April 25, 2008
A Khodadadi Radiology, P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 50910(U))
https://www.beynensonlaw.com/case-law/a-khodadadi-radiology-p-c-v-travelers-prop-cas-ins-co-2008-ny-slip-op50910u/
- Decided
- April 25, 2008
- Citation
- 2008 NY Slip Op 50910(U) · 19 Misc 3d 140(A)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Legal questions
- Proof of mailing · Lack of medical necessity (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 A Khodadadi Radiology, P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 50910(U))
| A Khodadadi Radiology, P.C. v Travelers Prop. Cas. Ins. Co. |
| 2008 NY Slip Op 50910(U) [19 Misc 3d 140(A)] |
| Decided on April 25, 2008 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports.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 and 11th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., WESTON PATTERSON and RIOS, JJ
2006-1974 K C.
against
Travelers Property Casualty Ins. Co., Respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Dolores L. Waltrous, J.), entered September 8, 2006. The order denied plaintiff’s motion for summary judgment.
Order affirmed without costs.
In this action by a provider to recover first-party no-fault benefits, plaintiff moved for summary judgment. Defendant opposed the motion, asserting that it timely denied plaintiff’s claim on the ground that the services provided were not medically necessary based on a peer review report. The court below denied plaintiff’s motion for summary judgment, and the instant appeal by plaintiff ensued.
Contrary to plaintiff’s contention, the affidavit submitted by defendant’s claims representative sufficiently established that the denial of claim form at issue was timely mailed pursuant to defendant’s standard office practice and procedure (see New York & Presbyt. Hosp. v Allstate Ins. Co., 29 AD3d 547 [2006]; 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]; see also New York & Presbyterian Hospital v AIU Ins. Co., 20 AD3d 515 [2005]; Hospital for Joint Diseases v Allstate Ins. Co., 5 AD3d 441 [2004]). Defendant’s papers submitted in opposition to plaintiff’s motion for summary judgment, which included a peer review report, were sufficient to demonstrate the existence of an issue of fact with respect to the defense of lack of medical necessity (see A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779 [2007]; Long Is. Radiology v Allstate Ins. Co., 36 AD3d 763 [2007]). Accordingly, the order denying plaintiff’s motion for summary judgment is affirmed, [*2]albeit on other grounds.
Pesce, P.J., Weston Patterson and Rios, JJ., concur.
Decision Date: April 25, 2008
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 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
Rejected the provider's challenge and held the claims representative's affidavit sufficiently established timely mailing of the denial pursuant to the insurer's standard office practice and procedure.
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.
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's opposition, including a peer review report, sufficed to raise an issue of fact on lack of medical necessity, so the provider's summary judgment motion was properly denied.
Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 67 (this one included) are in the same category.
Cited in this decision
- New York & Presbyt. Hosp. v Allstate Ins. Co. (2006 NY Slip Op 03558)The providers failed to establish mailing and receipt of the hospital bill asserted in their second cause of action.
- 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.
- New York & Presbyt. Hosp. v AIU Ins. Co. (2005 NY Slip Op 06014)A resubmitted no-fault claim previously and timely denied is not subject to a new 30-day payment-or-denial period.
- Hospital for Joint Diseases v Allstate Ins. Co. (2004 NY Slip Op 01546)Resubmission of a previously denied no-fault claim does not restart the insurer's 30-day period to deny it.
- A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. (2007 NY Slip Op 03636)An insurer denying no-fault benefits for lack of medical justification need not include a medical rationale in the prescribed denial form.
- Long Is. Radiology v Allstate Ins. Co. (2007 NY Slip Op 00496)An 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.
Similar decisions
- Avenue N Med., P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 52174(U))The insurer's timely denials and affirmed peer review raised a medical-necessity issue defeating the provider's summary judgment motion.
- Radiology Today, P.C. v Travelers Ins. Co. (2013 NY Slip Op 50849(U))The insurer's conclusory expert testimony failed to establish lack of medical necessity because it supplied no factual basis or medical rationale.
- 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.
- All County Open MRI & Diagn. Radiology P.C. v Travelers Ins. Co. (2006 NY Slip Op 50318(U))A peer review citing insufficient information cannot support denial without proof that the insurer sought that information through verification.
- Delta Diagnostic Radiology, P.C. v American Mfrs. Mut. Ins. Co. (2006 NY Slip Op 51439(U))The insurer raised a triable issue of medical necessity through detailed peer reviews and timely denials following verification.