September 5, 2012

Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51772(U))

https://www.beynensonlaw.com/case-law/flushing-traditional-acupuncture-p-c-v-geico-ins-co-2012-ny-slip-op51772u/

Court: Appellate Term, Second Department
Decided: September 5, 2012
Citation: 2012 NY Slip Op 51772(U) · 36 Misc 3d 156(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Fee schedule Medical necessity Timeliness and preclusion
Legal questions: Proof of mailing · Lack of medical necessity · Proving a fee schedule defense (see the maps)

Cite as

Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co., 36 Misc 3d 156(A), 2012 NY Slip Op 51772(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2012)

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 established timely denials, full fee-schedule payment for certain acupuncture services and lack of necessity for the remaining services. The Appellate Term, Second Department, reversed the provider's judgment, vacated the underlying order, denied the provider's motion and granted the insurer's cross motion for summary judgment dismissing the complaint. An employee's description of the mailing practice at the office that sent the denials established timely mailing. The insurer proved full payment for one group of services under the workers' compensation schedule for chiropractic acupuncture. For the remaining services, a licensed acupuncturist's sworn IME report supplied a factual basis and medical rationale for finding further treatment unnecessary. The treating acupuncturist's conclusory rebuttal failed to raise a triable issue.

Reported in New York Official Reports at Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51772(U))

[*1]

Flushing Traditional Acupuncture, P.C. v GEICO Ins. Co.

2012 NY Slip Op 51772(U) [36 Misc 3d 156(A)]

Decided on September 5, 2012

Appellate Term, Second 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This opinion is uncorrected and will not be published in the printed Official Reports.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 September 5, 2012

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., RIOS and ALIOTTA, JJ
2011-784 K C.

Flushing Traditional Acupuncture, P.C. as Assignee of ANTHONY KEPPEL, Respondent,
against
GEICO Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Sylvia G. Ash, J.), entered November 22, 2010, deemed from a judgment of the same court entered December 14, 2010 (see CPLR 5501 [c]). The judgment, entered pursuant to the November 22, 2010 order granting plaintiff’s motion for summary judgment and denying defendant’s cross motion for summary judgment dismissing the complaint, awarded plaintiff the principal sum of $3,071.33.

ORDERED that the judgment is reversed, without costs, the order entered November 22, 2010 is vacated, plaintiff’s motion for summary judgment is denied and defendant’s cross motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court entered November 22, 2010 which granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment dismissing the complaint. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).

Contrary to the determination of the Civil Court, the affidavit of defendant’s employee [*2]was sufficient to establish that defendant had timely mailed the denial of claim forms. The affidavit established that the denials had been mailed from defendant’s Woodbury office and described defendant’s standard mailing practice and procedure for that office (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]).

Defendant denied the claims for services rendered from March 31, 2009 to September 24, 2009 on the ground that the claims exceeded the amount permitted by the workers’ compensation fee schedule, and that defendant had fully paid plaintiff for the services billed for in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors. Defendant demonstrated that it had fully paid plaintiff for these services in accordance with the workers’ compensation fee
schedule. Accordingly, the branches of defendant’s cross motion for summary judgment seeking to dismiss so much of the complaint as sought to recover for these dates of service should have been granted (see Great Wall Acupuncture, P.C. v GEICO Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]).

Defendant denied the claims for services rendered on September 25, 2009 based upon an independent medical examination (IME). In support of its cross motion for summary judgment, defendant submitted the sworn report of the licensed acupuncturist who had conducted the IME of plaintiff’s assignor. The report set forth a factual basis and medical rationale for the examiner’s determination that there was no need for further acupuncture treatment. In opposition, plaintiff submitted an affidavit from the treating acupuncturist which, while referring to the IME report, offered only a conclusory rebuttal to the conclusions set forth therein (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). Accordingly, the branch of defendant’s cross motion seeking summary judgment dismissing so much of the complaint as sought to recover for services rendered on September 25, 2009 should have been granted (see A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

Accordingly, the judgment is reversed, the order entered November 22, 2010 is vacated, plaintiff’s motion for summary judgment is denied and defendant’s cross motion for summary judgment dismissing the complaint is granted.

Pesce, P.J., Rios and Aliotta, JJ., concur.
Decision Date: September 05, 2012

Legal questions (3)

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.

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

Reversed the lower court and held the employee's affidavit, describing the standard mailing practice of the office the denials were mailed from, established timely mailing.

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

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.

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 proof established lack of medical necessity and the provider failed to rebut it

Held the acupuncturist's sworn IME report set forth a factual basis and medical rationale, and the treating acupuncturist's affidavit offered only a conclusory rebuttal.

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

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.

Proving a fee schedule defense

Open the full map

Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?

This decision: Insurer proved the billed amount exceeded the applicable fee schedule

Held the insurer showed it had fully paid the acupuncture services under the fee schedule for acupuncture performed by chiropractors, so those claims were dismissed.

Excess shownNot established; openDefense rejectedSplit by chargeThis decisionCites it or cited by itCited or followed

Of the 285 decisions on this question in the Second Department courts and the Court of Appeals, 147 (this one included) are in the same category.

Cited in this decision

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

Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345)An insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
Great Wall Acupuncture, P.C. v Geico Ins. Co. (2009 NY Slip Op 29467) FollowedAn insurer may use the chiropractic acupuncture fee schedule to reimburse acupuncture services performed by a licensed acupuncturist.
Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) FollowedThe provider's conclusory disagreement with the insurer's supported peer review failed to raise a medical-necessity issue of fact.
A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U)) FollowedThe insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.

Cited by

American Tr. Ins. Co. v Right Choice Supply, Inc. (2023 NY Slip Op 23039)A no-fault arbitrator need not apply summary judgment rules requiring a provider's medical evidence to specifically rebut an insurer's peer review.

Similar decisions

MIA Acupuncture, P.C. v Geico Ins. Co. (2010 NY Slip Op 51899(U))The insurer established timely denials, proper fee schedule reductions, and lack of medical necessity for the remaining acupuncture services.
Megacure Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51291(U))The insurer proved full fee-schedule payment for earlier acupuncture services and lack of medical necessity for later services.
Gentle Care Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51290(U))The insurer proved full fee-schedule payment for earlier acupuncture claims and lack of medical necessity for later treatment.
Eastern Star Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51010(U))The insurer established full fee-schedule payment for four acupuncture claims and lack of medical necessity for a fifth.
Z.A. Acupuncture, P.C. v Geico Ins. Co. (2011 NY Slip Op 51842(U))The insurer established proper acupuncture reimbursement under the chiropractic fee schedule and lack of medical necessity for later services.