October 2, 2009

Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co. (2009 NY Slip Op 06984)

https://www.beynensonlaw.com/case-law/sunshine-imaging-assn-wny-mri-v-government-empls-ins-co-2009-ny-slip-op06984/

Court: Appellate Division, Fourth Department
Decided: October 2, 2009
Citation: 2009 NY Slip Op 06984 · 66 AD3d 1419
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity Discovery and procedure
Legal questions: Lack of medical necessity · Claimant's prima facie case on motions (see the maps)

Cite as

Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co., 66 AD3d 1419 (4th Dept 2009)

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 medical-necessity denials raised a triable issue, and severance was proper for claims arising from 14 unrelated accidents. The Appellate Division, Fourth Department, affirmed the denial of the provider's summary judgment motion and the grant of the insurer's motion to sever 14 causes of action. The provider established receipt of statutory billing forms and overdue payment, but the insurer's denial forms raised a factual issue concerning medical necessity. Under Insurance Law § 5102 (a) (1) and 11 NYCRR 65-1.1 (d), benefits covered only medically necessary expenses, and the assignee remained subject to that defense. Severance was within the trial court's discretion because unrelated assignors sustained diverse injuries in different accidents and required different treatment.

Reported in New York Official Reports at Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co. (2009 NY Slip Op 06984)

Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co.

2009 NY Slip Op 06984 [66 AD3d 1419]

October 2, 2009

Appellate Division, Fourth Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, December 9, 2009

Sunshine Imaging Association/WNY MRI, as Assignee of Carol L. Vancheri and Others, Appellant, v Government Employees Insurance Company, Also Known as “GEICO,” Respondent.

—[*1] Law Office of J. Michael Hayes, Buffalo (J. Michael Hayes of counsel), for plaintiff-appellant.

Law Office of Daniel R. Archilla, Buffalo (David H. Frech of counsel), for defendant-respondent.

Appeal from an order of the Supreme Court, Erie County (John A. Michalek, J.), entered July 25, 2008. The order denied plaintiff’s motion for summary judgment and granted defendant’s motion to sever the causes of action.

It is hereby ordered that the order so appealed from is unanimously affirmed without costs.

Memorandum: Plaintiff, as assignee of 14 patients to whom it provided radiological services, commenced this action seeking to recover no-fault benefits pursuant to the contract between each patient and defendant insurer. We conclude that Supreme Court properly denied plaintiff’s motion for summary judgment on the amended complaint. Although plaintiff made a prima facie showing of entitlement to judgment as a matter of law by submitting evidence that the prescribed statutory billing forms were received by defendant and that defendant’s payment of no-fault benefits to plaintiff was overdue (see A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779, 780 [2007]; LMK Psychological Servs., P.C. v Liberty Mut. Ins. Co., 30 AD3d 727, 728 [2006]), defendant raised a triable issue of fact by submitting its denial of claim forms setting forth that the services for which plaintiff sought to recover no-fault benefits were not medically necessary (see Countrywide Ins. Co. v 563 Grand Med., P.C., 50 AD3d 313, 314 [2008]; A.B. Med. Servs., PLLC, 39 AD3d at 780-781). Contrary to plaintiff’s contention, defendant is not precluded from denying the claims after the services were rendered on the ground of lack of medical necessity. Plaintiff’s assignors were entitled only to reimbursement for medically “necessary” expenses (Insurance Law § 5102 [a] [1]; see 11 NYCRR 65-1.1 [d]), and plaintiff assignee is subject to that lack of medical necessity defense (see Long Is. Radiology v Allstate Ins. Co., 36 AD3d 763, 765 [2007]).

Contrary to plaintiff’s further contention, the court did not abuse its discretion in granting defendant’s motion to sever the 14 causes of action. “The decision whether to grant severance ‘rests soundly in the discretion of the trial court and, on appeal, will be affirmed absent a demonstration of abuse of discretion or prejudice to a substantial right’ ” (Rapini v New Plan Excel Realty Trust, Inc., 8 AD3d 1013, 1014 [2004]; see Soule v Norton, 299 AD2d 827, 828 [2002]). [*2]Although this action was commenced “by a single assignee against a single insurer and all [causes of action] allege the erroneous nonpayment of no-fault benefits . . . , they arise from [14] different automobile accidents on various dates in which the [14] unrelated assignors suffered diverse injuries and required different medical treatment” (Poole v Allstate Ins. Co., 20 AD3d 518, 519 [2005]). Present—Scudder, P.J., Hurlbutt, Martoche, Smith and Centra, JJ.

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 was enough to defeat the provider's motion but not to win

Held the insurer raised a triable issue by submitting denial forms stating the services were not medically necessary, and that the defense was available against the radiology assignee after services were rendered.

Insurer raised triable issueInsurer's proof insufficientThis decision

Of the 3 decisions on this question in the Fourth Department courts and the Court of Appeals, 1 (this one included) is in the same category. 2 decisions in other departments that cite or are cited by this one are on the full map.

Claimant's prima facie case on motions

Open the full map

On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?

This decision: Claimant's proof held to make out its prima facie case (rules on the question, but another ground decided the case)

Held the provider made a prima facie showing by evidence that the statutory billing forms were received and payment was overdue, though its motion was denied on the insurer's triable issue.

Proof sufficientThis decisionCites it or cited by itCited or followed

Of the 4 decisions on this question in the Fourth Department courts and the Court of Appeals, 4 (this one included) are in the same category. 4 decisions in other departments that cite or are cited by this one are on the full map.

Cited in this decision

A label shows how this decision treated the case it cites.

A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. (2007 NY Slip Op 03636) FollowedAn insurer denying no-fault benefits for lack of medical justification need not include a medical rationale in the prescribed denial form.
LMK Psychological Servs., P.C. v Liberty Mut. Ins. Co. (2006 NY Slip Op 04486)The providers proved claim mailing, and the insurer waived assignment objections by failing to seek verification within 10 days.
Countrywide Ins. Co. v 563 Grand Med., P.C. (2008 NY Slip Op 03059) FollowedAn insurer need not state its medical rationale in the prescribed denial form, and a nurse's medical necessity review is not per se invalid.
Long Is. Radiology v Allstate Ins. Co. (2007 NY Slip Op 00496) FollowedAn insurer may assert lack of medical necessity against a radiologist seeking assigned no-fault benefits for prescribed MRIs. The provider argued that the defense was unavailable because it performed MRIs on prescription without diagnosing patients, conducting physical examinations, or assessing necessity.
Poole v Allstate Ins. Co. (2005 NY Slip Op 06017) FollowedA provider's 47 no-fault causes of action were severed because their differing facts and defenses would make a joint trial unwieldy.

Cited by

Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2015 NY Slip Op 04787)A provider establishes entitlement to summary judgment on overdue no-fault claims with admissible proof of mailing and receipt of statutory claim forms.
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2013 NY Slip Op 08430)A provider need not prove a claim's merits for summary judgment where the insurer failed to timely and properly deny the claim.
New York Cent. Mut. Ins. v McGee (2009 NY Slip Op 52385(U))The insurer's common-ownership allegations did not justify joining all provider defendants, and its requested injunction lacked evidentiary support.

Similar decisions

S.I.A. Med. Supply Inc. v GEICO Ins. Co. (2005 NYSlipOp 51170(U))The provider's claims for 11 assignors were severed because they presented few common issues and a joint trial risked confusion.
Westchester Radiology & Imaging, P.C. v GEICO Cas. Co. (2019 NY Slip Op 51703(U))The insurer was entitled to sever six assignors' claims arising from separate accidents and denied for lack of medical necessity.
RJA Physical Therapy, P.C. v Geico Cas. Co. (2012 NY Slip Op 52047(U))The insurer's severance motion was warranted because claims involving seven assignors and six accidents raised few common issues of law or fact.
Ladim DME, Inc. v GEICO Gen. Ins. Co. (2007 NY Slip Op 50997(U))The insurer's answer supplied a basis to sever five assignors' claims arising from separate accidents without a prejudice affidavit.
Ocean Diagnostics Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 50913(U))The provider's claims from 11 separate accidents were properly severed because the defenses raised few common issues of law or fact.