July 12, 2006
Amaze Med. Supply Inc. v Allstate Ins. Co. (2006 NY Slip Op 51412(U))
https://www.beynensonlaw.com/case-law/amaze-med-supply-inc-v-allstate-ins-co-2006-ny-slip-op-51412u/
- Decided
- July 12, 2006
- Citation
- 2006 NY Slip Op 51412(U) · 12 Misc 3d 142(A)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Later treatment
- Followed in 8 later decisions (see Cited by)
- Legal questions
- Lack of medical necessity · Claimant's prima facie case on motions (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 Amaze Med. Supply Inc. v Allstate Ins. Co. (2006 NY Slip Op 51412(U))
| Amaze Med. Supply Inc. v Allstate Ins. Co. |
| 2006 NY Slip Op 51412(U) [12 Misc 3d 142(A)] |
| Decided on July 12, 2006 |
| Appellate Term, Second Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
| As corrected in part through August 10, 2006; it will not be published in the printed Official Reports.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: : WESTON PATTERSON, J.P., GOLIA and BELEN, JJ
2005-858 K C. NO. 2005-858 K C
against
ALLSTATE INSURANCE COMPANY, Respondent.
Appeal from an order of the Civil Court of the City of New York, Kings County (Eileen Nadelson, J.), entered March 18, 2005. The order denied plaintiff’s motion for summary judgment.
Order affirmed without costs.
In this action to recover first-party no-fault benefits for medical supplies furnished to its assignor, plaintiff established a prima facie entitlement to summary judgment by proof that it submitted claims, setting forth the fact and the amounts of the losses sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86 [App Term, 2d & 11th Jud
Dists 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]).
Defendant timely denied the claims on the ground of lack of medical necessity based upon a peer review report. The peer reviewer set forth a “factual basis and medical rationale” (Park Neurological Servs. P.C. v GEICO Ins., 4 Misc 3d 95, 97 [App Term, 9th & 10th Jud Dists 2004]) for his conclusion that there was no medical necessity for the supplies furnished based on the documentation provided to him. This was sufficient to raise a triable issue of the supplies’ medical necessity. We note that contrary to plaintiff’s contention, under the facts presented the [*2]reviewer’s mere reference to unavailable reports and notes does not require the inference that the reviewer considered the information in his possession insufficient to permit a medical necessity determination and that recourse to the verification process was necessary to amplify the record. Accordingly, plaintiff’s motion for summary judgment was properly denied.
Weston Patterson, J.P., and Belen, J., concur.
Golia, J., concurs in a separate memorandum.
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: July 12, 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.
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 peer review's factual basis and medical rationale raised a triable issue of medical necessity, and the reviewer's reference to unavailable records did not mean verification was required, so the supplier's motion was 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.
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 supplier made its prima facie showing by proving it submitted claims stating the fact and amount of loss and that payment was overdue, though the motion failed on the insurer's defense.
Of the 1,063 decisions on this question in the Second Department courts and the Court of Appeals, 511 (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.
- A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co. (2004 NY Slip Op 24194)An insurer's timely medical-necessity denial does not replace admissible proof opposing a provider's summary judgment motion.
- 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.
- Park Neurological Servs. P.C. v GEICO Ins. (2004 NY Slip Op 24210) FollowedThe insurer's denial did not set forth a factual basis and medical rationale for lack of medical necessity, precluding its medical-necessity defense.
Cited by (13)
A label shows how the later decision treated this one.
- Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) FollowedThe provider's conclusory disagreement with the insurer's supported peer review failed to raise a medical-necessity issue of fact.
- Quality Psychological Servs., P.C. v Mercury Ins. Group (2010 NY Slip Op 50601(U)) FollowedThe insurer's timely denial and peer review report supported its defense, but the provider raised a medical-necessity fact issue.
- High Quality Med., P.C. v Mercury Ins. Co. (2010 NY Slip Op 51900(U)) FollowedThe provider's principal's affirmation was inadmissible under CPLR 2106 and failed to rebut the insurer's IME conclusions.
- St. Vincent Med. Care, P.C. v Mercury Cas. Co. (2009 NY Slip Op 50810(U)) FollowedThe provider's principal's affirmation was inadmissible under CPLR 2106 and failed to rebut the insurer's medical-necessity showing.
- Quality Rehab & P.T., P.C. v GEICO Ins. Co. (2009 NY Slip Op 52632(U)) FollowedThe insurer's timely denial and affirmed IME reports raised a triable issue of medical necessity.
- Right Aid Diagnostic Medicine, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52635(U)) FollowedThe insurer's proof of timely denials and supported peer reviews raised a triable issue of medical necessity.
- Metropolitan Med. Supplies, LLC v GEICO Ins. Co. (2010 NY Slip Op 50066(U)) FollowedThe insurer raised triable issues on medical necessity for the second cause of action and excessive fees for the third.
- Canarsie Family Med. Practice, PLLC v American Tr. Ins. Co. (2010 NY Slip Op 50070(U)) FollowedThe insurer proved lack of medical necessity for two claims but failed to establish IME nonappearance or excessive fees for the others.
- Exclusive Med. Supply, Inc. v Mercury Ins. Group (2009 NY Slip Op 52273(U))The insurer's timely denials and unrebutted peer reviews established that the medical equipment lacked medical necessity.
- Elmont Open MRI & Diagnostic Radiology, P.C. v Country-Wide Ins. Co. (2007 NY Slip Op 27072)Interest on unpaid no-fault benefits runs from 30 days after claim receipt when the insurer issues no valid denial within that period.
Similar decisions
- Amaze Med. Supply Inc. v Travelers Prop. Cas. Corp. (2005 NY Slip Op 50452(U))An insurer need not seek further verification when a peer review finds no substantiation of equipment's medical necessity in documents obtained for review.
- Amaze Med. Supply Inc. v Hereford Ins. Co. (2005 NYSlipOp 51331(U))The insurer's peer reviews raised a triable issue of medical necessity by providing a sufficient factual basis and medical rationale.
- Amaze Medical Supply Inc. v Allstate Ins. Co. (2004 NY Slip Op 51636(U))The insurer's denials issued more than 30 days after submission precluded its medical-necessity defense.
- Amaze Med. Supply Inc. v General Assur. Co. (2006 NY Slip Op 50307(U))The insurer's proof of pre-claim IME nonattendance raised a factual issue as to the medical necessity of the supplies.
- Amaze Med. Supply v Allstate Ins. Co. (2004 NY Slip Op 50211(U))The provider established entitlement to summary judgment by proving submission of complete claims that were not paid or denied within 30 days.