February 27, 2007

Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 27234)

https://www.beynensonlaw.com/case-law/delta-diagnostic-radiology-p-c-v-american-tr-ins-co-2007-ny-slip-op-27234/

Court: Appellate Term, Second Department
Decided: February 27, 2007
Citation: 2007 NY Slip Op 27234 · 16 Misc 3d 10
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity

Cite as

Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 16 Misc 3d 10 (App Term, 2d Dept 2007)

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.

A medical-necessity denial's reference to a negative peer review report sufficiently identifies the basis for denial. The provider sought summary judgment because the insurer's NF-10 form lacked specific facts and a medical rationale. The Appellate Term, Second Department, affirmed denial of the motion, following A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co. and relying on 11 NYCRR 65-3.8 (b) (4). It expressly directed that its contrary prior decisions concerning denial specificity should no longer be followed.

Reported in New York Official Reports at Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 27234)

Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co.

2007 NY Slip Op 27234 [16 Misc 3d 10]

Accepted for Miscellaneous Reports Publication

AT2

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

As corrected through Wednesday, July 18, 2007

[*1]

Delta Diagnostic Radiology, P.C., as Assignee of Vladimir Anichkin, Appellant,
v
American Transit Insurance Co., Respondent.

Supreme Court, Appellate Term, Second Department, June 4, 2007

APPEARANCES OF COUNSEL

Alden Banniettis, Brooklyn (Jeff Henle of counsel), for appellant.

{**16 Misc 3d at 21} OPINION OF THE COURT

Memorandum.

Order affirmed without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment, inter alia, on the ground that defendant’s NF-10 denial of claim form, which alleged the lack of medical necessity, failed to assert sufficient facts and a medical rationale based thereon to set forth, with the requisite specificity, a proper ground for the denial. The court denied the motion, finding the denial form’s reference to a negative peer review report sufficient to apprise plaintiff of the basis of its determination that the medical services provided were medically unnecessary. Plaintiff appeals, and we affirm (A.B. Med. Servs., PLLC v Liberty Mut. Ins. Co., 39 AD3d 779 [2d Dept 2007]). To the extent that A.B. Med. Servs. PLLC v GEICO Cas. Ins. Co. (12 Misc 3d 30 [App Term, 2d & 11th Jud Dists 2006]) and related cases are to the contrary, they should no longer be followed (see 11 NYCRR 65-3.8 [b] [4]).

Pesce, P.J., Golia and Rios, JJ., concur.

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.
A.B. Med. Servs. PLLC v GEICO Cas. Ins. Co. (2006 NY Slip Op 26133) OverruledA timely medical-necessity denial must state a sufficiently particular factual basis and medical rationale to avoid preclusion.

Similar decisions

Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 51852(U))The insurer's summary judgment award was vacated because medical necessity was not an issue raised by the provider's motion.
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.
Delta Diagnostic Radiology, P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 52370(U))The insurer's denial and affirmed peer-review report adequately stated the medical-necessity defense and raised a triable issue.
Delta Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51557(U))The insurer's timely denials and reasoned peer reviews raised triable issues of medical necessity.
Delta Diagnostic Radiology, P.C. v Allstate Ins. Co. (2006 NY Slip Op 52034(U))The insurer failed to prove timely mailing of its denial and was precluded from asserting lack of medical necessity.