July 8, 2020
Healthplus Surgery Ctr., LLC v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 03772)
https://www.beynensonlaw.com/case-law/healthplus-surgery-ctr-llc-v-global-liberty-ins-co-of-n-y-2020-ny-slip-op03772/
- Decided
- July 8, 2020
- Citation
- 2020 NY Slip Op 03772 · 185 AD3d 669
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Legal questions
- Lack of medical necessity · Proving a fee schedule defense (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 Healthplus Surgery Ctr., LLC v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 03772)
| Healthplus Surgery Ctr., LLC v Global Liberty Ins. Co. of N.Y. |
| 2020 NY Slip Op 03772 [185 AD3d 669] |
| July 8, 2020 |
| Appellate Division, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| Healthplus Surgery Center, LLC, Respondent, v Global Liberty Insurance Company of New York, Appellant. |
Law Office of Jason Tenenbaum, P.C., Garden City, NY (Shaakee Bhuiyan of counsel), for appellant.
Baker & Cantin, P.C., Rego Park, NY (Elyse Ulino of counsel), for respondent.
In an action to recover first-party no-fault benefits for medical services rendered, the defendant appeals from an order of the Supreme Court, Queens County (Janice A. Taylor, J.), entered June 20, 2019. The order denied that branch of the defendant’s motion which was for summary judgment dismissing the complaint.
Ordered that the order is affirmed, with costs.
The plaintiff, a New Jersey medical provider, commenced this action to recover first-party no-fault benefits against the defendant, an insurance company, alleging it provided medical services to an individual (hereinafter the insured) who was injured in a motor vehicle accident and insured by the defendant. The plaintiff also alleged that the insured assigned first-party no fault benefits to it but that the defendant had failed to pay for the medical services provided by the plaintiff to the insured. The defendant moved, inter alia, for summary judgment dismissing the complaint, contending that the claimed expenses were not medically necessary and that the claim for one particular expense was not reimbursable under the applicable New Jersey medical fee schedule for Automobile Insurance Personal Injury Protection and Motor Bus Medical Expense Insurance Coverage (see NJ Admin Code § 11:3-29.5). The parties agree that because the medical services were provided in New Jersey, the New Jersey fee schedule applies. By order entered June 20, 2019, the Supreme Court denied the motion. The defendant appeals, and we affirm.
“[T]he proponent of a summary judgment motion must make a prima facie showing of entitlement to judgment as a matter of law, tendering sufficient evidence to demonstrate the absence of any material issues of fact” (Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]; see Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]). “Failure to make such prima facie showing requires a denial of the motion, regardless of the sufficiency of the opposing papers” (Alvarez v Prospect Hosp., 68 NY2d at 324; see Winegrad v New York Univ. Med. Ctr., 64 NY2d at 853).
Here, the defendant made a prima facie showing that the services provided were not medically necessary and that the disputed surgical device was not reimburseable by submitting, inter alia, a peer review report, an independent medical examination report, and medical documentation (see AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C., 136 AD3d 722, 723 [2016]). In opposition, however, the plaintiff submitted an expert affidavit opining as to the medical necessity of the services based on, among other things, MRI results and findings made during the surgical procedure at issue. These submissions raised a triable issue of fact as to medical necessity (see AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C., 136 AD3d at 723; Excel Surgery Ctr., L.L.C. v Hertz Claim Mgt. Corp., 58 Misc 3d 145[A], 2017 NY Slip Op 51951[U], *1 [App Term, 2d Dept, 9th & 10th Jud Dists 2017]). The plaintiff also raised a triable issue of fact as to whether the disputed device qualified for reimbursement under New Jersey Administrative Code § 11:3-29.4 (f) (8).
Accordingly, we agree with the Supreme Court’s determination denying the defendant’s motion for summary judgment dismissing the complaint. Rivera, J.P., Chambers, Duffy and Barros, JJ., concur.
Legal questions (2)
Questions 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.
Did the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?
This decision: Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)
Held the insurer's peer review, IME report and records made a prima facie showing, but the provider's expert affidavit relying on MRI results and surgical findings raised a triable issue of medical necessity.
Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 94 (this one included) are in the same category.
Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?
This decision: Insurer's proof did not establish the excess as a matter of law; question left for trial
Held that although the insurer showed the surgical device was not reimbursable under the applicable New Jersey fee schedule, the provider raised a triable issue whether the device qualified for reimbursement under the New Jersey code.
Of the 285 decisions on this question in the Second Department courts and the Court of Appeals, 85 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C. (2016 NY Slip Op 00916) FollowedThe provider's affidavits and medical records raised a triable issue of medical necessity despite the insurer's prima facie showing.
- Excel Surgery Ctr., L.L.C. v Hertz Claim Mgt. Corp. (2017 NY Slip Op 51951(U)) FollowedThe provider's chiropractor raised a triable issue of medical necessity by sufficiently rebutting the insurer's peer review report.
Similar decisions
- Healthplus Surgery Ctr., LLC v American Tr. Ins. Co. (2022 NY Slip Op 02252)The insurer proved fee-schedule overbilling but failed to support its medical-necessity defense with a factual basis and medical rationale.
- Advanced Med. Diagnostics of Queens, P.C. v GEICO Ins. Co. (2013 NY Slip Op 50219(U))New Jersey law governed the provider's claim, and its failure to prove medical necessity defeated its summary judgment motion.
- NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U))The insurer failed to raise a medical necessity issue because it submitted neither the IME report supporting its denial nor other evidence.
- Advanced Orthopedics, PLLC v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 50418(U))The parties' conflicting medical expert opinions raised a triable issue of fact concerning medical necessity.
- Five Boro Med. Equip., Inc. v A. Cent. Ins. Co. (2016 NY Slip Op 50412(U))The insurer's incomplete peer review failed to support two denials, and the provider's medical affidavit raised factual issues on two other claims.