October 20, 2010

Active Imaging, P.C. v Progressive Northeastern Ins. Co. (2010 NY Slip Op 51842(U))

https://www.beynensonlaw.com/case-law/active-imaging-p-c-v-progressive-northeastern-ins-co-2010-ny-slip-op51842u/

Court: Appellate Term, Second Department
Decided: October 20, 2010
Citation: 2010 NY Slip Op 51842(U) · 29 Misc 3d 130(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Limited in 1 and followed in 3 later decisions (see Cited by)
Issues: Medical necessity Discovery and procedure
Legal questions: Lack of medical necessity · Proof of mailing (see the maps)

Cite as

Active Imaging, P.C. v Progressive Northeastern Ins. Co., 29 Misc 3d 130(A), 2010 NY Slip Op 51842(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2010)

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.

An insurer need not annex the third-party records reviewed by its peer reviewer as part of its prima facie summary judgment showing. The insurer established timely denials and submitted an affirmed peer review providing a factual basis and medical rationale for finding the services unnecessary. The provider argued that omission of the underlying records defeated the motion. The Appellate Term, Second Department, rejected that argument and affirmed summary judgment dismissing the complaint. Although CPLR 3212 (f) permits denial or a continuance for needed discovery, the provider supplied no evidentiary basis suggesting discovery would yield relevant evidence. Mere hope of uncovering a material factual issue did not warrant delay, and the provider failed to rebut the insurer's showing.

Reported in New York Official Reports at Active Imaging, P.C. v Progressive Northeastern Ins. Co. (2010 NY Slip Op 51842(U))

[*1]

Active Imaging, P.C. v Progressive Northeastern Ins. Co.

2010 NY Slip Op 51842(U) [29 Misc 3d 130(A)]

Decided on October 20, 2010

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This opinion is uncorrected and will not be published in the printed Official Reports.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 20, 2010

SUPREME COURT OF THE STATE OF NEW YORK

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

PRESENT: : PESCE, P.J., WESTON and STEINHARDT, JJ
2009-101 K C.

Active Imaging, P.C. a/a/o Zorea Limor, Appellant,
against
Progressive Northeastern Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Wavny Toussaint, J.), entered June 26, 2008. The order granted defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground that the services rendered were not medically necessary. Plaintiff opposed the motion. The Civil Court granted the motion, finding that plaintiff had failed to establish the existence of a triable issue of fact. The instant appeal by plaintiff ensued.

Defendant made a prima facie showing of its entitlement to summary judgment dismissing the complaint by establishing that it had timely denied the claims on the ground of lack of medical necessity (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]), and by submitting an affirmed peer review report from its doctor setting forth a factual basis and medical rationale for his conclusion that the services rendered were not medically necessary (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. [*2]Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

Plaintiff contends that defendant failed to establish its prima facie entitlement to summary judgment since, although defendant’s peer review doctor listed the medical reports and/or records of third parties that he had reviewed in reaching his
conclusion that the services rendered were not medically necessary, defendant failed to annex to its moving papers copies of these documents. We reject this contention since these reports and records are not part of defendant’s prima facie showing. We note that, pursuant to CPLR 3212 (f), a court has discretion to deny a motion for summary judgment or order a continuance to permit affidavits to be obtained or disclosure to be had, if “facts essential to justify opposition may exist but cannot then be stated.” However, plaintiff failed to “put forth some evidentiary basis to suggest that discovery might lead to relevant evidence” (Trombetta v Cathone, 59 AD3d 526, 527 [2009]; see Canarick v Cicarelli, 46 AD3d 587 [2007]; Kimyagarov v Nixon Taxi Corp., 45 AD3d 736 [2007]; Ruttura & Sons Constr. Co. v Petrocelli Constr., 257 AD2d 614 [1999]), and the “mere hope” that discovery will uncover the existence of a material issue of fact is insufficient to delay a summary judgment determination (Giraldo v Morrisey, 63 AD3d 784, 785 [2009]). Inasmuch as plaintiff failed to rebut defendant’s prima facie showing of its entitlement to summary judgment, defendant’s motion was properly granted. Accordingly, the order is affirmed.
Pesce, P.J., Weston and Steinhardt, JJ., concur.
Decision Date: October 20, 2010

Legal questions (2)

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.

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 set forth a factual basis and medical rationale, the insurer need not annex the records the reviewer relied on, and the provider failed to rebut it or justify discovery under CPLR 3212 (f).

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

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.

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 (rules on the question, but another ground decided the case)

Held the insurer established that it timely denied the claims on medical-necessity grounds, as part of its prima facie showing.

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

Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 806 (this one included) are in the same category.

Cited in this decision

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.
Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U))The 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))The 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))The 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.

Novacare Med. P.C. v Travelers Prop. Cas. Ins. Co. (2011 NY Slip Op 50500(U)) LimitedA peer review report must supply a sufficient factual basis and medical rationale before the provider must submit contrary expert proof.
Bajaj v GEICO (2012 NY Slip Op 51106(U)) FollowedA substitute medical expert may support a medical necessity defense at trial without admission of the underlying peer review report.
Total Equip. LLC v State Farm Fire & Cas. Co. (2012 NY Slip Op 22038) FollowedA rebuttal report based principally on a nontreating doctor's records review must include those records to raise a medical necessity issue.
Total Equip., LLC v Praetorian Ins. Co. (2011 NY Slip Op 21398) FollowedThe provider established a need for discovery of the no-fault file before opposing the insurer's medical-necessity motion.
East 75th St. Diagnostic Imaging v Clarendon Natl. Ins. Co. (2011 NY Slip Op 21315)The diagnostic provider showed that records underlying the insurer's peer reviews were needed to oppose summary judgment.

Similar decisions

Ortho-Med Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2012 NY Slip Op 50149(U))An insurer need not attach the records reviewed by its peer reviewer to establish lack of medical necessity on summary judgment.
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.
Manhattan Med. Imaging, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51737(U))The insurer's timely denial and supported peer review raised a triable issue of medical necessity, defeating provider summary judgment.
Medical Assoc., P.C. v Interboro Ins. Co. (2012 NY Slip Op 50392(U))The provider's unsworn medical report failed to defeat the insurer's supported motion for summary judgment on lack of medical necessity.
Complete Radiology, P.C. v Progressive Ins. Co. (2011 NY Slip Op 52015(U))The insurer's peer review report raised a triable issue of medical necessity and defeated the provider's summary judgment motion.