March 19, 2014

Webster Ave Med. Pavilion, PC v Allstate Ins. Co. (2014 NY Slip Op 50393(U))

https://www.beynensonlaw.com/case-law/webster-ave-med-pavilion-pc-v-allstate-ins-co-2014-ny-slip-op50393u/

Court: Appellate Term, First Department
Decided: March 19, 2014
Citation: 2014 NY Slip Op 50393(U) · 42 Misc 3d 148(A)
Posture: Trial
Outcome: Provider prevailed
Issues: Medical necessity Trial and evidence
Legal questions: Lack of medical necessity (see the maps)

Cite as

Webster Ave Med. Pavilion, PC v Allstate Ins. Co., 42 Misc 3d 148(A), 2014 NY Slip Op 50393(U) (App Term, 1st Dept 2014)

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 unopposed expert testimony failed to establish that the provider's diagnostic testing lacked medical necessity. The Appellate Term, First Department, affirmed the judgment awarding the provider assigned no-fault benefits after a nonjury trial. The trial court was entitled to reject the expert's sparse and confusing opinion, which reflected an admitted lack of knowledge of the assignor's medical condition at the time of testing. The absence of opposing expert testimony did not require acceptance of that opinion. Any misstatement in the trial court's written decision concerning the source of the records the expert reviewed did not undermine the result.

Reported in New York Official Reports at Webster Ave Med. Pavilion, PC v Allstate Ins. Co. (2014 NY Slip Op 50393(U))

[*1]

Webster Ave Med. Pavilion, PC v Allstate Ins. Co.

2014 NY Slip Op 50393(U) [42 Misc 3d 148(A)]

Decided on March 19, 2014

Appellate Term, First Department

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This opinion is uncorrected and will not be published in the printed Official Reports.

Decided on March 19, 2014

SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT

PRESENT: Torres, J.P., Shulman, Hunter, Jr., JJ
14-028.

Webster Ave Medical Pavilion, PC, a/a/o Ariel Bello, Plaintiff-Respondent, – –
against
Allstate Insurance Company, Defendant-Appellant.

Defendant appeals from a judgment of the Civil Court of the City of New York, Bronx County (Raul Cruz, J.), entered on or about November 3, 2010, after a nonjury trial, in favor of plaintiff and awarding it damages in the principal sum of $3,045.08.

Per Curiam.

Judgment (Raul Cruz, J.), entered on or about November 3, 2010, affirmed, with $25 costs.

We agree that defendant failed to meet its evidentiary burden of establishing the lack of medical necessity of the diagnostic testing giving rise to plaintiff’s claim for assigned first-party no-fault benefits. The trial court was entitled to reject the sparse and confusing opinion testimony offered by defendant’s medical expert — which reflected the expert’s confessed lack of knowledge as to the assignor’s medical condition at the time of testing — even though the expert’s testimony was unopposed (see Chabourne & Parke, LLP v HGK Assets Mgt., Inc., 295 AD2d 208, 209 [2002]). Any misstatement in the court’s written decision as to the source of the medical records reviewed by defendant’s expert does not serve to undermine the court’s otherwise proper resolution of the matter.

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
Decision Date: March 19, 2014

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.

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: Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)

Held the insurer failed its burden at trial because the court could reject its expert's sparse, confusing testimony, which admitted ignorance of the assignor's condition at testing, even though it was unopposed.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decision

Of the 73 decisions on this question in the First Department courts and the Court of Appeals, 22 (this one included) are in the same category.

Similar decisions

Ap Orthopedic & Rehabilitation, P.C. v Allstate Ins. Co. (2015 NY Slip Op 51656(U))The insurer failed at trial to prove lack of medical necessity, and the record supported the provider's recovery on the third cause of action.
Greater NY Med. Care, P.C. v Allstate Ins. Co. (2017 NY Slip Op 51849(U))The provider's trial judgment was reversed because it contradicted findings that the insurer proved lack of medical necessity without rebuttal.
Bronx Expert Radiology, P.C. v Allstate Ins. Co. (2007 NY Slip Op 50682(U))The insurer's investigator affidavit failed to show a founded belief that the claimed injuries did not arise from an insured incident.
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.
James J. Kim, L.A.C., P.C. v Allstate Ins. Co. (2023 NY Slip Op 50587(U))A provider bears the ultimate burden of proving medical necessity by a preponderance of the evidence at a no-fault trial.