December 13, 2006

Starrett Med. L.C.P.C. v GEICO Cas. Ins. Co. (2006 NY Slip Op 52493(U))

https://www.beynensonlaw.com/case-law/starrett-med-l-c-p-c-v-geico-cas-ins-co-2006-ny-slip-op-52493u/

Court: Appellate Term, Second Department
Decided: December 13, 2006
Citation: 2006 NY Slip Op 52493(U) · 14 Misc 3d 127(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Medical necessity Timeliness and preclusion Provider's prima facie case
Legal questions: Claimant's prima facie case on motions · Proof of mailing (see the maps)

Cite as

Starrett Med. L.C.P.C. v GEICO Cas. Ins. Co., 14 Misc 3d 127(A), 2006 NY Slip Op 52493(U) (App Term, 2d Dept, 2d & 11th Jud Dists 2006)

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 was precluded from asserting medical necessity because its denials lacked factual grounds and timely delivery of peer reviews was unproved. The NF-10 forms referred to peer review reports available on written request but supplied no factual basis or medical rationale. No evidence showed that the reports reached the provider within the 30-day claim determination period. Although the provider's initial mailing proof was deficient, the insurer's denials established receipt and cured that deficiency in the prima facie showing under Insurance Law § 5106 (a). The Appellate Term, Second Department, affirmed summary judgment for the provider; a separate concurrence agreed only with the result and disagreed with propositions in the cited cases.

Reported in New York Official Reports at Starrett Med. L.C.P.C. v GEICO Cas. Ins. Co. (2006 NY Slip Op 52493(U))

[*1]

Starrett Med. L.C.P.C. v GEICO Cas. Ins. Co.

2006 NY Slip Op 52493(U) [14 Misc 3d 127(A)]

Decided on December 13, 2006

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This opinion is uncorrected and will not be published in the printed Official Reports.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 December 13, 2006

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., GOLIA and BELEN, JJ
2005-1862 K C. NO.2005-1862 K C

Starrett Medical L.C.P.C., a/o Jose Vidal, Francois Emery, Ilissa Codrington, and Marilyn Ford, Respondent,
against
GEICO Casualty Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Lila Gold, J.), entered August 3, 2005. The order granted plaintiff’s motion for summary judgment.

Order affirmed without costs.

In an action to recover assigned first-party no-fault benefits, a provider generally establishes its prima facie entitlement to summary judgment by proof of the submission of statutory claim forms, setting forth the fact and the amounts of the losses sustained, and that payment of no-fault benefits is overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2005]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). In the instant case, plaintiff’s moving papers were insufficient to establish the mailing of any of the appended claim forms to defendant. However, said deficiency was cured by defendant’s denial of claim forms which adequately established that plaintiff sent, and defendant received, said claim forms (see PDG Psychological P.C. v Utica Mut. Ins. Co., 11 Misc 3d 128[A], 2006 NY Slip Op 50246[U] [App Term, 2d & 11th Jud Dists]).

This court has repeatedly held that where a denial of claim form fails to set forth with sufficient particularity the factual basis and medical rationale for its denial based upon a lack of medical necessity, the defendant is precluded from asserting said defense (see A.M. Med. Servs., P.C. v Allstate Ins. Co., 12 Misc 3d 144[A], 2006 NY Slip Op 51426[U] [App Term, 2d & 11th Jud Dists]; SZ Med. P.C. v Clarendon Natl. Ins. Co., 12 Misc 3d 144[A], 2006 NY Slip Op 51428[U] [App Term, 2d & 11th Jud Dists]). In the instant case, defendant’s NF-10 denial of claim forms merely advised plaintiff that the claims were denied pursuant to peer review reports [*2]and that a copy of these reports would be furnished upon written request. Since there is no evidence that the peer review reports were sent to plaintiff within the 30-day claim determination period, and the denials were otherwise devoid of any factual basis to support them, defendant is precluded from asserting lack of medical necessity as a defense to said claims (see A.M. Med. Servs., P.C. v Allstate Ins. Co., 12 Misc 3d 144[A], 2006 NY Slip Op 51426[U], supra) and plaintiff is entitled to summary judgment upon said claims.

Pesce, P.J., and Belen, J., concur.

Golia, J., concurs in a separate memorandum.

Golia, J., concurs with the result only, in the following memorandum:

I am constrained to agree with the ultimate disposition in the decision reached by the majority. I, however, wish to note that I do not agree with certain propositions of law set forth in cases cited therein which are inconsistent with my prior expressed positions and generally contrary to my views.
Decision Date: December 13, 2006

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.

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

Held the provider's failure to prove mailing of the claim forms was cured by the insurer's denial forms, which established that the claims were sent and received.

Proof sufficientMailing/receipt not shownOverdue not shownBusiness-record foundation lackingOther element missingThis decisionCites it or cited by itCited or followed

Of the 1,065 decisions on this question in the Second Department courts and the Court of Appeals, 513 (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 provider's or claimant's proof established mailing of its claim form, NF-2 or verification response

Held the provider's papers did not prove mailing of the claim forms, but the insurer's denial forms cured the deficiency by establishing receipt.

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

Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 106 (this one included) are in the same category.

Cited in this decision

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

Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359)The hospitals established entitlement to summary judgment by proving that statutory billing forms were mailed and received and payment was overdue.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U))A provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.
PDG Psychological P.C. v Utica Mut. Ins. Co. (2006 NY Slip Op 50246(U)) FollowedA provider may rely on denial forms annexed to an insurer's motion to establish the insurer's receipt of the claims.
A.M. Med. Servs., P.C. v Allstate Ins. Co. (2006 NY Slip Op 51426(U)) FollowedThe insurer's conclusory medical-necessity denials were ineffective, but policy-limit exhaustion remained a factual issue.
SZ Med. P.C. v Clarendon Natl. Ins. Co. (2006 NY Slip Op 51428(U))The insurer's timely denial lacked a factual basis or medical rationale, precluding its medical-necessity defense.

Similar decisions

Neomy Med., P.C. v Geico Ins. Co. (2012 NY Slip Op 50145(U))The provider's doctor's affidavit raised a triable question of medical necessity despite the insurer's sufficient peer review.
New York Diagnostic Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50419(U))The provider's doctor's affidavit raised a factual issue on medical necessity, defeating the insurer's cross motion for summary judgment.
New Life Med., P.C. v Geico Ins. Co. (2012 NY Slip Op 50150(U))The provider's doctor's affirmation failed to meaningfully address or rebut the insurer's peer reviews finding lack of medical necessity.
Elmont Open MRI & Diagnostic Radiology, P.C. v GEICO Ins. Co. (2006 NY Slip Op 51185(U))A medical necessity denial must state the factual basis and medical rationale with sufficient particularity, even when timely issued.
Park Neurological Servs. P.C. v GEICO Ins. (2004 NY Slip Op 24210)The insurer's denial did not set forth a factual basis and medical rationale for lack of medical necessity, precluding its medical-necessity defense.