May 11, 2012

Raz Acupuncture, P.C. v Nationwide Mut. Ins. Co. (2012 NY Slip Op 50871(U))

https://www.beynensonlaw.com/case-law/raz-acupuncture-p-c-v-nationwide-mut-ins-co-2012-ny-slip-op50871u/

Court: Appellate Term, Second Department
Decided: May 11, 2012
Citation: 2012 NY Slip Op 50871(U) · 35 Misc 3d 140(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Fee schedule
Legal questions: Proving a fee schedule defense (see the maps)

Cite as

Raz Acupuncture, P.C. v Nationwide Mut. Ins. Co., 35 Misc 3d 140(A), 2012 NY Slip Op 50871(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 fee-schedule payment challenge failed, and its remaining contention relied on material outside the record. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, granting the insurer summary judgment dismissing the challenged acupuncture claims for two assignors. The Civil Court had implicitly found timely fee-schedule denials. The appellate court rejected the argument that the insurer had not demonstrated full payment under the schedule. It declined to consider the remaining contention because the provider conceded that it rested on material outside the record.

Reported in New York Official Reports at Raz Acupuncture, P.C. v Nationwide Mut. Ins. Co. (2012 NY Slip Op 50871(U))

[*1]

Raz Acupuncture, P.C. v Nationwide Mut. Ins. Co.

2012 NY Slip Op 50871(U) [35 Misc 3d 140(A)]

Decided on May 11, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 May 11, 2012

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

PRESENT: : PESCE, P.J., RIOS and ALIOTTA, JJ
2010-1967 K C.

Raz Acupuncture, P.C. as Assignee of NATALIA AGUDELO and MARIA SALAZAR, Appellant, —
against
Nationwide Mutual Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Margaret A. Pui Yee Chan, J.), entered October 23, 2009. The order, insofar as appealed from as limited by the brief, granted the branches of defendant’s motion seeking summary judgment dismissing the complaint as to services rendered to Natalia Agudelo from September 11, 2006 to November 16, 2006 and as to services rendered to Maria Salazar from November 11, 2006 to November 15, 2006.

ORDERED that the order, insofar as appealed from, is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, the Civil Court granted the branches of defendant’s motion seeking summary judgment dismissing the complaint as to services rendered to Natalia Agudelo from September 11, 2006 to November 16, 2006 and as to services rendered to Maria Salazar from November 11, 2006 to November 15, 2006, implicitly finding that defendant had timely denied these claims based upon the workers’ compensation fee schedule.

Plaintiff’s argument that defendant failed to demonstrate that it had fully paid plaintiff for [*2]the acupuncture services at issue in accordance with the workers’ compensation fee schedule lacks merit. Plaintiff’s remaining contention is, as plaintiff concedes, based upon material that is dehors the record, and will not be considered.

Accordingly, the order, insofar as appealed from, is affirmed.

Pesce, P.J., Rios and Aliotta, JJ., concur.
Decision Date: May 11, 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.

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

Affirmed dismissal of the acupuncture claims, rejecting the provider's argument that the insurer failed to show it had fully paid the services in accordance with the workers' compensation fee schedule.

Excess shownNot established; openDefense rejectedSplit by chargeThis decision

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.

Similar decisions

Raz Acupuncture, P.C. v Geico Gen. Ins. Co. (2012 NY Slip Op 51716(U))The insurer's summary judgment dismissing the disputed acupuncture claims on fee-schedule grounds was affirmed.
Raz Acupuncture, P.C. v New S. Ins. Co. (2012 NY Slip Op 50865(U))The insurer established full payment under the workers' compensation fee schedule for the four challenged causes of action.
Raz Acupuncture, P.C. v AIG Indem. Ins. Co. (2010 NY Slip Op 51177(U))An insurer may use the workers' compensation acupuncture fee schedule for chiropractors to reimburse a licensed acupuncturist.
Raz Acupuncture, P.C. v Travelers Prop. Cas. Ins. Co. (2010 NY Slip Op 50065(U))The provider failed to establish admissible business records through its third-party billing company's employee.
Natural Therapy Acupuncture, P.C. v Nationwide Ins. (2017 NY Slip Op 50943(U))The insurer established full payment for acupuncture services under the workers' compensation fee schedule applicable to chiropractors.