December 12, 2005

Air Plus Surgical Supply, Inc. v Progressive Ins. Co. (2005 NY Slip Op 52088(U))

https://www.beynensonlaw.com/case-law/air-plus-surgical-supply-inc-v-progressive-ins-co-2005-ny-slip-op-52088u/

Court: Appellate Term, Second Department
Decided: December 12, 2005
Citation: 2005 NY Slip Op 52088(U) · 10 Misc 3d 133(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity · Claimant's prima facie case on motions (see the maps)

Cite as

Air Plus Surgical Supply, Inc. v Progressive Ins. Co., 10 Misc 3d 133(A), 2005 NY Slip Op 52088(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2005)

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 factually specific, unaffirmed peer review report can support a denial for lack of medical necessity but is inadmissible on summary judgment. The provider established prima facie entitlement to overdue no-fault benefits for medical supplies under Insurance Law § 5106 (a). The insurer's timely denials included a factually specific peer review report sufficient to assert lack of medical necessity, but the unaffirmed report could not rebut the provider's showing. The Appellate Term, Second Department, reversed the order, insofar as appealed from by the provider, granted its summary judgment motion and remanded for statutory interest and attorney fees. The insurer's cross appeal was dismissed in accordance with its brief.

Reported in New York Official Reports at Air Plus Surgical Supply, Inc. v Progressive Ins. Co. (2005 NY Slip Op 52088(U))

[*1]

Air Plus Surgical Supply, Inc. v Progressive Ins. Co.

2005 NY Slip Op 52088(U) [10 Misc 3d 133(A)]

Decided on December 12, 2005

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This opinion is uncorrected and will not be published in the printed Official Reports.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 12, 2005

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT:: RUDOLPH, P.J., McCABE and TANENBAUM, JJ.
2005-178 N C

Air Plus Surgical Supply, Inc. As Assignee of SAMPSON ODURO, Appellant-Respondent,
against
Progressive Insurance Co., Respondent-Appellant.

Appeal and cross appeal from an order of the District Court of Nassau County, First District (Norman Janowitz, J.), entered December 23, 2004. The order denied plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment.

Order insofar as appealed from by plaintiff unanimously reversed without costs, plaintiff’s motion for summary judgment granted in the principal sum of $2,983 and matter remanded to the court below for a calculation of statutory interest and an assessment of attorney’s fees. [*2]

Cross appeal by defendant unanimously dismissed.

In this action to recover first-party no-fault benefits for medical supplies provided to its assignor, plaintiff established its prima facie entitlement to summary judgment by showing that it submitted completed proofs of claims, setting forth the fact and the amount of the loss sustained, and that payments of no-fault benefits were overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Damadian MRI In Elmhurst v Liberty Mut. Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51700[U] [App Term, 9th & 10th Jud Dists]). The burden then shifted to defendant to demonstrate a triable issue of fact (Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]).

The timely denials containing the unaffirmed but factually specific peer review report constituted a sufficient assertion of a defense of lack of medical necessity. However, in opposition to a motion for summary judgment defendant was required to submit proof in admissible form to rebut plaintiff’s prima facie showing. Since the report [*3]
was not in admissible form, plaintiff’s motion should have been granted (A.B. Med. Servs. v New York Cent. Mut. Fire Ins. Co., 3 Misc 3d 136[A], 2004 NY Slip Op 50507[U] [App Term, 2d & 11th Jud Dists]).

We note that, in accordance with the brief submitted by defendant, its cross appeal is dismissed.
Decision Date: December 12, 2005

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.

Lack of medical necessity

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Did the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?

This decision: Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)

Held the factually specific peer review, though enough to assert the defense in the denial, was unaffirmed and not in admissible form, so it could not defeat the supplier's summary judgment motion.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decisionCites it or cited by itCited or followed

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 109 (this one included) are in the same category.

Claimant's prima facie case on motions

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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 established its prima facie case by showing it submitted completed proofs of claim and that payment was overdue, shifting the burden to the insurer.

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.

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.
Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U))A provider need not submit additional medical-necessity evidence to obtain summary judgment when the insurer is precluded from that defense.
A.B. Med. Servs. v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50507(U)) FollowedAn insurer opposing summary judgment on medical necessity must submit admissible proof even if unaffirmed reports supported a timely denial.

Similar decisions

Comfort Supply, Inc. v Progressive Northeastern Ins. Co. (2011 NY Slip Op 52289(U))A peer review report is not inadmissible merely because the insurer omits the underlying medical records considered by the reviewer.
Iav Med. Supply, Inc. v Progressive Ins. Co. (2010 NY Slip Op 52155(U))The insurer's peer review established lack of medical necessity for the supplies, and the provider did not oppose the cross motion.
Amaze Med. Supply Inc. v Allstate Ins. Co. (2006 NY Slip Op 51412(U))The insurer's peer review supplied a factual basis and medical rationale sufficient to raise a triable issue of medical necessity.
Ortho-Med Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2012 NY Slip Op 50149(U))An insurer need not attach the records reviewed by its peer reviewer to establish lack of medical necessity on summary judgment.
Five Boro Med. Equip., Inc. v A. Cent. Ins. Co. (2016 NY Slip Op 50412(U))The insurer's incomplete peer review failed to support two denials, and the provider's medical affidavit raised factual issues on two other claims.