Arco Med. NY, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51800(U))

Reported in New York Official Reports at Arco Med. NY, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51800(U))

Arco Med. NY, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51800(U)) [*1]
Arco Med. NY, P.C. v Praetorian Ins. Co.
2014 NY Slip Op 51800(U) [46 Misc 3d 128(A)]
Decided on December 17, 2014
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This opinion is uncorrected and will not be published in the printed Official Reports.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 17, 2014

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-893 K C
Arco Medical NY, P.C., as Assignee of VIVIAN BONILLA, Respondent, -and

against

Megacure Acupuncture, P.C. as Assignee of VIVIAN BONILLA, Plaintiff, Praetorian Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Dawn Jimenez Salta, J.), entered March 29, 2012. The order, insofar as appealed from and as limited by the brief, denied the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon a claim for services rendered by plaintiff Arco Medical NY, P.C. on April 11, 2008.

ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.

In this action by providers to recover assigned first-party no-fault benefits, defendant appeals, as limited by its brief, from so much of an order of the Civil Court as denied the branch of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon a claim for services rendered by plaintiff Arco Medical NY, P.C. on April 11, 2008.

Upon a review of the record, we find that there is a triable issue of fact regarding the medical necessity of the services at issue (see Zuckerman v City of New York, 49 NY2d 557 [1980]).

Accordingly, the order, insofar as appealed from, is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: December 17, 2014
LMS Acupuncture, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51799(U))

Reported in New York Official Reports at LMS Acupuncture, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51799(U))

LMS Acupuncture, P.C. v Eveready Ins. Co. (2014 NY Slip Op 51799(U)) [*1]
LMS Acupuncture, P.C. v Eveready Ins. Co.
2014 NY Slip Op 51799(U) [46 Misc 3d 128(A)]
Decided on December 17, 2014
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 17, 2014

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-847 K C
LMS Acupuncture, P.C. as Assignee of ISABEL CRUZ, Appellant, –

against

Eveready Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin Kelly Sheares, J.), entered December 20, 2011. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order is modified by providing that the branch of defendant’s cross motion seeking summary judgment dismissing so much of the complaint as sought to recover upon a claim which had been denied based on a lack of medical necessity is denied; as so modified, the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Contrary to plaintiff’s contentions on appeal regarding the claims which had been denied based upon the workers’ compensation fee schedule, defendant adequately demonstrated that it had fully paid plaintiff for those services in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors (see Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]), and plaintiff failed to raise a triable issue of fact in response.

With respect to the remaining claim, which had been denied based upon a lack of medical necessity, we find that there is a triable issue of fact as to the medical necessity of the services rendered (see Zuckerman v City of New York, 49 NY2d 557 [1980]), and that therefore defendant was not entitled to summary judgment dismissing this claim.

Accordingly, the order is modified by providing that the branch of defendant’s cross motion seeking summary judgment dismissing so much of the complaint as sought to recover upon the claim which had been denied based on a lack of medical necessity is denied.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: December 17, 2014
Eagle Surgical Supply, Inc. v Allstate Ins. Co. (2014 NY Slip Op 51798(U))

Reported in New York Official Reports at Eagle Surgical Supply, Inc. v Allstate Ins. Co. (2014 NY Slip Op 51798(U))

Eagle Surgical Supply, Inc. v Allstate Ins. Co. (2014 NY Slip Op 51798(U)) [*1]
Eagle Surgical Supply, Inc. v Allstate Ins. Co.
2014 NY Slip Op 51798(U) [46 Misc 3d 128(A)]
Decided on December 17, 2014
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 17, 2014

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-846 Q C
Eagle Surgical Supply, Inc. as Assignee of CAROL HORTON, Appellant,

against

Allstate Insurance Company, Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Joseph E. Capella, J.), entered March 9, 2012, deemed from a judgment of the same court entered March 15, 2012 (see CPLR 5501 [c]). The judgment, entered pursuant to the March 9, 2012 order granting defendant’s motion for summary judgment, dismissed the complaint.

ORDERED that the judgment is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground that plaintiff had failed to appear for duly scheduled examinations under oath (EUOs). Plaintiff appeals from an order of the Civil Court granting defendant’s motion. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).

On appeal, plaintiff contends that the EUO scheduling letters were defective because they did not adequately advise plaintiff as to why the EUO was being requested. However, since plaintiff does not claim to have responded in any way to the EUO requests, its objections regarding the EUO requests will not now be heard (see Viviane Etienne Med. Care, P.C. v State Farm Mut. Auto. Ins. Co., 35 Misc 3d 127[A], 2012 NY Slip Op 50579[U] [App Term, 2d, 11th & 13th Jud Dists 2012]; Crescent Radiology, PLLC v American Tr. Ins. Co., 31 Misc 3d 134[A], 2011 NY Slip Op 50622[U] [App Term, 9th & 10th Jud Dists 2011]). In any event, plaintiff’s contention lacks merit since the EUO scheduling letters advised that the EUO would concern, among other things, plaintiff’s eligibility to be reimbursed for assigned no-fault benefits (see also 2006 Ops Ins Dept No. 06-12-16 [http://www.dfs.ny.gov/insurance/ogco2006/rg061216.htm]).

Plaintiff’s remaining contentions are improperly raised for the first time on appeal and, therefore, are not properly before this court (see NYU Hosp. for Joint Diseases v Country Wide Ins. Co., 84 AD3d 1043 [2011]; Matter of Panetta v Carroll, 62 AD3d 1010 [2009]; KPSD Mineola, Inc. v Jahn, 57 AD3d 853, 854 [2008]).

Accordingly, the judgment is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: December 17, 2014
Excel Imaging, P.C. v Infinity Select Ins. Co. (2014 NY Slip Op 51796(U))

Reported in New York Official Reports at Excel Imaging, P.C. v Infinity Select Ins. Co. (2014 NY Slip Op 51796(U))

Excel Imaging, P.C. v Infinity Select Ins. Co. (2014 NY Slip Op 51796(U)) [*1]
Excel Imaging, P.C. v Infinity Select Ins. Co.
2014 NY Slip Op 51796(U) [46 Misc 3d 128(A)]
Decided on December 17, 2014
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 17, 2014

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-792 Q C
Excel Imaging, P.C. as Assignee of NESHIA DUNCAN, Respondent, –

against

Infinity Select Insurance Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Cheree A. Buggs, J.), entered September 16, 2011, deemed from a judgment of the same court entered March 8, 2012 (see CPLR 5501 [c]). The judgment, entered pursuant to the September 16, 2011 order granting plaintiff’s motion for summary judgment and denying defendant’s cross motion for summary judgment dismissing the complaint, awarded plaintiff the principal sum of $1,626.53.

ORDERED that the judgment is reversed, with $30 costs, the order entered September 16, 2011 is vacated, plaintiff’s motion for summary judgment is denied and defendant’s cross motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court which granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment dismissing the complaint. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).

In opposition to plaintiff’s motion for summary judgment, and in support of its cross motion for summary judgment dismissing the complaint, defendant established that its time to pay or deny plaintiff’s claim had been tolled by the timely mailing of examination under oath (EUO) scheduling letters (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), that plaintiff’s assignor had failed to appear for either of the properly scheduled EUOs, and that the claim had been timely and properly denied on that ground (see id.; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]). Furthermore, since plaintiff does not claim that its assignor objected to the reasonableness of the EUO requests, its objections regarding the requests will not now be heard (see Viviane Etienne Med. Care, P.C. v State Farm Mut. Auto. Ins. Co., 35 Misc 3d 127[A], 2012 NY Slip Op 50579[U] [App Term, 2d, 11th & 13th Jud Dists 2012]; Crescent Radiology, PLLC v American Tr. Ins. Co., 31 Misc 3d 134[A], 2011 NY Slip Op 50622[U] [App Term, 9th & 10th Jud Dists 2011]). An assignor’s appearance at an EUO is a condition precedent to the insurer’s liability on the policy (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720, 722 [2006]).

Accordingly, the judgment is reversed, the order entered September 16, 2011 is vacated, plaintiff’s motion for summary judgment is denied and defendant’s cross motion for summary judgment dismissing the complaint is granted.


Pesce, P.J., Aliotta and Solomon, JJ., concur.
Decision Date: December 17, 2014
Island Chiropractic Testing, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51795(U))

Reported in New York Official Reports at Island Chiropractic Testing, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51795(U))

Island Chiropractic Testing, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51795(U)) [*1]
Island Chiropractic Testing, P.C. v Praetorian Ins. Co.
2014 NY Slip Op 51795(U) [46 Misc 3d 128(A)]
Decided on December 17, 2014
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 17, 2014

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-581 K C
Island Chiropractic Testing, P.C. as Assignee of SHAWN KILLINGBECK, Respondent,

against

Praetorian Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Dawn Jimenez Salta, J.), entered February 7, 2012. The order denied defendant’s motion for summary judgment dismissing the complaint and granted plaintiff’s cross motion for summary judgment.

ORDERED that the order is modified by providing that plaintiff’s cross motion for summary judgment is denied; as so modified, the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint, arguing that the action is premature because plaintiff had not provided verification as requested by defendant, and plaintiff cross-moved for summary judgment. The Civil Court denied defendant’s motion and granted plaintiff’s cross motion.

Since a claim need not be paid or denied until all demanded verification is provided (see Westchester County Med. Ctr. v New York Cent. Mut. Fire Ins. Co., 262 AD2d 553, 554 [1999]), any action to recover payment is premature when the provider has failed to respond to a request for verification (see Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492, 493 [2005]). In support of its motion, defendant demonstrated it had timely mailed initial and follow-up requests for verification (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). However, upon the record before us, we find that there is a triable issue of fact as to whether plaintiff adequately responded to those verification requests.

Accordingly, the order is modified by providing that plaintiff’s cross motion for summary judgment is denied.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: December 17, 2014
Right Solution Med. Supply, Inc. v Praetorian Ins. Co. (2014 NY Slip Op 51793(U))

Reported in New York Official Reports at Right Solution Med. Supply, Inc. v Praetorian Ins. Co. (2014 NY Slip Op 51793(U))

Right Solution Med. Supply, Inc. v Praetorian Ins. Co. (2014 NY Slip Op 51793(U)) [*1]
Right Solution Med. Supply, Inc. v Praetorian Ins. Co.
2014 NY Slip Op 51793(U) [46 Misc 3d 127(A)]
Decided on December 17, 2014
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 17, 2014

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-559 Q C
Right Solution Medical Supply, Inc. as Assignee of SHERITA DESSELLE, Respondent,

against

Praetorian Ins. Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Anna Culley, J.), entered January 18, 2012. The order, insofar as appealed from, granted the branch of plaintiff’s motion seeking summary judgment on the fourth cause of action and denied defendant’s cross motion for summary judgment dismissing the complaint. So much of the appeal as is from the portion of the order which granted the branch of plaintiff’s motion seeking summary judgment on the fourth cause of action and denied the branch of defendant’s cross motion seeking summary judgment dismissing that cause of action is deemed to be an appeal from a judgment of the same court entered February 14, 2012, awarding plaintiff the principal sum of $2,357.95 (see CPLR 5501 [c]).

ORDERED that the judgment is reversed, without costs, so much of the order entered January 18, 2012 as granted the branch of plaintiff’s motion seeking summary judgment on the fourth cause of action is vacated and that branch of plaintiff’s motion is denied; and it is further,

ORDERED that the order, insofar as reviewed on direct appeal and insofar as appealed from, is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. By order entered January 18, 2012, the Civil Court denied defendant’s cross motion, granted the branch of plaintiff’s motion seeking summary judgment on the fourth cause of action and otherwise denied plaintiff’s motion. A judgment was subsequently entered on February 14, 2012, awarding plaintiff the principal sum of $2,357.95. On appeal, defendant argues that its cross motion for summary judgment dismissing the complaint should have been granted and that, in any event, the branch of plaintiff’s motion seeking summary judgment on the fourth cause of action should have been denied.

Defendant argued in its cross motion that this action was premature because plaintiff had failed to comply with its verification requests. Inasmuch as a triable issue of fact exists as to whether plaintiff’s responses to the verification requests were sufficient, the Civil Court properly denied defendant’s cross motion, and it should have denied the branch of plaintiff’s motion seeking summary judgment on the fourth cause of action.

Accordingly, the judgment is reversed, so much of the order entered January 18, 2012 as granted the branch of plaintiff’s motion seeking summary judgment on the fourth cause of action [*2]is vacated and that branch of plaintiff’s motion is denied. The order, insofar as reviewed on direct appeal and insofar as appealed from, is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: December 17, 2014
MML Med. Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51792(U))

Reported in New York Official Reports at MML Med. Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51792(U))

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

MML Medical Care, P.C. as Assignee of STEVE HOLLEY, Respondent,

against

Praetorian Insurance Company, Appellant.

Appeal from orders of the Civil Court of the City of New York, Richmond County (Philip S. Straniere, J.), entered October 20, 2011 and October 31, 2011, respectively. The order entered October 20, 2011 denied defendant’s motion for summary judgment dismissing the complaint. The order entered October 31, 2011 granted plaintiff’s cross motion for summary judgment.

ORDERED that the orders are reversed, with $30 costs, defendant’s motion for summary judgment dismissing the complaint is granted and plaintiff’s cross motion for summary judgment is denied.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court entered October 20, 2011 which denied defendant’s motion for summary judgment dismissing the complaint and from an order of the same court entered October 31, 2011 which granted plaintiff’s cross motion for summary judgment.

Defendant established that it had timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]) letters and follow-up letters scheduling examinations under oath (EUOs) by both first class and certified mail, return receipt requested. Defendant further demonstrated that it had timely mailed (see St. Vincent’s Hosp. of Richmond, 50 AD3d 1123; Delta Diagnostic Radiology, P.C., 17 Misc 3d 16) the denial of claim forms, which denied the claims on the ground that plaintiff’s assignor had failed to appear for duly scheduled EUOs. In support of its motion, defendant also submitted certified transcripts of the scheduled EUOs, which demonstrated that plaintiff’s assignor had failed to appear. Plaintiff does not claim to have responded in any way to the EUO requests. As a result, defendant established its prima facie entitlement to judgment as a matter of law (see 11 NYCRR 65-1.1; Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Plaintiff failed to raise a triable issue of fact in opposition.

While the Civil Court held that the tracking numbers associated with the copies of the letters which had been sent by certified mail, return receipt requested, reflected that these copies of the EUO scheduling letters had apparently not been delivered to the assignor, such a fact, even if true, would not excuse the failure of plaintiff’s assignor to appear for the duly scheduled EUOs since the record does not contain any evidence showing that the mailing of the EUO scheduling letters to plaintiff’s assignor by first class mail had been insufficient.

Accordingly, the orders are reversed, defendant’s motion for summary judgment dismissing the complaint is granted, and plaintiff’s cross motion for summary judgment is denied.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: December 17, 2014
Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. (2014 NY Slip Op 51766(U))

Reported in New York Official Reports at Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. (2014 NY Slip Op 51766(U))

Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co. (2014 NY Slip Op 51766(U)) [*1]
Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co.
2014 NY Slip Op 51766(U) [46 Misc 3d 126(A)]
Decided on December 17, 2014
Appellate Term, First 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 17, 2014

SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT
PRESENT: Lowe, III, P.J., Shulman, Hunter, Jr., JJ.
570325/14
Easy Care Acupuncture, P.C., a/a/o Olevia Moore, Plaintiff-Appellant, –

against

21 Century Advantage Ins. Co. Defendant-Respondent.

Plaintiff, as limited by its brief, appeals from so much of an order of the Civil Court of the City of New York, New York County,(Jennifer G. Schecter, J.), dated July 16, 2013, as granted defendant’s motion for summary judgment dismissing plaintiff’s no-fault claim in the amount of $355.

Per Curiam.

Order (Jennifer G. Schecter, J.), dated July 16, 2013, insofar as appealed from, reversed, with $10 costs, and plaintiff’s claim for first-party no-fault benefits in the amount of $355 reinstated.

Defendant’s motion for summary judgment dismissing plaintiff’s first-party no-fault claim seeking payment of $355 – stemming from acupuncture services rendered by plaintiff on December 1, 2009, December 10, 2009 and January 7, 2010 – should have been denied. Defendant failed to demonstrate, prima facie, that its denials were properly mailed (see Country-Wide Ins. Co. v Zabloski, 257 AD2d 506 [1999]). In this regard, the affidavit submitted by an employee of Farmers Insurance Exchange, defendant’s claims administrator, failed to adequately describe its office mailing procedures (see Matter of Lumbermens Mut. Cas. Co. [Collins], 135 AD2d 373, 375 [1987]), merely stating that items placed in its “mail bin” are picked up by a nonparty entity – Pitney Bowes Services, Inc. (“Pitney Bowes”) – which brings the items on a daily basis to the post office. The affiant professed no personal knowledge of, nor did she attempt to describe, the procedures utilized by Pitney Bowes to assure timely and proper delivery. Nor were these deficiencies remedied by defendant’s submission in its reply papers below of an affidavit from a Pitney Bowes representative (see Batista v Santiago, 25 AD3d 326 [2006]).

Moreover, even beyond defendant’s shortcomings in proof concerning the mailing issue, the report of defendant’s peer review acupuncturist failed to set forth sufficient facts or medical rationale for his stated conclusion that further acupuncture treatment of plaintiff’s assignor was not medically necessary. That the assignor may have subjectively reported during the course of the peer review examination that she “feels worse” after three months of acupuncture treatment did not, by itself and without any objective medical explanation by the peer reviewer, eliminate [*2]all triable issues regarding the medical necessity of continued acupuncture treatment.


THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concurI concurI concur
Decision Date: December 17, 2014
Medcare Supply, Inc. v Farmers New Century Ins. Co. (2014 NY Slip Op 51752(U))

Reported in New York Official Reports at Medcare Supply, Inc. v Farmers New Century Ins. Co. (2014 NY Slip Op 51752(U))

Medcare Supply, Inc. v Farmers New Century Ins. Co. (2014 NY Slip Op 51752(U)) [*1]
Medcare Supply, Inc. v Farmers New Century Ins. Co.
2014 NY Slip Op 51752(U) [45 Misc 3d 135(A)]
Decided on December 15, 2014
Appellate Term, First 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 15, 2014

SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT
PRESENT: Lowe, III, Shulman, Hunter, Jr., JJ.
570173/14
Medcare Supply, Inc., a/a/o Tristan Hinds, Plaintiff-Appellant, –

against

Farmers New Century Ins. Co. Defendant-Respondent.

Plaintiff appeals from an order of the Civil Court of the City of New York, New York County (Jennifer G. Schecter, J.), entered April 15, 2013, which granted defendant’s motion for summary judgment dismissing the complaint.

Per Curiam.

Order (Jennifer G. Schecter, J.), entered April 15, 2013, reversed, with $10 costs, motion denied and complaint reinstated.

The action, seeking recovery of first-party no-fault benefits, is not ripe for summary dismissal. The defendant insurer failed to establish, prima facie, that it did not timely receive the plaintiff provider’s no-fault claim. In this regard, defendant relied on the affidavit of a claims representative employed in the Hicksville, New York office of non-party Farmers Insurance Exchange (“Exchange”), the entity which “administers claims” on defendant’s behalf. Although the affiant averred that there was no record of the underlying no-fault claim in his office’s paper and computer files, he professed no personal knowledge of the practice and procedures put in place by defendant in connection with the handling of no-fault claims sent to its Oklahoma City office, the designated mailing address for the submission of such claims (see Westchester Med. Ctr. v Philadelphia Indem. Ins. Co., 69 AD3d 613, 614 [2010]).

In any event, plaintiff, in opposition, raised a triable issue as to the mailing of the claim by producing a stamped mailing certificate tending to support its assertion that it timely mailed the no-fault claim to defendant at its designated Oklahoma City address (see LMK Psychological Servs., P.C. v Liberty Mut. Ins. Co., 30 AD3d 727 [2006]; Badio v Liberty Mut. Fire Ins. Co., 12 AD3d 229 [2004]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.


I concur I concurI concur.
Decision Date: December 15, 2014
Avanguard Med. Group, PLLC(b) v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51940(U))

Reported in New York Official Reports at Avanguard Med. Group, PLLC(b) v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51940(U))



Avanguard Medical Group, PLLC(b) a/a/o Patria Martell, Plaintiff,

against

State Farm Mutual Automobile Ins. Co., Defendant.

CV- 703200/13

For plaintiff, Avanguard Medical Group, PLLC(b)

Law Offices of Leon Kucherovsky, Esq.

Rachita Sharma Pate, Esq.

115 S. Corona Ave.

Valley Stream, NY 11580

(516) 881-7755

For defendant, State Farm Mutual Automobile Ins. Co.

Nicolini, Paradise, Ferretti & Sabella, PLLC

Francis J. Ammendolea, Esq.

114 Old Country Road

Mineola, New York 11501

(516) 741-6355


James E. d’Auguste, J.

Defendant State Farm Mutual Automobile Insurance Company (“State Farm”), a No-Fault insurance provider, moves, pursuant to CPLR 3212, for summary judgment dismissing the complaint. Plaintiff Avanguard Medical Group, PLLC(b) (“Avanguard”) is the assignee of Patria Martell, an individual covered under a policy of insurance issued by State Farm. The complaint seeks to recover payment of an assigned No-Fault insurance claim that was denied by State Farm on the basis of improper fee schedule billing. For the reasons stated herein, State Farm’s motion for summary judgment is granted.

Facts

Avanguard is a duly accredited office-based surgical facility (“OBS facility”) operated pursuant to New York State’s Public Health Law Section 230-d, entitled “Office-based surgery.” Avanguard alleges that it provided health services to Patria Martell for injuries she sustained during a September 16, 2012 automobile accident. Martell was covered under a policy with State Farm, which included payment of No-Fault benefits for her accident related healthcare. On [*2]January 16, 2013, Avanguard billed State Farm $2,550.00 for services it provided to Martell. The bill was based on a fee schedule that incorporated a “facility fee” in accordance with “The Products of Ambulatory Surgery” (“PAS”) classification. State Farm received the bill on January 29, 2013. On February 15, 2013, State Farm responded with an NF-10 “Denial of Claim” form, refusing to pay Avanguard’s bill in its entirety.

State Farm argues, inter alia, that it properly denied the claim because Avanguard, as an OBS facility, improperly billed pursuant to a PAS facility-fee-inclusive fee schedule authorized exclusively for use by facilities licensed under Article 28 of the New York State Public Health Law (“Art. 28”).[FN1] Avanguard acknowledges that it is not licensed under Art. 28, but contends that: (1) its bill was permissible because an OBS facility should be entitled under Insurance Law Section 5108(a) to recover its facility fee and (2) the PAS fee schedule, which authorizes facility fee reimbursement for Art. 28 facilities, does not expressly exclude an OBS facility from billing on the PAS fee schedule. On April 1, 2013, Avanguard commenced this action, alleging State Farm wrongfully denied its insurance claim and demands judgment for $2,550.00 plus interest and attorneys’ fees.

Discussion

The issue to be resolved in this motion for summary judgment is whether an OBS facility may properly bill for reimbursement pursuant to the PAS facility-fee-inclusive fee schedule. This issue is addressed by way of statutory interpretation, pending legislation, persuasive case law, and statements published regarding this subject by the New York State Department of Health (“DOH”). For the reasons discussed below, this Court finds that Avanguard, as an OBS facility, is not authorized to bill pursuant to the PAS facility-fee-inclusive fee schedule and, therefore, State Farm properly denied Avanguard’s insurance claim on the basis of improper fee schedule billing.

A. Statutory Consideration

State Farm alleges that Avanguard’s insurance claim was properly denied because it was billed on a PAS fee schedule reserved by its terms exclusively for Art. 28 licensed facilities. See Ammendolea Aff. ¶ 18. New York State Insurance Law Section 5102(a)(1) provides for the reimbursement for “economic loss” relating to “all necessary expenditures incurred for medical and surgical services.” Upper East Side Surgical, PLLC v. State Farm Ins. Co., 34 Misc 3d 1219(A), at *4 (Dist. Ct., Nassau County 2012). Compensation, pursuant to Insurance Law Section 5108(a), is, however, “limited to the amount permissible under the schedules prepared and established by the chairman of the workers’ compensation board for industrial accidents.” Id.

Among the established fee schedules are billing codes for reimbursement in accordance with the PAS classification system, which includes facility fee reimbursements expressly authorized for facilities licensed under Art. 28. Avanguard, however, is not a “Hospital” or “Ambulatory Surgery Facility” licensed under Art. 28, but rather an OBS facility under Public Health Law Section 230-d, which offers no provision for an OBS facility to recover a facility fee. Further, there is no prepared or established fee schedule pursuant to Insurance Law Section 5108(a) upon which an OBS facility may claim reimbursement for its facility fees. Thus, Avanguard fails to demonstrate how State Farm was obligated to reimburse its OBS facility fees pursuant to the PAS fee schedule.

Both parties reference the same pending legislation introduced in the New York State Senate aimed at amending Public Health Law Section 230-d to include, inter alia, authorization for OBS facilities to “seek payment from a health plan for the use of such facility.” 2011 New York State Senate Bill S4597-B, ¶ 6. It is evident from the fact that the proposed legislation was never adopted into law that there is a necessity for a legislative enactment to require No-Fault insurers to reimburse OBS facility fees along the PAS fee schedule and that such reimbursement is not currently permitted. This conclusion can be based upon principles governing the construction and interpretation of statutes in New York: The maxim expressio unius est exclusio alterius is applied in the construction of the statutes, so that where a law expressly describes a particular act, thing or person to which it shall apply, an irrefutable inference must be drawn that what is omitted or not included was intended to be omitted or excluded.

McKinney’s Cons. Laws of NY, Book 1, Statutes, § 240; see also UMG Recordings, Inc. v. Escape Media Grp., Inc., 107 AD3d 51 (1st Dep’t 2013). The maxim is particularly appropriate here where the legislature recently, in 2007, addressed authorization and accreditation requirements for OBS facilities by enacting Public Health Law Section 230-d, which has been amended in part as recently as 2012. The right to seek reimbursement for OBS facility fees could have been included in that legislation but it was omitted. Accordingly, the current regulations requiring No-Fault insurers to reimburse Art. 28 facilities along the PAS fee schedule that includes facility fees should not be extended to OBS facilities by way of judicial fiat, but rather by legislation.

B. Case Law Considerations

Despite the unresolved controversy over what rights and billing processes, if any, might apply to an OBS facility seeking to recover its facility fees, the rule emerging from judicial decisions cited by both parties in this case is that an OBS facility is “not authorized to be reimbursed for the medical/surgical services it provided to its assignor under the facility fee’ schedule in accordance with [the PAS] system because it is not an Art. 28 facility.” Upper East Side, 34 Misc 3d 1219(A), at *4; see also Gov’t Emps. Ins. Co. v. Avanguard Med. Grp. PLLC. (GEICO), 2012 NY Misc. LEXIS 2687, at *8 (Sup. Ct., Nassau County May 31, 2012).

In Upper East Side, supra, the court found that the plaintiff, an OBS facility, was “entitled to reimbursement under Insurance Law § 5102(a)(1) for the medical/surgical services it provided to its assignor,” but that it was not authorized to bill the insurer for its facility fees pursuant to the PAS classification system “because it is not an Art. 28 facility.” 34 Misc 3d 1219(A), at *4. In doing so, the Upper East Side Court speculated that other billing alternatives might be available for an OBS facility to claim its facility fees. For example, in the absence of a [*3]prescribed OBS facility fee schedule, Avanguard could have billed the “prevailing fee in the geographic location of the provider.” Id. at *4, citing 11 N.Y.C.R.R. 68.5(1)(b). Yet, despite this ruling, Avanguard submitted its insurance claims to State Farm based upon the PAS Art. 28 facility fee schedule.

Nor does the GEICO decision provide authority for an OBS facility to predicate its facility fee claim on the PAS fee schedule established for Art. 28 facilities. The court in GEICO denied the insurer’s request for an order to stay all proceedings and preliminarily enjoin the OBS facility “from commencing any new actions, arbitrations, or proceedings against [the insurer]” wherein the OBS facility seeks to recover No-Fault benefits for facility fees. GEICO, supra, at *12. GEICO relates to any facility fee reimbursement sought by an OBS facility and was not limited, as in this case, to the insurer’s denial of the OBS facility fee claim predicated on the PAS fee schedule. Given the broad injuctive relief sought by GEICO, the court found that a triable issue existed as to whether an OBS facility may ever seek a facility fee from an insurer—pursuant to any billing method.

C. Statements Published on the DOH’s Website

Finally, the parties both cite to statements published on the DOH’s website reflecting its position concerning facility fee reimbursements to OBS facilities:

Reimbursement

35. Does OBS accreditation qualify a private OBS practice to receive a “facility fee”? PHL § 230-d does not address or require reimbursement of an OBS facility fee. Accreditation status does not require a third party insurer to pay a facility fee. An OBS practice is not a health care facility under PHL Article 28 or as defined by PHL § 18. Neither Medicaid nor Medicare pays a facility fee to private physicians’ offices for office-based surgery. DOH does not establish fee schedules or billing guidelines for OBS.

Office-Based Surgery (OBS) Frequently Asked Questions (FAQ’s) for Practitioners, NY State Dep’t of Health, https://www.health.ny.gov/professionals/office-based_surgery/obs_faq.htm (last updated Mar. 2014). These statements support the conclusion that State Farm was under no obligation to reimburse Avanguard’s facility fee. Accordingly, summary judgment should be entered in favor of State Farm and Avanguard’s complaint should be dismissed.

Conclusion

Accordingly, it is hereby ordered that State Farm’s motion for summary judgment is granted, the complaint is dismissed, and the Clerk is directed to enter judgment accordingly. This constitutes the decision and order of this Court.

Dated: December 12, 2014

___________________________

Hon. James E. d’Auguste, J.C.C.

Footnotes

Footnote 1:. In the “Explanation of Review” accompanying the NF-10 “Denial of Claim” form, State Farm explains, inter alia, that Avanguard is not eligible to bill pursuant to a PAS fee schedule which includes a “facility fee” because it is not a licensed Art. 28 facility. Code “X3796” on the final page of the “Explanation of Review” is explained in part as follows:

Your claim seeking payment of a facility fee is denied because you are not a licensed facility pursuant to Article 28 of New York’s Public Health Law, and are therefore ineligible to collect benefits pursuant to 11 N.Y.C.R.R. 65-3.16(a)(12). See Ammendolea Aff. Exh. A.