February 10, 2016

AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C. (2016 NY Slip Op 00916)

https://www.beynensonlaw.com/case-law/autoone-ins-gen-assur-v-eastern-is-med-care-p-c-2016-ny-slip-op00916/

Court: Appellate Division, Second Department
Decided: February 10, 2016
Citation: 2016 NY Slip Op 00916 · 136 AD3d 722
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Contrasted (cf., but see) in 1 and followed in 4 later decisions (see Cited by)
Issues: Medical necessity Timeliness and preclusion
Legal questions: Lack of medical necessity · Proof of mailing (see the maps)

Cite as

AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C., 136 AD3d 722 (2d Dept 2016)

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 provider's affidavits and medical records raised a triable issue of medical necessity despite the insurer's prima facie showing. The insurer sought summary judgment declaring that it owed no payment for treatment furnished to the assignor. Its branch manager's affidavit established timely mailing of denials through standard office practices, and the provider raised no triable issue on that point. Affirmed medical evaluations also established prima facie that the services were unnecessary, but the provider's opposing proof required further proceedings on medical necessity. The Appellate Division, Second Department, affirmed the order, insofar as appealed from, denying the insurer's motion, leaving the provider's claims unresolved.

Reported in New York Official Reports at AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C. (2016 NY Slip Op 00916)

AutoOne Ins./Gen. Assur. v Eastern Is. Med. Care, P.C.

2016 NY Slip Op 00916 [136 AD3d 722]

February 10, 2016

Appellate Division, Second Department

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

As corrected through Wednesday, March 23, 2016

[*1]

AutoOne Insurance/General Assurance, Appellant,
v
Eastern Island Medical Care, P.C., as Assignee of Juana Coyotl, Respondent.

Jason Tenenbaum, P.C., Garden City, NY (Eric Wahrburg of counsel), for appellant.

Don L. Hochler, P.C., Woodbury, NY (Don L. Hochler of counsel), for respondent.

In an action for a judgment declaring that the plaintiff is not obligated to pay certain no-fault insurance claims submitted by the defendant, the plaintiff appeals, as limited by its brief, from so much of an order of the Supreme Court, Nassau County (Bruno, J.), entered November 17, 2014, as denied its motion for summary judgment on the complaint.

Ordered that the order is affirmed insofar as appealed from, with costs.

On March 25, 2012, Juana Coyotl was injured in an automobile accident. At the time of her accident, Coyotl was insured under an automobile liability policy issued by the plaintiff, which contained a “no-fault” provision covering any necessary expenses incurred by Coyotl as a result of such an accident. Coyotl assigned these insurance benefits to the defendant, which provided her with medical treatment for the injuries she sustained in the accident. The defendant then billed the plaintiff for the costs of treating Coyotl, but the plaintiff denied the defendant’s claims on the ground that the services rendered were not medically necessary.

The plaintiff subsequently commenced this action seeking a declaration that it was not obligated to pay the defendant for no-fault benefits relating to Coyotl’s treatment, since those services were not medically necessary. The plaintiff moved for summary judgment, contending that its denials of coverage were properly and timely sent to the defendant, and that the treatment rendered to Coyotl by the defendant was not medically necessary. The Supreme Court denied the motion.

Contrary to the Supreme Court’s determination, the affidavit of the plaintiff’s branch manager, submitted by the plaintiff in support of its motion for summary judgment, was sufficient to establish, prima facie, that its denial of claim forms were timely mailed in accordance with the plaintiff’s standard and appropriate office mailing practices and procedures (see Preferred Mut. Ins. Co. v Donnelly, 22 NY3d 1169 [2014]; cf. Progressive Cas. Ins. Co. v Infinite Ortho Prods., Inc., 127 AD3d 1050, 1051 [2015]). In opposition, the defendant failed to raise a triable issue of fact as to the timeliness of the denial of claim.

Furthermore, with respect to the medical necessity of the services provided by the defendant, the plaintiff submitted affirmed medical evaluations which made a prima facie showing [*2]that the services at issue were not medically necessary (see Gaetane Physical Therapy, P.C. v Great N. Ins. Co., 47 Misc 3d 145[A], 2015 NY Slip Op 50698[U] [App Term, 2d Dept, 9th & 10th Jud Dists 2015]; Dr. Todd Goldman, D.C., P.C. v Kemper Cas. Ins. Co., 36 Misc 3d 153[A], 2012 NY Slip Op 51713[U] [App Term, 2d Dept, 11th & 13th Jud Dists 2012]).

However, in opposition to the motion, the defendants submitted affidavits and various medical records relating to Coyotl’s treatment which were sufficient to raise a triable issue of fact as to the necessity of that treatment (see Westcan Chiropractic, P.C. v Hertz Claim Mgt., 48 Misc 3d 133[A], 2015 NY Slip Op 51066[U] [App Term, 2d Dept, 9th & 10th Jud Dists 2015]; Meridian Acupuncture Care, P.C. v Mercury Cas. Co., 47 Misc 3d 143[A], 2015 NY Slip Op 50681[U] [App Term, 2d Dept, 9th & 10th Jud Dists 2015]; Fine Healing Acupuncture, P.C. v Country-Wide Ins. Co., 33 Misc 3d 55 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]).

Accordingly, the Supreme Court properly denied the plaintiff’s motion for summary judgment, as further proceedings are necessary to determine the issue of the medical necessity of the treatment rendered to Coyotl.

The plaintiff’s remaining contentions are without merit. Mastro, J.P., Hall, Maltese and LaSalle, 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.

Lack of medical necessity

Open the full map

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 affirmed medical evaluations made a prima facie showing of no medical necessity, but the provider's affidavits and medical records raised a triable issue, so the insurer's declaratory summary judgment motion was properly denied.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decisionCites it or cited by itCited or followedDistinguished or limited

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. 3 decisions in other departments that cite or are cited by this one are on the full map.

Proof of mailing

Open the full map

Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?

This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)

Held the branch manager's affidavit established prima facie that the denials were timely mailed under the insurer's standard office mailing practices, and the provider raised no triable issue on timeliness.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followedDistinguished or limited

Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Cited in this decision

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

Progressive Cas. Ins. Co. v Infinite Ortho Prods., Inc. (2015 NY Slip Op 03340) Contrasted (cf., but see)The insurers failed to establish timely and proper mailing of denials based on missing verification and EUO nonappearance.
Gaetane Physical Therapy, P.C. v Great N. Ins. Co. (2015 NY Slip Op 50698(U))The insurer's orthopedic IME report established lack of medical necessity, and the provider offered no medical evidence to rebut it.
Dr. Todd Goldman, D.C., P.C. v Kemper Cas. Ins. Co. (2012 NY Slip Op 51713(U))The insurer's sworn IME report established lack of medical necessity, and the provider did not rebut the insurer's prima facie showing.
Westcan Chiropractic, P.C. v Hertz Claim Mgt. (2015 NY Slip Op 51066(U))The provider's treating-doctor affidavit rebutted the peer review and raised a triable issue of medical necessity.
Meridian Acupuncture Care, P.C. v Mercury Cas. Co. (2015 NY Slip Op 50681(U))The insurer's reliance on an IME of someone other than the assignor failed to establish lack of medical necessity.
Fine Healing Acupuncture, P.C., v Country-Wide Ins. Co. (2011 NY Slip Op 21361)An insurer's medical-necessity denial need not rest on an examination by a practitioner in the treating provider's specialty.

Cited by

A label shows how the later decision treated this one.

Allstate Ins. Co. v Buffalo Neurosurgery Group (2019 NY Slip Op 03749) Contrasted (cf., but see)The insurer established a fee-schedule defense but failed to show that the assignor's spinal fusion surgery was medically unnecessary.
TC Acupuncture, P.C. v Tri-State Consumer Ins. Co. (2016 NY Slip Op 50978(U)) FollowedThe insurer's IME report supported dismissal of later acupuncture claims, but its proof did not justify denying earlier claims outright.
Five Boro Med. Equip., Inc. v A. Cent. Ins. Co. (2016 NY Slip Op 50412(U)) FollowedThe insurer's incomplete peer review failed to support two denials, and the provider's medical affidavit raised factual issues on two other claims.
Lotus Acupuncture PC v Unitrin Advantage Ins. Co. (2016 NY Slip Op 50603(U)) FollowedThe insurer's peer review reports failed to establish lack of medical necessity for the acupuncture services at issue.
Healthplus Surgery Ctr., LLC v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 03772) FollowedThe provider's expert affidavit raised factual issues on medical necessity and reimbursement for a surgical device under New Jersey's fee schedule.

Similar decisions

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.
All Is. Med. Care, P.C. v State Farm Mut. Auto. Ins. Co. (2011 NY Slip Op 52227(U))The insurer's doctor's testimony and peer review report established at trial that the services lacked medical necessity.
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.
NY Comprehensive Med., P.C. v Maryland Cas. Co. (2008 NY Slip Op 50521(U))The provider's summary judgment cross motion failed because conflicting medical affirmations raised a triable issue of medical necessity.
North Bronx Med. Health Care v NY Cent. Mut. Ins. Co. (2012 NY Slip Op 51658(U))The provider's medical affirmation failed to rebut the insurer's IME and peer review conclusions that the disputed services were unnecessary.