May 23, 2007

A.I.D. Med. Supplies v GEICO Gen. Ins. Co. (2007 NY Slip Op 51044(U))

Headnote

The main issue in this case was whether the defendant, GEICO General Insurance Co., was entitled to summary judgment in the principal sum of $6,139.59 against A.I.D. Medical Supplies. The court considered the fact that the defendant had timely denied the plaintiff's no-fault claim on the grounds of lack of medical necessity, supported by a peer review report. The court determined that the defendant had raised a triable issue of fact and was entitled to deny the claim, as the regulations provide that if a claim is denied based on a medical examination or peer review report, the insurer must release a copy of the report to the applicant or its attorney. The court held that the denial of claim form did not require the carrier to set forth a medical rationale, reversing the order of the Civil Court and remanding the matter for further proceedings.

Reported in New York Official Reports at A.I.D. Med. Supplies v GEICO Gen. Ins. Co. (2007 NY Slip Op 51044(U))

A.I.D. Med. Supplies v GEICO Gen. Ins. Co. (2007 NY Slip Op 51044(U)) [*1]

A.I.D. Med. Supplies v GEICO Gen. Ins. Co.

2007 NY Slip Op 51044(U) [15 Misc 3d 140(A)]

Decided on May 23, 2007

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This opinion is uncorrected and will not be published in the printed Official Reports.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 May 23, 2007

APPELLATE TERM OF THE SUPREME COURT, FIRST DEPARTMENT

PRESENT: McKEON, J.P., McCOOE, SCHOENFELD, JJ
570523/06.

A.I.D. Medical Supplies & Inter- trade, Inc. a/a/o David Trevino, Daniel Sierra, Alejandro Rodriguez Plaintiff-Respondent,
against
GEICO General Insurance Co., Defendant-Appellant.

Defendant appeals from an order of the Civil Court of the City of New York, Bronx County (Julia I. Rodriguez J.), dated October 18, 2005, which granted plaintiff’s motion for summary judgment in the principal sum of $6,139.59.

PER CURIAM:

Order (Julia I. Rodriguez J.), dated October 18, 2005, reversed, with $10 costs, motion denied and matter remanded for further proceedings.

In opposition to the plaintiff’s prima facie showing of entitlement to judgment as a matter of law, defendant raised a triable issue of fact by demonstrating that it timely denied plaintiff’s no-fault claim on the ground of lack of medical necessity based upon a peer review report. “The applicable regulations provide that if a no-fault claim is denied in whole or in part based on a medical examination or peer review report requested by the insurer, then the insurer shall release a copy of that report to, among others, the applicant or its attorney, upon written request (see 11 NYCRR 65-3.8[b][4]). Had it been the intent of the Department of Insurance to require the carrier to set forth a medical rationale in the prescribed denial of claim form (see NYS Form N-F 10; 11 NYCRR 65-3.4[c][11]), it would have so provided” (A.B. Med. Servs., PLLC v Geico Cas. Ins. Co., AD3d , 2007 NY Slip Op. 03635 [2007]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
[*2]
Decision Date: May 23, 2007