August 11, 2005

Amaze Med. Supply Inc. v Hereford Ins. Co. (2005 NYSlipOp 51331(U))

https://www.beynensonlaw.com/case-law/amaze-med-supply-inc-v-hereford-ins-co-2005-nyslipop-51331u/

Court: Appellate Term, Second Department
Decided: August 11, 2005
Citation: 2005 NY Slip Op 51331(U)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity · Claimant's prima facie case on motions (see the maps)

Cite as

Amaze Med. Supply Inc. v Hereford Ins. Co., 2005 NY Slip Op 51331(U) (App Term, 2d Dept, 2d & 11th 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.

The insurer's peer reviews raised a triable issue of medical necessity by providing a sufficient factual basis and medical rationale. The provider sought summary judgment for no-fault benefits for medical supplies furnished to its assignor. It established prima facie entitlement by showing that it submitted claims stating the fact and amounts of the losses and that payment was overdue under Insurance Law § 5106 (a). The insurer's opposing peer reviews nevertheless required denial of the motion. The Appellate Term, Second Department, affirmed the order denying the provider summary judgment; a separate concurrence agreed only with the result and disagreed with certain propositions in the cited cases.

Reported in New York Official Reports at Amaze Med. Supply Inc. v Hereford Ins. Co. (2005 NYSlipOp 51331(U))

[*1]

Amaze Med. Supply Inc. v Hereford Ins. Co.

2005 NYSlipOp 51331(U)

Decided on August 11, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 August 11, 2005

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: PESCE, P.J., PATTERSON and GOLIA, JJ.
2004-1070 K C NO. 2004-1070 K C

Amaze Medical Supply Inc., a/a/o Lacos Moscoso Martinez, Appellant,
against
Hereford Insurance Company, Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Eileen Nadelson, J.), entered June 15, 2004. 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]; 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 opposition to the motion, defendant submitted peer reviews asserting a factual basis and medical rationale sufficient to raise a triable issue as to the medical equipment’s medical necessity (Park Health Ctr. v Peerless Ins. Co., 2 Misc 3d 127[A], 2003 NY Slip Op 51687[U] [App Term, 2d & 11th Jud Dists]).

Pesce, P.J., and Patterson, J., concur.

Golia, J., concurs in a separate memorandum. [*2]
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS
PRESENT: PESCE, P.J., PATTERSON and GOLIA, JJ.
AMAZE MEDICAL SUPPLY INC.
a/a/o Lacos Moscoso Martinez,

Appellant,

-against-
HEREFORD INSURANCE COMPANY,

Respondent.

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 disagree 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: August 11, 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

Open the full map

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 insurer's peer reviews set forth a factual basis and medical rationale sufficient to raise a triable issue on the equipment's medical necessity, so the supplier's motion was properly denied.

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, 67 (this one included) are in the same category.

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 (rules on the question, but another ground decided the case)

Held the supplier established a prima facie case by proof that it submitted claims stating the fact and amount of loss and that payment was overdue.

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

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.
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 Health Ctr. v Peerless Ins. Co. (2003 NY Slip Op 51687(U)) FollowedThe insurer's affirmed peer review raised a triable issue of medical necessity by supplying a sufficient factual basis and medical rationale.

Similar decisions

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 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.
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 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.
Amaze Med. Supply Inc. v GEICO Ins. (2005 NYSlipOp 51053(U))The insurer's unsworn peer review report was inadmissible and failed to rebut the provider's prima facie entitlement to payment.