October 27, 2011

Trimed Med. Supply, Inc. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52014(U))

https://www.beynensonlaw.com/case-law/trimed-med-supply-inc-v-clarendon-natl-ins-co-2011-ny-slip-op52014u/

Court: Appellate Term, Second Department
Decided: October 27, 2011
Citation: 2011 NY Slip Op 52014(U) · 33 Misc 3d 135(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Trimed Med. Supply, Inc. v Clarendon Natl. Ins. Co., 33 Misc 3d 135(A), 2011 NY Slip Op 52014(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011)

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 unrebutted peer review established that the supplies lacked medical necessity and warranted summary judgment. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted the insurer's cross motion dismissing the provider's action for assigned no-fault benefits. The affirmed report supplied a factual basis and medical rationale for the doctor's conclusion. The provider did not challenge the Civil Court's implicit finding under CPLR 3212 (g) that the insurer timely denied the claim on that ground. Following Urban Radiology, the appellate court rejected the provider's argument that dismissal was unwarranted because it lacked the documents relied upon by the peer reviewer.

Reported in New York Official Reports at Trimed Med. Supply, Inc. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52014(U))

[*1]

Trimed Med. Supply, Inc. v Clarendon Natl. Ins. Co.

2011 NY Slip Op 52014(U) [33 Misc 3d 135(A)]

Decided on October 27, 2011

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This opinion is uncorrected and will not be published in the printed Official Reports.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 October 27, 2011

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., WESTON and RIOS, JJ
2010-1416 RI C.

Trimed Medical Supply, Inc. as Assignee of NATALIE NEVINS, Respondent,
against
Clarendon National Ins. Co., Defendant.

Appeal from an order of the Civil Court of the City of New York, Richmond County (Katherine A. Levine, J.), dated April 17, 2008. The order, insofar as appealed from as limited by the brief, denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, without costs, 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, as limited by its brief, from so much of an order as denied its cross motion for summary judgment dismissing the complaint.

In support of its cross motion, defendant submitted, among other things, an affirmed peer review report which set forth the factual basis and medical rationale for the doctor’s determination that there was a lack of medical necessity for the supplies at issue. Defendant’s showing that such supplies were not medically necessary was not rebutted by plaintiff. In light of the foregoing, and the Civil Court’s implicit CPLR 3212 (g) finding that defendant had timely denied the claim based on a lack of medical necessity, a finding which plaintiff does not challenge, defendant’s cross motion for summary judgment dismissing the complaint should have been granted (see Urban Radiology, P.C. v Tri-State Consumer Ins. Co., 27 Misc 3d 140[A], 2010 NY Slip Op 50987[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; 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]). Plaintiff’s contention that the order denying defendant’s cross motion for summary judgment should be affirmed since plaintiff was not in possession of the documents that the peer reviewer relied upon is without merit (see Urban Radiology, P.C., 27 Misc 3d 140[A], 2010 NY Slip Op 50987[U]).

Accordingly, the order, insofar as appealed from, is reversed and defendant’s cross motion for summary judgment dismissing the complaint is granted. [*2]

Pesce, P.J., Weston and Rios, JJ., concur.
Decision Date: October 27, 2011

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

Held the affirmed peer review report showed lack of necessity for the supplies and was not rebutted, rejecting the argument that the provider lacked the documents the reviewer relied on, so the insurer won.

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.

Urban Radiology, P.C. v Tri-State Consumer Ins. Co. (2010 NY Slip Op 50987(U)) FollowedThe insurer established premature claims for unanswered verification and lack of medical necessity for the remaining claims.
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.

Similar decisions

Trimed Med. Supply, Inc. v American Tr. Ins. Co. (2011 NY Slip Op 51880(U))The insurer established lack of medical necessity for three claims, but a factual issue remained over the fourth claim's late submission.
Bath Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 50189(U))The insurer's peer reviews established lack of medical necessity, and the provider failed to offer a meaningful rebuttal.
All Points Med. Supply, Inc. v Clarendon Ins. Co. (2011 NY Slip Op 52292(U))The insurer's peer review reports established that the supplies lacked medical necessity, and the provider did not 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.
Queens Med. Supply, Inc. v Tri State Consumer Ins. Co. (2012 NY Slip Op 50414(U))The insurer's unrebutted peer review reports established lack of medical necessity for the supplies at issue.