May 26, 2004

Park Neurological Servs. P.C. v GEICO Ins. (2004 NY Slip Op 24210)

https://www.beynensonlaw.com/case-law/park-neurological-servs-p-c-v-geico-ins-2004-ny-slip-op-24210/

Court: Appellate Term, Second Department
Decided: May 26, 2004
Citation: 2004 NY Slip Op 24210 · 4 Misc 3d 95
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Contrasted (cf., but see) in 2 and followed in 8 later decisions (see Cited by)
Issues: Medical necessity Provider's prima facie case
Legal questions: Claimant's prima facie case on motions (see the maps)

Cite as

Park Neurological Servs. P.C. v GEICO Ins., 4 Misc 3d 95 (App Term, 2d Dept 2004)

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.

The insurer's denial did not set forth a factual basis and medical rationale for lack of medical necessity, precluding its medical-necessity defense. The Appellate Term, Second Department, reversed the order, insofar as appealed from, granted the provider summary judgment, and remanded for statutory interest and attorney's fees under Insurance Law § 5106 (a). The billing manager's affidavit, though imprecisely worded, established the provider's prima facie case under CPLR 4518 (a); personal medical knowledge was unnecessary where properly completed claim forms were submitted. Although the denial was timely, the peer reviewer found no medical necessity because information was insufficient to make that determination. The denial therefore failed to state its reasons fully and explicitly or inform the provider of the insurer's position on the disputed matter.

Reported in New York Official Reports at Park Neurological Servs. P.C. v GEICO Ins. (2004 NY Slip Op 24210)

Park Neurological Servs. P.C. v GEICO Ins.

2004 NY Slip Op 24210 [4 Misc 3d 95]

Accepted for Miscellaneous Reports Publication

AT2

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, October 20, 2004

[*1]

Park Neurological Services P.C., as Assignee of Alma Shelton, Appellant,
v
GEICO Insurance, Respondent.

Supreme Court, Appellate Term, Second Department, May 26, 2004

APPEARANCES OF COUNSEL

Amos Weinberg, Great Neck, for appellant. Teresa M. Spina, Woodbury (Steven A. Giampaolo of counsel), for respondent.

{**4 Misc 3d at 96} OPINION OF THE COURT

Memorandum.

Order, insofar as appealed from, unanimously reversed without costs, plaintiff’s motion for summary judgment granted and matter remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees.

Plaintiff commenced this action to recover $1,606.87 in first-party no-fault benefits, as well as statutory interest and attorney’s fees, for medical services rendered to its assignor, pursuant to Insurance Law § 5101 et seq. Thereafter, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. Both motions were denied by order entered May 14, 2003.

Contrary to the determination of the court below, we find that the affidavit of plaintiff’s billing manager, though imprecisely worded, sufficed to establish its cause of action prima facie (CPLR 4518 [a]; People v Kennedy, 68 NY2d 569 [1986]; Damadian MRI in Elmhurst v Liberty Mut. Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51700[U] [App Term, 9th & 10th Jud Dists 2003]). Moreover, the billing manager was not required to have personal medical knowledge to establish the medical necessity of the claim inasmuch as a prima facie showing of entitlement to summary judgment is established in the first instance by the submission of a properly completed claim form (see Damadian MRI in Elmhurst v Liberty Mut. Ins. Co., supra; Amaze [*2]Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists 2003]). Consequently, the burden shifted to defendant to show a triable issue of fact (see Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).

It is uncontroverted that defendant’s denial was made within 30 days of its receipt of the claim (see Insurance Law § 5106 [a]). However, inasmuch as the peer review, upon which the denial is based, concludes that there was no medical necessity due to the lack of sufficient information upon which the reviewer could make such a determination, we find that the denial did not “fully and explicitly” set forth the reasons therefor (section 31 of the NF-10 form), did not inform plaintiff of defendant’s position regarding the disputed matter, and, thus,{**4 Misc 3d at 97} did not set forth a factual basis and medical rationale sufficient to establish the absence of medical necessity (see Amaze Med. Supply v Eagle Ins. Co., supra). Accordingly, defendant is precluded from asserting the defense of lack of medical necessity (Amaze Med. Supply v Eagle Ins. Co., supra).

In view of the foregoing, plaintiff is granted summary judgment in the amount of $1,606.87, and the matter is remanded for the calculation of statutory interest and an assessment of attorney’s fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated pursuant thereto.

McCabe, P.J., Rudolph and Angiolillo, JJ., concur.

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.

Claimant's prima facie case on motions

Open the full map

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 billing manager's imprecisely worded affidavit established the prima facie case, since a properly completed claim form suffices and the affiant needed no personal medical knowledge of medical necessity.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followedDistinguished or limited

Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (this one included) are in the same category.

Cited in this decision

A label shows how this decision treated the case it cites.

Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U)) FollowedA provider need not submit additional medical-necessity evidence to obtain summary judgment when the insurer is precluded from that defense.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U)) FollowedA provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.

Cited by (15)

A label shows how the later decision treated this one.

Amaze Med. Supply Inc. v Travelers Prop. Cas. Corp. (2005 NY Slip Op 50452(U)) Contrasted (cf., but see)An insurer need not seek further verification when a peer review finds no substantiation of equipment's medical necessity in documents obtained for review.
Elmont Open MRI & Diagnostic Radiology, P.C. v Country-Wide Ins. Co. (2007 NY Slip Op 27072) Contrasted (cf., but see)Interest on unpaid no-fault benefits runs from 30 days after claim receipt when the insurer issues no valid denial within that period.
Amaze Med. Supply Inc. v Allstate Ins. Co. (2006 NY Slip Op 51412(U)) FollowedThe insurer's peer review supplied a factual basis and medical rationale sufficient to raise a triable issue of medical necessity.
All County Open MRI & Diagn. Radiology P.C. v Travelers Ins. Co. (2006 NY Slip Op 50318(U)) FollowedA peer review citing insufficient information cannot support denial without proof that the insurer sought that information through verification.
Olympic Chiropractic, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50011(U)) FollowedA timely but factually insufficient IME denial does not preserve a medical-necessity defense.
A.B. Med. Servs. PLLC v Peerless Ins. Co. (2006 NY Slip Op 26318) FollowedA provider need not prove assignment validity where the insurer neither sought verification nor raised an assignment defect in its denials.
East Coast Acupuncture Servs., P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50213(U)) FollowedThe provider obtained summary judgment on two claims because the insurer's peer review lacked an adequate factual basis and medical rationale.
Mega Supply & Billing, Inc. v American Tr. Ins. Co. (2005 NY Slip Op 51569(U)) FollowedA denial stating only that a claim is denied based on an EUO is too vague to defeat a provider's summary judgment motion.
Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51185(U)) FollowedA medical necessity denial must state the factual basis and medical rationale with sufficient particularity, even when timely issued.
Hempstead Turnpike Open Mri & Imaging v Progressive Ins. Co. (2006 NY Slip Op 51287(U)) FollowedThe insurer's affirmed peer review raised a triable issue whether a CAT scan was medically necessary after an MRI of the same area.

Show all 15 citing decisions

Similar decisions

A.B. Med. Servs. v GEICO Ins. (2003 NY Slip Op 23949)A provider need not prove medical necessity at the claim stage or on a subsequent motion for summary judgment.
Neomy Med., P.C. v GEICO Ins. Co. (2010 NY Slip Op 51252(U))The insurer established timely denials and unrebutted defenses of lack of medical necessity and charges exceeding the fee schedule.
New York Diagnostic Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 23360)The provider established claim submission through the insurer's denials and proved the loss through admissible claim forms.
Parkway Med. Care, P.C. v GEICO Gen. Ins. Co. (2018 NY Slip Op 51005(U))The insurer's unrebutted peer review established lack of medical necessity, and the provider's discovery inaction did not defeat summary judgment.
Neomy Med., P.C. v Auto One Ins. Co. (2010 NY Slip Op 51727(U))The insurer's timely denial and supported peer review raised a medical necessity issue defeating summary judgment on the appealed claim.