August 24, 2012

North Bronx Med. Health Care v NY Cent. Mut. Ins. Co. (2012 NY Slip Op 51658(U))

https://www.beynensonlaw.com/case-law/north-bronx-med-health-care-v-ny-cent-mut-ins-co-2012-ny-slip-op51658u/

Court: Appellate Term, Second Department
Decided: August 24, 2012
Citation: 2012 NY Slip Op 51658(U) · 36 Misc 3d 149(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

North Bronx Med. Health Care v NY Cent. Mut. Ins. Co., 36 Misc 3d 149(A), 2012 NY Slip Op 51658(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 provider's medical affirmation failed to rebut the insurer's IME and peer review conclusions that the disputed services were unnecessary. The insurer appealed the denial of summary judgment on three claims for assigned no-fault benefits. Its affirmed reports each supplied a factual basis and medical rationale for finding a lack of medical necessity. The provider's doctor did not meaningfully address either report's conclusions, and the provider did not challenge the finding that the insurer was otherwise entitled to judgment on those claims. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted summary judgment dismissing the three claims.

Reported in New York Official Reports at North Bronx Med. Health Care v NY Cent. Mut. Ins. Co. (2012 NY Slip Op 51658(U))

[*1]

North Bronx Med. Health Care v NY Cent. Mut. Ins. Co.

2012 NY Slip Op 51658(U) [36 Misc 3d 149(A)]

Decided on August 24, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 August 24, 2012

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

PRESENT: : PESCE, P.J., RIOS and ALIOTTA, JJ
2011-1064 Q C.

North Bronx Medical Health Care as Assignee of ELESIA FULLERTON, Respondent, —
against
NY Central Mutual Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Richard G. Latin, J.), entered March 24, 2011. The order, insofar as appealed from, denied the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims for $1,712.58, $49.26 and $67.60.

ORDERED that the order, insofar as appealed from, is reversed, without costs, and the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims for $1,712.58, $49.26 and $67.60 are granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from so much of an order of the Civil Court as denied the branches of defendant’s motion seeking summary judgment dismissing the complaint insofar as it sought to recover upon claims for $1,712.58, $49.26 and $67.60.

In support of its motion, defendant submitted an affirmed independent medical examination (IME) report and an affirmed peer review report, each of which set forth a factual basis and a medical rationale for the respective doctor’s determination that there was a lack of medical necessity for the services at issue. In opposition, plaintiff submitted an affirmation from [*2]a doctor which failed to meaningfully refer to, let alone rebut, the conclusions set forth in the IME report and the peer review report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2010 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). As plaintiff has not challenged the Civil Court’s finding, in effect, that defendant is otherwise entitled to judgment on the relevant claims, the order is reversed and the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims for $1,712.58, $49.26 and $67.60 are granted (see Delta Diagnostic Radiology,
P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).

Pesce, P.J., Rios and Aliotta, JJ., concur.
Decision Date: August 24, 2012

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

Granted the insurer summary judgment on three claims because its affirmed IME and peer review reports set forth a factual basis and medical rationale, and the provider's doctor's affirmation failed to meaningfully refer to them.

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.

Cited in this decision

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

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.
Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U)) FollowedThe insurer's examining physician supplied an unrebutted factual basis and medical rationale that the billed MRI was unnecessary.

Similar decisions

Bronx Mega Care Med, PLLC v Federal Ins. Co. (2015 NY Slip Op 51060(U))The provider's doctor's affirmation failed to meaningfully address or rebut the insurer's IME conclusions on medical necessity.
Bronx Park Med., P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 51832(U))The insurer's unrebutted peer review established a factual basis and medical rationale for denying the services as medically unnecessary.
Midtown Med. Assoc., P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51351(U))The insurer established payment of one claim, untimely submission of three claims, and lack of medical necessity for the remaining services.
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.
High Quality Med., P.C. v GEICO Ins. Co. (2011 NY Slip Op 52373(U))The insurer's peer review and IME reports established lack of medical necessity, and the provider's medical affidavit failed to rebut them.