October 1, 2010
Altair Med., P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 51721(U))
https://www.beynensonlaw.com/case-law/altair-med-p-c-v-clarendon-natl-ins-co-2010-ny-slip-op-51721u/
- Decided
- October 1, 2010
- Citation
- 2010 NY Slip Op 51721(U) · 29 Misc 3d 127(A)
- Posture
- Summary judgment
- Outcome
- Split result
- Issues
- Medical necessity
- Legal questions
- Lack of medical necessity · Proof of mailing (see the maps)
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.
Reported in New York Official Reports at Altair Med., P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 51721(U))
| Altair Med., P.C. v Clarendon Natl. Ins. Co. |
| 2010 NY Slip Op 51721(U) [29 Misc 3d 127(A)] |
| Decided on October 1, 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., RIOS and STEINHARDT, JJ
2009-726 RI C.
against
Clarendon National Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Richmond County (Katherine A. Levine, J.), entered January 16, 2009. 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 modified by providing that defendant’s cross motion for summary judgment is granted to the extent of dismissing the complaint with respect to the claim by plaintiff S & R Medical, P.C. in the sum of $2,831.08; as so modified, the order, insofar as appealed from, is affirmed without costs.
In this action by providers to recover assigned first-party no-fault benefits, plaintiffs moved for summary judgment, and defendant cross-moved for summary judgment dismissing the complaint on the ground that the services rendered were not medically necessary. The Civil Court denied plaintiffs’ motion and defendant’s cross motion. Defendant appeals, as limited by its brief, from so much of the order as denied its cross motion for summary judgment dismissing the complaint.
The affidavit submitted by defendant established that the denial of claim forms, which denied the claims at issue on the ground of lack of medical necessity, were timely mailed in accordance with defendant’s standard office practices and procedures (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; 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]). Defendant also submitted an affirmed peer review report, which set forth a factual basis and medical rationale for the conclusion that there was a lack of medical necessity for the services provided by plaintiff S & [*2]R Medical, P.C. in the amount of $2,831.08. As S & R Medical, P.C. failed to submit any evidence to rebut defendant’s showing of lack of medical necessity, defendant’s cross motion for summary judgment should have been granted as to the $2,831.08 claim (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]).
Defendant’s contention that the Civil Court should have granted it summary judgment dismissing the claim by plaintiff Altair Medical, P.C. and the claim by plaintiff S & R Medical, P.C. in the amount of $793.24 lacks merit because the “peer review report” pertaining to these claims was unsigned. Accordingly, defendant failed to establish its prima facie entitlement to summary judgment dismissing these claims (see Zuckerman v City of New York, 49 NY2d 557 [1980]).
Pesce, P.J., Rios and Steinhardt, JJ., concur.
Decision Date: October 01, 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.
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 an affirmed peer review established lack of medical necessity for one claim the provider did not rebut, but an unsigned peer review failed to establish the insurer's prima facie case on the other claims.
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.
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's affidavit established timely mailing of the medical-necessity denials under its standard office practices and procedures.
Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (this one included) are in the same category.
Cited in this decision
- St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072)The insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
- 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.
Similar decisions
- Biobalance Med., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52378(U))The insurer established lack of medical necessity through a supported peer review report that the provider failed to rebut.
- 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.
- Alfa Med. Supplies v Progressive Northeastern Ins. Co. (2010 NY Slip Op 51733(U))The insurer established full payment of one claim and an unrebutted medical necessity defense to the remaining claim.
- SAL Med., P.C. v Clarendon Natl. Ins. Co. (2015 NY Slip Op 51449(U))The insurer cured an unsigned peer review report by submitting an identical signed report in reply, without prejudice to the provider.