January 24, 2012

Total Equip., LLC v Praetorian Ins. Co. (2012 NY Slip Op 50155(U))

https://www.beynensonlaw.com/case-law/total-equip-llc-v-praetorian-ins-co-2012-ny-slip-op-50155u/

Court: Appellate Term, Second Department
Decided: January 24, 2012
Citation: 2012 NY Slip Op 50155(U) · 34 Misc 3d 145(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 2 later decisions (see Cited by)
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Total Equip., LLC v Praetorian Ins. Co., 34 Misc 3d 145(A), 2012 NY Slip Op 50155(U) (App Term, 2d Dept, 9th & 10th 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's affirmed IME report established lack of medical necessity for the supplies, and the provider failed to rebut that showing. The District Court had found that the insurer timely denied the assigned no-fault claim but denied summary judgment because it considered the IME report insufficient. The Appellate Term, Second Department, concluded that the report supplied a factual basis and medical rationale for the doctor's determination. The provider did not challenge the finding that the insurer was otherwise entitled to judgment. The appellate court reversed the order, insofar as appealed from, and granted the branch of the insurer's motion seeking summary judgment dismissing the complaint.

Reported in New York Official Reports at Total Equip., LLC v Praetorian Ins. Co. (2012 NY Slip Op 50155(U))

[*1]

Total Equip., LLC v Praetorian Ins. Co.

2012 NY Slip Op 50155(U) [34 Misc 3d 145(A)]

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This opinion is uncorrected and will not be published in the printed Official Reports.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

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : NICOLAI, P.J., MOLIA and IANNACCI, JJ
2010-2245 N C.

Total Equipment, LLC as Assignee of PAULINO ESPINAL-NUNEZ, Respondent,
against
Praetorian Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, First District (Andrea Phoenix, J.), dated July 14, 2010. The order, insofar as appealed from, denied the branch of defendant’s motion seeking summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, without costs, and the branch of defendant’s motion seeking summary judgment dismissing the complaint is 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 District Court as denied the branch [*2]of its motion seeking summary judgment dismissing the complaint. Insofar as is relevant to this appeal, the District Court found that defendant had demonstrated that it had timely denied plaintiff’s claim, but denied defendant’s motion on the ground that the independent medical examination (IME) report annexed to defendant’s motion did not establish a lack of medical necessity for the supplies provided.

In support of its motion, defendant submitted, among other things, an affirmed IME report which set forth a factual basis and a medical rationale for the doctor’s determination that there was a lack of medical necessity for the supplies provided (see Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co., 27 Misc 3d 136[A], 2010 NY Slip Op 50829[U] [App Term, 9th & 10th Jud Dists 2010]; B.Y., M.D., P.C. v Progressive Cas. Ins. Co., 26 Misc 3d 135[A], 2010 NY Slip Op 50144[U] [App Term, 9th & 10th Jud Dists 2010]). Defendant’s showing of a lack of medical necessity was not rebutted by plaintiff (see Speciality Surgical Servs. v Travelers Ins. Co., 27 Misc 3d 134[A], 2010 NY Slip Op 50715[U] [App Term, 9th & 10th Jud Dists 2010]). As plaintiff has not challenged the District Court’s finding, in effect, that defendant is otherwise entitled to judgment, defendant’s motion for summary judgment dismissing the complaint is 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]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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 order, insofar as appealed from, is reversed and the branch of defendant’s motion seeking summary judgment dismissing the complaint is granted.

Nicolai, P.J., Molia and Iannacci, JJ., concur.
Decision Date: January 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

Reversed and granted the insurer summary judgment because its affirmed IME report set forth a factual basis and medical rationale for lack of medical necessity of the supplies, and the provider did not rebut it.

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.

Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2010 NY Slip Op 50829(U)) FollowedThe insurer's affirmed peer reviews raised a triable issue of medical necessity and defeated the provider's summary judgment motion.
B.Y., M.D., P.C. v Progressive Cas. Ins. Co. (2010 NY Slip Op 50144(U)) FollowedThe providers' treating doctor's affirmation failed to rebut the insurer's peer review and IME evidence of lack of medical necessity.
Speciality Surgical Servs. v Travelers Ins. Co. (2010 NY Slip Op 50715(U)) FollowedThe insurer's unrebutted medical testimony and affirmed peer review report established that the services were not medically necessary.
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.
Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 52455(U)) FollowedThe insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
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

A label shows how the later decision treated this one.

Gaetane Physical Therapy, P.C. v Great N. Ins. Co. (2015 NY Slip Op 50698(U)) FollowedThe insurer's orthopedic IME report established lack of medical necessity, and the provider offered no medical evidence to rebut it.
Brownsville Advance Med., P.C. v Kemper Independence Ins. Co. (2012 NY Slip Op 51629(U)) FollowedThe insurer's IME report established lack of medical necessity, and the provider offered no opposing sworn evidence from a medical professional.
Huntington Regional Chiropractic, P.C. v Truck Ins. Exch. (2015 NY Slip Op 51068(U))The providers' medical affidavits raised a triable issue of medical necessity despite the insurer's sufficient IME reports.

Similar decisions

Total Equip., LLC v Mercury Cas. Co. (2013 NY Slip Op 52220(U))The insurer established lack of medical necessity for supplies dispensed after its IME cutoff, despite a prescription written before the IME. An affirmed orthopedic IME report supplied a factual basis and medical rationale that the assignor's injuries had resolved and no equipment, testing, or treatment was needed.
Five S & A Rehab Pt, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51724(U))The insurer's affirmed IME report established lack of medical necessity, and the provider failed to rebut that showing.
Manhattan Med. Imaging, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51541(U))The insurer's unrebutted peer review supplied a factual basis and medical rationale establishing lack of medical necessity.
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.
Jamaica Dedicated Med. Care, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50259(U))The provider failed to rebut the insurer's IME report establishing lack of medical necessity for the services rendered.