December 8, 2006
Delta Diagnostic Radiology, P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 52370(U))
https://www.beynensonlaw.com/case-law/delta-diagnostic-radiology-p-c-v-state-farm-mut-auto-ins-co-2006-ny-slip-op-52370u/
- Decided
- December 8, 2006
- Citation
- 2006 NY Slip Op 52370(U) · 14 Misc 3d 126(A)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Legal questions
- Claimant's prima facie case on motions · 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 Delta Diagnostic Radiology, P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 52370(U))
| Delta Diagnostic Radiology, P.C. v State Farm Mut. Auto. Ins. Co. |
| 2006 NY Slip Op 52370(U) [14 Misc 3d 126(A)] |
| Decided on December 8, 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., GOLIA and BELEN, JJ
2005-955 Q C. NO. 2005-955 Q C
against
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY, Respondent.
Appeal from an order of the Civil Court of the City of New York, Queens County (Gerald Dunbar, J.), entered May 2, 2005. The order, insofar as appealed from as limited by plaintiff’s brief, denied plaintiff’s cross motion for summary judgment.
Order, insofar as appealed from, affirmed without costs.
In an action to recover first-party no-fault benefits for medical services rendered to its assignor, a plaintiff generally establishes its prima facie entitlement to summary judgment by proof of the submission of a statutory claim form, setting forth the fact and
the amount of the loss 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 [2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). Herein, plaintiff established submission of its claim by annexing defendant’s denial of claim form, dated July 25, 2003, to its moving papers which states that defendant received said claim on June 30, 2003 (see e.g. Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co., 11 Misc 3d 136[A], 2006 NY Slip Op 50491[U] [App Term, 2d & 11th Jud Dists]). Plaintiff asserts that defendant’s denial of claim form was insufficient in that it did not explicitly set forth the reason for the denial.
Defendant denied plaintiff’s claim on the basis of a peer review finding a lack of medical [*2]necessity. Upon a review of the denial and affirmed peer review report annexed to defendant’s opposition papers, we find that defendant “fully and explicitly” set forth the reasons for the denial (see e.g. Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co., 11 Misc 3d 136[A], 2006 NY Slip Op 50491[U], supra; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U], supra). Plaintiff’s remaining contentions regarding the denial lack merit.
Accordingly, we find that defendant raised a triable issue of fact and that the court below properly denied plaintiff’s cross motion for summary judgment.
Pesce, P.J., and Belen, J., concur.
Golia, J., concurs in a separate memorandum.
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS
PRESENT : PESCE, P.J., GOLIA and BELEN, JJ.
DELTA DIAGNOSTIC RADIOLOGY, P.C.
A/A/O AURELIO RONDON,
Appellant,
-against-
STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY,
Respondent.
[*3]
Golia, J., concurs with the result only, in the following memorandum:
While I agree with the ultimate disposition in the decision reached by the majority, I wish to emphasize that I am constrained to 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 8, 2006
Legal questions (3)
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.
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 established submission of its claim through the insurer's annexed denial form acknowledging receipt, but its cross motion failed because the insurer raised a triable issue.
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.
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 (rules on the question, but another ground decided the case)
Held the provider established submission of its claim through the insurer's own denial form, annexed to its moving papers, which stated the date the claim was received; the result rested on the insurer's triable issue.
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.
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 (rules on the question, but another ground decided the case)
Held the insurer, whose denial and affirmed peer review report fully set forth a lack of medical necessity, raised a triable issue defeating the provider's cross motion.
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
A label shows how this decision treated the case it cites.
- Mary Immaculate Hosp. v Allstate Ins. Co. (2004 NY Slip Op 02359) FollowedThe 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.
- Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co (2006 NYSlipOp 50491(U)) FollowedAn insurer's bill-of-particulars demand is improper when it seeks evidentiary material rather than amplification of the pleadings.
Cited by
- Top Choice Pharm. Corp. v Merchants Mut. Ins. Co. (2022 NY Slip Op 50867(U))The insurer waived its assignment objection and failed to support its medical-necessity defense with a nonconclusory opinion.
Similar decisions
- 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 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.
- Delta Diagnostic Radiology, P.C. v State Farm Mut. Ins. Co. (2006 NY Slip Op 51345(U))The insurer's investigator affidavit raised a coverage issue concerning an alleged fraud scheme, but neither side was entitled to summary judgment.
- Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 50293(U))The insurer failed to establish timely denials because it mailed them more than 30 days after receiving the claims without proving tolling.
- 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.