March 31, 2005
T.S. Med. P.C. v Country Wide Ins. Co. (2005 NY Slip Op 50581(U))
https://www.beynensonlaw.com/case-law/t-s-med-p-c-v-country-wide-ins-co-2005-ny-slip-op-50581u/
- Judge
- Spodek, J.
- Decided
- March 31, 2005
- Citation
- 2005 NY Slip Op 50581(U)
- Posture
- Article 75 petition
- Outcome
- Provider prevailed
- Legal questions
- Claimant's prima facie case on motions (see the maps)
Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.
Summary
Editorial summary by Beynenson Law, not part of the court’s decision.
Reported in New York Official Reports at T.S. Med. P.C. v Country Wide Ins. Co. (2005 NY Slip Op 50581(U))
| T.S. Med. P.C. v Country Wide Ins. Co. |
| 2005 NY Slip Op 50581(U) |
| Decided on March 31, 2005 |
| Civil Court Of The City Of New York, Kings County |
| Spodek, J. |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| This opinion is uncorrected and will not be published in the printed Official Reports. |
Civil Court of the City of New York, Kings County
T.S. Medical P.C. a/a/o XUE AL ZHENG, Petitioner,
against Country Wide Insurance Company, Respondent. |
108436/04
Ellen M. Spodek, J.
Upon the foregoing papers, petitioner T.S. Medical P.C. moves for an order, pursuant to Article 75 of the CPLR, vacating a No-Fault Master Arbitration Award.
After petitioner was denied no-fault benefits, it filed a request for arbitration. The arbitration award that was rendered on March 23, 2004 denied petitioner’s claim. Petitioner then requested a review of the arbitration award by a Master Arbitrator. The case was reviewed and the Master Arbitrator upheld the lower arbitration award. This decision was rendered on or around July 22, 2004. This petition is filed less than ninety (90) days since receipt of the Master Arbitrator Award.
The Second Department holds “[w]hen a party to a controversy is compelled by statute to submit to arbitration—and thereby loses the right of initial resort to a judicial forum—the right to review the resulting arbitration award cannot in turn be overly limited in scope, without involving a due process issue. Thus the Court of Appeals has interpreted CPLR article 75 as requiring broader review when compulsory arbitration is in issue than when the matter has a consensual origin.” (Shand v Aetna Ins. Co., 74AD2d 442, 446 (2d Dept 1980); citing Furstenberg v Aetna Casualty & Surety Co., 49 NY2d 757 [1980]; Mounty St. Mary’s Hosp. of Niagara Falls v Catherwood, 26 [*2]NY2d 493 [1970]; Caso v Cofey, 41 NY2d 153, 155 [1976]; 1 NY Jur 2d, Administrative Law §190). In the case at bar, petitioner chose to go to arbitration. Arbitration was only mandatory for the defendant thus a narrow review is required. Further, a master arbitrator’s award may be vacated if it is arbitrary and capricious, irrational or without a plausible basis. (Steinauer v. N.Y Central Mutual Fire Insurance Company, 707, N.Y.S.2d 706).
In it’s report, the arbitrator states that “Respondent’s denial for treatment in October 2001 is late and for those subsequent treatments the denial is improperly based on a nurse’s audit.” However, he concludes that the applicant had to prove medical necessity in it’s prima facie case. This position was upheld by the Master Arbitrator. It is well established that the burden is on the insurer to prove the lack of medical necessity and not on the insured to prove medical necessity in establishing their prima facie case. (Amaze Medical Supply Inc. v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U][App Term, 2d and 11th Jud Dists]; Damadian MRI In Elmhust, P.C. v Liberty Mutual Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51700[U], [App Term, 9th and 10th Jud Dists]; see also A.B. Medical Services PLLC v Lumbermens Mutual Casualty Co., 4 Misc 3d 86, 87 [App Term, 2d and 11th Jud. Dists].)
The courts have consistently held that it is proper to “vacate the determinations of a master arbitrator who denied a petitioner payment for overdue no-fault benefits because it did not have rational basis.” (In the Matter of Pradip Das/N.Y. Medical Rehab P.C. v Allstate Insurance Company, 297 AD2d 321 (2nd Dept. 2002)). Clearly, in order for the decision of the Master Arbitrator to be rational it would have to comport with the established principles of law. The insurance regulations clearly enumerate the methods of review available to the Master Arbitrator including the ability to overturn an award that was “incorrect as a matter of law. “NYCRR 65.17 (a)(4). In this action, the Master Arbitrator had the power to correctly apply the law, but chose not to.
Accordingly, this Court grants the petitioner’s motion and finds that the Master Arbitrator’s award should be vacated.
The foregoing constitutes the decision and order of this court.
E N T E R,
Dated: March 31, 2005__________________
Hon. Ellen M. Spodek
Legal questions
A question of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.
On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?
This decision: Claimant's proof held to make out its prima facie case
Held the arbitrators erred as a matter of law in requiring the provider to prove medical necessity as part of its prima facie case, since that burden rests on the insurer.
Of the 1,063 decisions on this question in the Second Department courts and the Court of Appeals, 511 (this one included) are in the same category.
Cited in this decision
- Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U))A provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
- Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U))A provider need not submit additional medical-necessity evidence to obtain summary judgment when the insurer is precluded from that defense.
- A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co. (2004 NY Slip Op 24194)An insurer's timely medical-necessity denial does not replace admissible proof opposing a provider's summary judgment motion.
Similar decisions
- Preferred Med. Imaging, P.C. v Liberty Mut. Fire Ins. Co. (2006 NY Slip Op 50278(U))A master arbitrator's award requiring proof of medical necessity despite an untimely denial lacks a rational basis under settled law.
- First Help Acupuncture, P.C. v Hudson Ins. Co. (2005 NY Slip Op 50565(U))A provider must establish medical necessity in its prima facie case when the insurer timely denies the claim.
- 101 Acupuncture, P.C. v Utica Mut. Ins. Co. (2007 NY Slip Op 51488(U))A master arbitrator's substantive legal determination must be upheld if it has a rational basis, even if legally erroneous.
- Kew Gardens Imaging v Liberty Mut. Ins. Co. (2004 NY Slip Op 51077(U))An insurer's failure to deny a claim within 30 days precludes challenging the provider's proof of medical necessity.
- 563 Grand Med., P.C. v Progressive Northeastern Ins. Co. (2008 NY Slip Op 50090(U))A no-fault arbitrator may raise any issue the arbitrator deems relevant under 11 NYCRR 65-4.4 (e) and 65-4.5 (o).