factual basis and medical rationale for the doctor's determination that there was a lack of medical necessity for the medical services at issue. The affirmation from plaintiff's doctor failed to meaningfully refer to, let alone rebut, the conclusions set forth in the peer review report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).
In light of the foregoing, and the Civil Court's implicit CPLR 3212 (g) finding that defendant had established that it had timely denied the claim, a finding which plaintiff does not dispute, defendant's cross motion for summary judgment dismissing the complaint should have been granted (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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]).
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co., 2011 NY Slip Op 51877(U)
After the trial of this action by a provider to recover assigned first-party no-fault benefits, the Civil Court granted defendant's motion for a directed verdict and dismissed the complaint. The court found that plaintiff had not established that the claim at issue was overdue, as the testimony of plaintiff's witness was not based upon personal knowledge. We agree. Accordingly, the judgment is affirmed.
BLR Chiropractic, P.C. v MVAIC, 2011 NY Slip Op 51878(U)
Since plaintiff and its assignor were aware of the identity of the owner of the vehicle in which the assignor had been a passenger at the time of the accident, plaintiff, as assignee, was required to exhaust its remedies against the vehicle's owner before seeking relief from MVAIC (Hauswirth v American Home Assur. Co., 244 AD2d 528 [1997]; Modern Art Med., P.C. v MVAIC, 22 Misc 3d 126[A], 2008 NY Slip Op 52586[U] [App Term, 2d & 11th Jud Dists 2008]; Doctor Liliya Med., P.C. v MVAIC, 21 Misc 3d 143[A], 2008 NY Slip Op 52453[U] [App Term, 2d & 11th Jud Dists 2008]; Dr. Abakin, D.C., P.C. v MVAIC, 21 Misc 3d 134[A], 2008 NY Slip Op 52186[U] [App Term, 2d & 11th Jud Dists 2008]; Complete Med. Servs. of NY, P.C. v MVAIC, 20 Misc 3d 137[A], 2008 NY Slip Op 51541[U] [App Term, 2d & 11th Jud Dists 2008]). As plaintiff did not demonstrate that it had exhausted its remedies against the owner of the vehicle, the judgment is reversed, the order is vacated, plaintiff's motion for summary judgment is denied and defendant's cross motion for summary judgment dismissing the complaint is granted.
Trimed Med. Supply, Inc. v American Tr. Ins. Co., 2011 NY Slip Op 51880(U)
As defendant served discovery responses less than one week later than required by a so-ordered discovery stipulation, we find, under the totality of the circumstances presented, that the Civil Court did not improvidently exercise its discretion in declining to preclude defendant from offering evidence in this matter and in denying the branch of plaintiff's motion seeking summary judgment (see Conciatori v Port Auth. of NY & N.J., 46 AD3d 501 [2007]).
With respect to defendant's cross motion for summary judgment dismissing the complaint, we find that defendant demonstrated that its claim denial forms were timely mailed in accordance with defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). As to the claims for $341.34, $195.50 and $795, defendant submitted an affirmed peer review report which set forth a factual basis and medical rationale for the doctor's determination that there was a lack of medical necessity for the medical supplies at issue. Defendant's showing was not rebutted by plaintiff. Consequently, defendant's cross motion for summary judgment dismissing the complaint should have been granted as to these claims (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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]).
The papers submitted in support of defendant's cross motion indicate that, while plaintiff's claim for $178 was not submitted within 45 days of the provision of the equipment at issue, plaintiff offered an explanation for the claim's untimeliness (see Insurance Department Regulations [11 NYCRR] § 65-3.3 [e]), and there is an issue of fact as to the reasonableness of that explanation (see Zuckerman v City of New York, 49 NY2d 557 [1980]). Consequently, defendant's cross motion for summary judgment was properly denied as to this claim.
Jamaica Med. Supply, Inc. v NY Central Mut. Fire Ins. Co., 2011 NY Slip Op 21359
In Roggio, the Court of Appeals held that a claimant who elected to arbitrate disputed claims for first-party no-fault benefits waived the right to commence an action to litigate subsequent claims arising from the same accident (see also Cortez v Countrywide Ins. Co., 17 AD3d 508 [2005]). However, a prior arbitration proceeding involving a different claimant provider does not preclude another provider from commencing its own action seeking reimbursement of assigned no-fault benefits, even though the claims may arise from the same accident (see A.B. Med. Servs. PLLC v USAA Gen. Indem. Co., 9 Misc 3d 19 [App Term, 2d & 11th Jud Dists 2005]). "Pursuant to Insurance Law § 5106 (b), each claimant provider may independently exercise the right to elect to submit their respective claims to arbitration, and the election to arbitrate by one provider does not bar another provider from resorting to the court in the first instance for resolution of disputed no-fault benefits . . . Moreover, in the absence of privity between the providers, the determination in the prior arbitration proceeding cannot be accorded res judicata or collateral estoppel effect against plaintiffs in the instant action" (id. at 23). Since plaintiff was not involved in the prior arbitration proceeding, and since there was no showing of privity between plaintiff and the provider who was a party to that proceeding, plaintiff was not barred from commencing the instant action, and it was error for the Civil Court to dismiss the complaint without prejudice to plaintiff's pursuing the matter in arbitration.
With respect to defendant's alternative ground for dismissal, we find that defendant did not establish its prima facie entitlement to summary judgment based on its lack of coverage defense "premised on the fact or founded belief that the alleged injury does not arise out of an insured incident" (Central Gen. Hosp. v Chubb Group of Ins. Cos., 90 NY2d 195, 199 [1997]), as the proof offered in support of this branch of its motion seeking summary judgment was not in admissible form (see LMS Med. Care, P.C. v State Farm Mut. Auto. Ins. Co., 15 Misc 3d 141[A], 2007 NY Slip Op 51072[U] [App Term, 2d & 11th Jud Dists 2007]; A.B. Med. Servs. PLLC v Utica Mut. Ins. Co., 10 Misc 3d 50, 52 [App Term, 2d & 11th Jud Dists 2005]). Consequently, defendant's motion should have been denied in its entirety.
Accordingly, the order is reversed, defendant's motion to dismiss the complaint is denied, and the complaint is reinstated.
Pesce, P.J., and Rios, J., concur.
Steinhardt, J., dissents in a separate memorandum.
Steinhardt, J., dissents and votes to affirm the order in the following memorandum:
Although I am in full agreement with the majority that plaintiff is not limited as to the choice of forum (A.B. Med. Servs. PLLC v USAA Gen. Indem. Co., 9 Misc 3d 19 [App Term, 2d & 11th Jud Dists 2005]), I would affirm the order because I believe plaintiff's case should be dismissed with prejudice. The dismissal by the arbitrator in the prior proceeding involving the assignor herein should be binding on this court. It was previously determined that Klever Guaman was not present in the motor vehicle at the time and place of the accident that allegedly caused his injuries. The police report submitted in support of defendant's motion clearly indicates that the only people present in the respective vehicles were the drivers. In other words, Guaman's claim of being in the passenger seat of the car being driven by Joffre Gonzalez is belied by the police officer's observation at the scene. Were the police officer to testify, that portion of the report would be admissible. The arrest report, wherein Guaman admits that he was not involved in the accident for which a provider sought to recover no-fault benefits, is, in this writer's opinion, an admission against interest and, therefore, admissible evidence that may be considered on a motion for summary judgment. I would dismiss plaintiff's complaint on the theory that the assignor is a person not entitled to recover.
Fine Healing Acupuncture, P.C. v Country-Wide Ins. Co., 2011 NY Slip Op 21361
Although plaintiff contends that defendant's neurologist was not competent to give an opinion on the medical necessity of the acupuncture services rendered, we note that the Insurance Department has stated in an opinion letter, to which we must accord great deference (see LMK Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co., 12 NY3d 217 [2009]; see also Allstate Social Work & Psychological Servs., PLLC v Utica Mut. Ins. Co., 30 Misc 3d 90 [App Term, 2d, 11th & 13th Jud Dists 2011]), that there is no requirement that a claim denial be based upon a medical examination conducted by a health provider of the same specialty area as the treating provider (see 2004 Ops Ins Dept No. 04-03-10). As there was a factual basis and medical rationale for the doctor's determination that there was a lack of medical necessity for the acupuncture services provided to plaintiff's assignor (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]), the burden shifted to plaintiff to rebut defendant's prima facie showing (see Alur Med. Supply, Inc. v Clarendon Natl. Ins. Co., 27 Misc 3d 132[A], 2010 NY Slip Op 50700[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).
Upon a review of the record, we find that the affidavit of plaintiff's treating acupuncturist was sufficient to raise a triable issue of fact as to whether the acupuncture services rendered to plaintiff's assignor were medically necessary (see Quality Psychological Servs., P.C. v Mercury Ins. Group, 27 Misc 3d 129[A], 2010 NY Slip Op 50601[U] [App Term, 2d, 11th & 13th Dists 2010]). Accordingly, the judgment dismissing plaintiff's complaint is reversed, so much of the order as granted defendant's cross motion for summary judgment dismissing the complaint is vacated, and defendant's cross motion for summary judgment is denied.
Peace of Mind, Social Work, P.C. v MVAIC, 2011 NY Slip Op 51834(U)
In its decision, the Civil Court stated that although plaintiff had submitted the claim form more than 45 days after the services had been rendered, MVAIC had failed to establish that its denial of plaintiff's claim advised plaintiff that the untimely submission of the claim form would be excused if plaintiff had a reasonable excuse for the untimely submission (Insurance Department Regulations [11 NYCRR] § 65-3.3 [e]). As a result, the court awarded judgment to plaintiff.
"The filing of a timely affidavit providing the MVAIC with notice of intention to file a claim is a condition precedent to the right to apply for payment from [MVAIC]' (see Insurance Law § 5208 [a] [1], [3]). Compliance with the statutory requirement of timely filing a notice of claim must be established in order to demonstrate that the claimant is a covered person,' within the meaning of the statute, entitled to recover no-fault benefits from the MVAIC (see Insurance [*2]Law § 5221 [b] [2]; Ocean Diagnostic Imaging v Motor Veh. Acc. Indem. Corp., 8 Misc 3d 137[A], 2005 NY Slip Op 51271[U] [App Term, 2d & 11th Jud Dists 2005])" (A.B. Med. Servs. PLLC v Motor Veh. Acc. Indem. Corp., 10 Misc 3d 145[A], 2006 NY Slip Op 50139[U], *3 [App Term, 2d & 11th Jud Dists 2006]; see also M.N.M. Med. Health Care, P.C. v MVAIC, 22 Misc 3d 128[A], 2009 NY Slip Op 50041[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Bell Air Med. Supply, LLC v MVAIC, 16 Misc 3d 135[A], 2007 NY Slip Op 51607[U] [App Term, 2d & 11th Jud Dists 2007]). As plaintiff did not establish that a notice of intention to make claim form was submitted to MVAIC, plaintiff failed to establish its prima facie case (Insurance Law § 5202 [b]; §§ 5208, 5221 [b] [2]). Accordingly, the judgment is reversed and the matter is remitted to the Civil Court for the entry of a judgment dismissing the complaint.
Complete Med. Servs. of NY, P.C. v MVAIC, 2011 NY Slip Op 51835(U)
Although MVAIC contends that plaintiff's assignor failed to demonstrate that she was a resident of New York State (see Insurance Law § 5202 [b]), the record establishes that defendant received the notarized notice of intention to make claim form, executed by plaintiff's assignor one day after the accident, which form sets forth the New York residence of plaintiff's assignor (see generally Insurance Law § 5221 [b] [2]). In addition, plaintiff's moving papers establish that plaintiff's claim form for the services at issue was mailed to MVAIC (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), that the claim was not paid, that MVAIC did not timely deny plaintiff's claim and that the claim form was admissible pursuant to CPLR 4518 (see Art of Healing Medicine, P.C. v Travelers Home & Mar. Inc. Co., 55 AD3d 644 [2008]; Dan Med., P.C. v New York Cent. Mut. Fire Ins. Co., 14 Misc 3d 44 [App Term, 2d & 11th Jud Dists 2006]). In light of the foregoing, plaintiff made a prima facie showing of its entitlement to summary judgment (see New York & Presbyt. Hosp. v Allstate Ins. Co., 31 AD3d 512 [2006]; cf. Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]).
Park v Zurich American Ins. Co., 2011 NY Slip Op 51836(U)
Contrary to plaintiff's contention, the affidavit of defendant's no-fault specialist sufficiently established that the denial of claim forms, which denied plaintiff's claims on the ground that they had been submitted more than 45 days after the services at issue had been rendered (Insurance Department Regulations [11 NYCRR] § 65-3.3 [e]), were timely mailed in accordance with defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). However, as defendant did not demonstrate that its denial of claim forms advised plaintiff that late submission of the proofs of claim would be excused if plaintiff could provide a reasonable justification for the late submissions (Insurance Department Regulations [11 NYCRR] § 65-3.3 [e]), defendant failed to establish its entitlement to summary judgment dismissing the complaint (see Zuckerman v City of New York, 49 NY2d 557 [1980]; Delta Diagnostic Radiology, P.C. v Interboro Ins. Co., 25 Misc 3d 134[A], 2009 NY Slip Op 52222[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; SZ Med. P.C. v Country-Wide Ins. Co., 12 Misc 3d 52 [App Term, 2d & 11th Jud Dists 2006]).
Viviane Etienne Med. Care, P.C. v Auto One Ins. Co., 2011 NY Slip Op 51837(U)
Plaintiff failed to serve responses to the demands within the 60-day period provided for in the Civil Court's order of July 16, 2008. Moreover, the responses which plaintiff served after defendant had made its cross motion were incomplete. A conditional order of preclusion becomes absolute upon a party's failure to timely and sufficiently comply therewith (see Panagiotou v Samaritan Vil., Inc., 66 AD3d 979 [2009]; State Farm Mut. Auto. Ins. Co. v Hertz Corp., 43 AD3d 907 [2007]; Siltan v City of New York, 300 AD2d 298 [2002]). To avoid the adverse impact of the conditional order of preclusion, plaintiff was required to demonstrate a reasonable excuse for the failure to timely comply with the order and the existence of a meritorious cause of action (see Panagiotou, 66 AD3d at 980; State Farm Mut. Auto. Ins. Co., 43 AD3d at 908). Plaintiff failed to meet this burden. As the preclusion order became absolute, plaintiff is unable to offer any evidence at trial in this action. Consequently, the Civil Court properly granted defendant's cross motion to dismiss the complaint.
Delta Diagnostic Radiology, P.C. v Autoone Ins. Co., 2011 NY Slip Op 51839(U)
In support of its motion, defendant submitted an affidavit of a manager employed by the company retained by defendant to schedule the IMEs. The affidavit established that the IME scheduling letters had been timely mailed pursuant to the affiant's employer's standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant also submitted an affidavit of the chiropractor who was to perform the IMEs to establish that plaintiff's assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). The appearance of the assignor at an IME is a condition precedent to the insurer's liability on the policy (see Insurance Department Regulations [11 NYCRR] § 65-1.1; Stephen Fogel Psychological, P.C., 35 AD3d at 721). Consequently, the judgment is affirmed.
Fiutek v Clarendon Natl. Ins. Co., 2011 NY Slip Op 51840(U)
Also included among defendant's moving papers was an affidavit from its claims examiner, which set forth defendant's standard office practices and procedures for mailing denial of claim forms. Among other things, he stated that, pursuant to defendant's standard office practices and procedures, denial of claims forms are mailed on the date they are generated. However, with respect to plaintiff's claim for services rendered between July 5, 2006 and July 31, 2006, while the denial of claim form pertaining to this claim is dated August 23, 2006, defendant's claims examiner averred that it was mailed on September 26, 2006. As a result, there is an issue of fact with respect to defendant's mailing of this denial of claim form (see Zuckerman v City of New York, 49 NY2d 557 [1980]). With respect to the remaining claims at issue, defendant's claim examiner established that defendant's denial of claim forms, which denied these claims based upon plaintiff's assignor's failure to appear for the IMEs, had been timely mailed in accordance with defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16).
Lynbrook Med., P.C. v GEICO Gen. Ins. Co., 2011 NY Slip Op 51841(U)
Defendant established that the denial of claim forms, which denied plaintiffs' claims on the grounds of lack of medical necessity and that payment had been made in accordance with the workers' compensation fee schedule, had been timely mailed in accordance with defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Inasmuch as plaintiffs failed to show that the grounds for the denials were conclusory, vague or without merit as a matter of law, plaintiffs failed to make a prima facie showing of their entitlement to judgment as a matter of law (see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]). As a result, we need not consider the sufficiency of defendant's paper's submitted in opposition to the motion (see id.). Accordingly, the order, insofar as appealed from, is affirmed.
Z.A. Acupuncture, P.C. v Geico Ins. Co., 2011 NY Slip Op 51842(U)
We find that the workers' compensation fee schedule, which is mandated by law (see Workers' Compensation Law § 13) and incorporated by reference into the Insurance Department Regulations (see 11 NYCRR 68.1 [a]), is "of sufficient authenticity and reliability that it may be given judicial notice" (Kingsbrook Jewish Med. Ctr. v Allstate Ins. Co., 61 AD3d 13, 20 [2009]; see also CPLR 4511 [b]). Defendant demonstrated that it had fully paid plaintiff for the services rendered between November 17, 2005 and January 19, 2006 in accordance with the Official New York Workers' Compensation Chiropractic Fee Schedule and that it had issued partial denials on that ground (see Great Wall Acupuncture, P.C. v GEICO Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]). It is noted that defendant's submissions also demonstrate that services billed under former fee schedule treatment code 97780, which at the time the services were rendered should have been billed under the new fee schedule treatment code, 97810, were properly re-coded accordingly. Consequently, the branches of defendant's cross motion seeking summary judgment dismissing the complaint as to these claims are granted.
The claims for services rendered between January 23, 2006 and March 9, 2006, were denied on the ground of lack of medical necessity. In support of its cross motion, defendant annexed a report written by the acupuncturist who had performed an independent medical examination (IME), as well as the acupuncturist's affidavit attesting to the truth of the report, which established, prima facie, a lack of medical necessity for any services rendered after the IME took place, including these services. Contrary to plaintiff's assertion on appeal, plaintiff did not submit opposition to defendant's cross motion, nor was there any admissible evidence in the record establishing the medical necessity of the services rendered in order to raise an issue of fact (see CPLR 2219 [a]; Zuckerman v City of New York, 49 NY2d 557 [1980]). Consequently, the branches of defendant's cross motion seeking summary judgment dismissing the complaint as to the claims for these services are granted (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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]).
Points of Health Acupuncture, P.C. v GEICO Ins. Co., 2011 NY Slip Op 51843(U)
Defendant failed to establish why it changed the fee schedule treatment code for several of the services rendered between July 5, 2006 and July 17, 2006, and between July 28, 2006 and August 10, 2006. Accordingly, the branches of defendant's cross motion seeking summary judgment dismissing the complaint as to these claims were properly denied.
The claims for services rendered between August 14, 2006 and September 11, 2006 were denied on the ground of lack of medical necessity. In support of its cross motion, defendant annexed peer review reports, as well as affidavits executed by the acupuncturists who had performed the peer reviews, which set forth a factual basis and medical rationale for the conclusions that there was a lack of medical necessity for those services. Contrary to plaintiff's assertion on appeal, plaintiff did not submit opposition to defendant's cross motion, nor was there any admissible evidence in the record establishing the medical necessity of these services in order to raise an issue of fact (see CPLR 2219 [a]; Zuckerman v City of New York, 49 NY2d 557 [1980]). Consequently, the branches of defendant's cross motion seeking summary judgment dismissing the complaint as to these claims are granted (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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]).
LVOC Acupuncture, P.C. v GEICO, 2011 NY Slip Op 51844(U)
Defendant did not proffer any evidence or argument to warrant the dismissal of plaintiff's claim of $160.56 for the initial acupuncture visit on May 20, 2005, billed under fee schedule treatment code 99204 (cf. Rogy Med., P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). Accordingly, we do not disturb so much of the order appealed from as granted the branch of plaintiff's motion seeking summary judgment as to this claim.
We decline defendant's request that we search the record and grant defendant summary judgment as to the claims for services rendered between September 1, 2005 and September 6, 2005 (see e.g. New York Univ. Hosp. Rusk Inst. v Government Empls. Ins. Co., 39 AD3d 832 [2007]).
Accordingly, the order, insofar as appealed from, is modified by providing that the branches of plaintiff's motion seeking summary judgment as to the claims for services rendered between May 20, 2005 and August 26, 2005 are granted only to the extent of awarding plaintiff summary judgment in the sum of $160.56 for the initial acupuncture visit on May 20, 2005 and are otherwise denied, and, upon searching the record, partial summary judgment is awarded to defendant dismissing the remaining claims for these services.
LVOV Acupuncture, P.C. v GEICO Ins. Co., 2011 NY Slip Op 51845(U)
Defendant did not proffer any evidence or argument to warrant the dismissal of plaintiff's claim of $160.56 for the initial acupuncture visit on October 6, 2005, billed under fee schedule treatment code 99204 (cf. Rogy Medical, P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). Accordingly, we do not disturb so much of the order appealed from as granted the branch of plaintiff's motion seeking summary judgment as to this claim, and which denied defendant's cross motion insofar as it sought summary judgment dismissing the complaint as to this claim.
In light of the foregoing, the order is modified by providing that plaintiff's motion for summary judgment is granted only to the extent of awarding plaintiff summary judgment in the sum of $160.56 for the initial acupuncture visit on October 6, 2005 and is otherwise denied, and by further providing that defendant's cross motion for summary judgment is granted only to the extent of awarding summary judgment dismissing the remaining claims.
Five Boro Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co., 2011 NY Slip Op 51846(U)
The affidavits submitted by defendant established that the EUO scheduling letters and the denial of claim form were timely mailed in accordance with its standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant also submitted an affirmation from one of the attorneys who was responsible for conducting the EUOs at issue, which established that plaintiff had failed to appear at either of the duly scheduled EUOs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]; W & Z Acupuncture, P.C. v Amex Assur. Co., 24 Misc 3d 142[A], 2009 NY Slip Op 51732[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). Such an appearance at an EUO is a condition precedent to an insurer's liability on a policy (see Insurance Department Regulations [11 NYCRR] § 65-1.1; Stephen Fogel Psychological, P.C., 35 AD3d at 722; Crotona Hgts. Med., P.C. v Farm Family Cas. Ins. Co., 27 Misc 3d 134[A], 2010 NY Slip Op 50716[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Furthermore, contrary to the Civil Court's determination, there is no requirement that EUO scheduling letters conspicuously highlight the information contained therein (see Insurance Department Regulations [11 NYCRR] § 65-3.5 [b], [e]). Accordingly, the order is reversed, plaintiff's motion for summary judgment is denied and defendant's cross motion for summary judgment dismissing the complaint is granted.
Alfa Medical Supplies, Inc. v Auto One Ins. Co., 2011 NY Slip Op 51851(U)
Contrary to plaintiff's assertion, the fact that the peer reviewer took into consideration medical records of other providers in formulating his opinion did not render the peer review reports inadmissible (see Urban Radiology, P.C. v Tri-State Consumer Ins. Co., 27 Misc 3d 140[A], 2010 NY Slip Op 50987[U] [App Term, 2d, 11th & 13th Jud Dists 2010]).
PMR Physical Therapy v GEICO Gen. Ins. Co., 2011 NY Slip Op 51852(U)
"Plaintiff's motion for summary judgment was supported by an affidavit of the president of a third-party billing company, who did not demonstrate that he possessed personal knowledge of plaintiff's business practices and procedures to establish that the documents annexed to plaintiff's motion papers constituted evidence in admissible form pursuant to CPLR 4518. As a result, plaintiff failed to make a prima facie showing of its entitlement to summary judgment" (PMR Physical Therapy v Country-Wide Ins. Co., 20 Misc 3d 127[A], 2010 NY Slip Op 51729[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; see Matter of Carothers v GEICO Indem. Co., 79 AD3d 864 [2010]; Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 31 Misc 3d 21 [App Term, 2d, 11th & 13th Jud Dists 2011]).
Parkway Imaging & Diagnostic, P.C. v Clarendon Natl. Ins. Co., 2011 NY Slip Op 51853(U)
In support of its motion, defendant submitted an affidavit of the president of Media Referral, Inc., the independent medical review service retained by defendant to schedule IMEs, which affidavit sufficiently established that the IME requests had been timely mailed in accordance with Media Referral, Inc.'s standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant also submitted an affirmation of the doctor who was retained to perform the IMEs, which was sufficient to establish that plaintiff's assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). In addition, an affidavit executed by defendant's claims examiner demonstrated that the claim denial form, based on plaintiff's assignor's nonappearance at the IMEs, had been timely mailed pursuant to defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16). Since an assignor's appearance at an IME "is a condition precedent to the insurer's liability on the policy" (Stephen Fogel Psychological, P.C., 35 AD3d at 722; see also Insurance Department Regulations [11 NYCRR] § 65-1.1), defendant properly denied plaintiff's claim based upon the assignor's failure to satisfy a condition precedent to coverage and, thus, was not precluded from raising such issue (see Westchester Med. Ctr. v Lincoln Gen. Ins. Co., 60 AD3d 1045 [2d Dept 2009]; but see Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559 [1st Dept 2011]). The opposing affirmation submitted by plaintiff's counsel was insufficient to raise a triable issue of fact.
S.M. LAC, LLP v Nationwide Mut. Ins. Co., 2011 NY Slip Op 51857(U)
Although plaintiff asserts that it attempted to submit opposition to defendant's motion, it acknowledges that the Civil Court rejected the papers as untimely. Thus, the order deciding the motion recites that the court considered only the moving papers (see CPLR 2219 [a]). In this posture, the judgment entered pursuant to the order must be considered as having been entered on default, and no appeal lies therefrom by the defaulting party (see CPLR 5511; Coneys v Johnson Controls, Inc., 11 AD3d 576 [2004]; Marino v Termini, 4 AD3d 342 [2004]; Millennium Med. Instruments v MVAIC, 27 Misc 3d 127[A], 2010 NY Slip Op 50583[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; Infinity Chiropractic, P.C. v New York Cent. Mut. Ins. Co., 14 Misc 3d 138 [A], 2007 NY Slip Op 50262[U] [App Term, 2d & 11th Jud Dists 2007]). Accordingly, the appeal is dismissed.
Crotona Hgts. Med., P.C. v New York Cent. Mut. Fire Ins. Co., 2011 NY Slip Op 51859(U)
Contrary to defendant's contention on appeal, the claim at issue in the sixth cause of action was not denied based upon medical necessity. Since defendant failed to demonstrate that the medical necessity defense was preserved as to this claim, and further failed to establish the defense actually set forth in the denial of claim form, the branch of defendant's cross motion seeking the dismissal of this cause of action was properly denied. Furthermore, defendant did not proffer sufficient evidence to warrant the dismissal of the claim underlying the seventh cause of action, for an office visit. While defendant asserts that its partial payment was made at the proper, although reduced, rate, defendant failed to substantiate this assertion (cf. Rogy Medical, P.C. v Mercury Cas. Co., 23 Misc 3d 132[A], 2009 NY Slip Op 50732[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).
App. Term, 1st Dept.
Pomona Med. Diagnostic, P.C. v MVAIC, 2011 NY Slip Op 51891(U) (App. Term, 1st 2011)
In this action to recover assigned no-fault benefits, Civil Court properly denied defendant's motion for summary judgment dismissing the claim. Defendant failed to meet its burden to establish, prima facie, that plaintiff's assignor was not a "qualified person" entitled to no-fault coverage (see Englington Med., P.C. v Motor Veh. Acc. Indem. Corp., 81 AD3d 223, 229 [2011]; Matter of MVAIC v Interboro Med. Care & Diagnostic PC, 73 AD3d 667 [2010]). Nor has defendant shown, on this record, that plaintiff was required to "exhaust its remedies" prior to seeking reimbursement (see Omega Diagnostic Imaging, P.C. v MVAIC, 30 Misc 3d 145[A], 2011 NY Slip Op 50432[U] [2011]; Omega Diagnostic Imaging, P.C. v MVAIC., 29 Misc 3d 129[A], 2010 NY Slip Op 51779[U] [2010]).
Multi-Specialty Pain Mgt. PC v New York Cent. Mut. Fire Ins. Co., 2011 NY Slip Op 51677(U)(App. Term, 1st 2011)
In this action to recover assigned first-party no-fault benefits, defendant's submissions established prima facie that it properly mailed initial and follow-up notices of independent medical examinations (IMEs) to the assignor and her attorney, and that the assignor failed to appear (see Unitrin Advantage Ins. Co. v Bayshore Physical Therapy, PLLC, 82 AD3d 559, 560 [2011]; Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720, 721 [2006]). In opposition, plaintiff failed to raise a triable issue regarding the reasonableness of the IME requests or the assignor's failure to attend (see Unitrin Advantage Ins. Co., 82 AD3d at 560; Inwood Hill Med., P.C. v General Assur. Co., 10 Misc 3d 18, 20 [2005]).
Court of Appeals
New York & Presbyt. Hosp. v Country Wide Ins. Co., 2011 NY Slip Op 07149 (2011)
Country Wide argues that the Appellate Division decision eviscerates the 30-day written notice of accident requirement and that the aforementioned regulations do not contain any language which provides that submission of a proof of claim for health care services within 45 days excuses the failure to give the threshold notice of accident within 30 days of the accident. In response, Presbyterian construes the stated no-fault regulations as exempting health care providers from the 30-day notice of accident requirement. In Presbyterian's view, its filing of the hospital facility form within 45 days of the date services were rendered constitutes both "proof of claim" and timely "notice of accident". For the reasons that follow, we agree with Country Wide's position.
The primary goals of New York's no-fault automobile insurance system are "to ensure prompt compensation for losses incurred by accident victims without regard to fault or negligence, to reduce the burden on the courts and to provide substantial premium savings to New York motorists" (Matter of Medical Socy. of State of N.Y. v Serio, 100 NY2d 854, 860 [2003]). In furtherance of these objectives, "the Superintendent of Insurance has adopted regulations implementing the No-Fault Law (Insurance Law art 51), including circumscribed time frames for claim procedures" (Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co., 9 NY3d 312, 317 [2007] [emphasis added]).
11 NYCRR 65-1.1, the mandatory personal injury protection endorsement for motor vehicle liability insurance policies, provides:
"Conditions
"Action Against [Insurance] Company. No action shall lie against the Company unless, as a condition precedent thereto, there shall have been full compliance with the terms of this coverage.
"Notice. In the event of an accident, written notice setting forth details sufficient to identify the eligible injured person, along with reasonably obtainable information regarding the time, place and circumstances of the accident, shall be given by, or on behalf of, each eligible injured person, to the Company, or any of the Company's authorized agents, as soon as reasonably practicable, but in no event more than 30 days after the date of the accident . . .
"Proof of Claim; Medical, Work Loss, and Other Necessary Expenses. In the case of a claim for health service expenses, the eligible injured person or that person's assignee or representative [e.g., a health care services provider] shall submit written proof of claim to the Company, including full particulars of the nature and extent of the injuries and treatment received and contemplated, as soon as reasonably practicable but, in no event later than 45 days after the date services are rendered. . . ."
(emphasis added). In addition, 11 NYCRR 65-3.3 (d) states:
"The written notice required by . . . the mandatory and additional personal injury protection endorsement(s) shall be deemed to be satisfied by the insurer's receipt of a completed prescribed application for motor vehicle no-fault benefits (NYS Form N-F 2) forwarded to the applicant pursuant to subdivision 65-3.4 (b) of this subpart or by the insurer's receipt of a completed hospital facility form (NYS Form N-F 5)"
(emphasis added).
The "notice of accident" and "proof of claim" under 11 NYCRR 65-1.1 are independent conditions precedent to a no-fault insurer's liability (see Hospital for Joint Diseases, 9 NY3d at 317 ["These regulations require an accident victim to submit a notice of claim to the insurer as soon as practicable and no later than 30 days after an accident. Next, the injured party or the assignee (typically a hospital . . .) must submit proof of claim for medical treatment no later than 45 days after services are rendered" (9 NY3d at 317 [emphasis added] [internal citations omitted])]). By ruling that the notice of accident condition was satisfied based on the plain language of 11 NYCRR 65-3.3 (d), the Appellate Division disregarded the separate and distinct nature and purpose of these requirements. Even more troubling, such a construction effectively reads the 30-day written notice of accident requirement out of the no-fault regulations. But nothing in 11 NYCRR 65-3.3 (d) explicitly dispenses with the 30-day notice of accident requirement. Rather, 11 NYCRR 65-3.3 (d) merely provides that a NF-5 form may constitute the written notice required under the notice of accident provision.
In other words, these regulations (read alone or in tandem) cannot be interpreted to mean that a hospital/assignee's timely submission of a proof of claim for health services within 45 days of discharge of the injured person excuses the insured/assignor's failure to give the threshold notice of accident within 30 days of the accident, or that health care service providers are exempt from the written 30-day notice of accident requirement. Neither 11 NYCRR 65-1.1 nor 11 NYCRR 65-3.3 (d) contains such language. That is, while 11 NYCRR 65-3.3 (d) allows a completed hospital facility form to satisfy the written notice of accident requirement, the regulation does not provide (or suggest) that a "proof of claim" in that form filed within 45 days of treatment satisfies the 30-day notice of accident requirement where, as here, the form was submitted to Country Wide after the 30-day period has expired.
Although the Department of Insurance has not issued any interpretive statements or opinions regarding the subject regulations, our case law provides some guidance as to the importance of the "notice of accident" and "proof of claim" requirements to the no-fault regulatory scheme. In Serio, the Court explained that in 2001, the Superintendent of Insurance, in response to an alarming increase in insurance fraud over the preceding nine years, amended these regulations (see 100 NY2d at 861-863). Specifically, the notice of accident requirement was reduced from 90 days to 30 days, and the time to provide proof of claim was reduced from 180 days to 45 days (id. at 860, 862) in order to, among other things, prevent the fraud and abuse the Superintendent linked to the lengthy time frames (id. at 862) — for example, there were numerous cases where individuals were "exploiting the time lag between the alleged loss and the deadline for submitting proof of the loss, coupled with the reality that insurers are given only 30 days to review and investigate claims before paying them without risk of penalties for denying or delaying a claim" (id. at 861). Thus, it is clear that the Superintendent of Insurance — the official responsible for administering the Insurance Law and promulgating the insurance regulations — viewed both the "notice of accident" and "proof of claim" as integral requirements/time periods that further the goals of the no-fault system. Moreover, Presbyterian's interpretation of 11 NYCRR 65-3.3 (d) would undercut the anti-fraud purpose of the reduced time periods, particularly in cases where treatment does not occur until months or years after the accident.
Based on the foregoing, the proper construction of the subject regulations is that an NF-5 form (or other form that can serve as proof of claim) may constitute timely notice of an accident, as permitted by 11 NYCRR 65-3.3 (d), only if such proof of claim is given within the 30-day period prescribed by 11 NYCRR 65-1.1. Any other construction is unwarranted and would undermine the importance of the 30-day time period to the no-fault system.
Presbyterian nevertheless argues that interpreting 11 NYCRR 65-3.3 (d) in Country Wide's favor "would severely impact the hospital's ability to submit a timely bill" in cases where the insurer is not readily identifiable. But the Superintendent has addressed these concerns. The regulations allow late notices of accident if there is "written proof providing clear and reasonable justification for the failure to comply with such time limitation" (11 NYCRR 65-1.1)[FN1]. Indeed, the regulations specifically direct carriers to consider whether the injured person was a pedestrian or an occupant of a vehicle who may have difficulty identifying the proper carrier in assessing untimely notices of accident:
"The insurer shall establish standards for review of its determinations that applicants have provided late notice of claim or late proof of claim. In the case of notice of claim, such standards shall include, but not be limited to, appropriate consideration for pedestrians and non-related occupants of motor vehicles who may have difficulty ascertaining the identity of the insurer"
(11 NYCRR 65-3.5 [l]).
Finally, as an assignee of all the rights, privileges and remedies to which Benitez was entitled under the No-Fault law, Presbyterian stood in the shoes of Benitez and acquired no greater rights than he had (see Matter of International Ribbon Mills [Arjan Ribbons], 36 NY2d 121, 126 [1975] [Chief Judge Breitel wrote, "[i]t is elementary ancient law that an assignee never stands in any better position than his assignor."]). Here, because no written notice of accident was given, there was a failure to fully comply with the terms of the no-fault policy, which is a condition precedent to insurer liability. As a result, the assignment effectively became worthless (i.e., Benitez assigned nothing to Presbyterian) — you cannot assign your right to benefits if your right to those benefits has not been triggered, or if you had no right to those benefits in the first place.
For the foregoing reasons, the submission of the proof of claim within 45 days of the date health care services are rendered may not serve as timely written notice of accident after the 30-day period for providing such written notice has expired.
Recent Comments