December 1, 2009
AJS Chiropractic, P.C. v Travelers Ins. Co. (2009 NY Slip Op 52446(U))
https://www.beynensonlaw.com/case-law/ajs-chiropractic-p-c-v-travelers-ins-co-2009-ny-slip-op-52446u/
- Decided
- December 1, 2009
- Citation
- 2009 NY Slip Op 52446(U) · 25 Misc 3d 140(A)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Issues
- Medical necessity
- Legal questions
- Lack of medical necessity · Proof of mailing (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 AJS Chiropractic, P.C. v Travelers Ins. Co. (2009 NY Slip Op 52446(U))
| AJS Chiropractic, P.C. v Travelers Ins. Co. |
| 2009 NY Slip Op 52446(U) [25 Misc 3d 140(A)] |
| Decided on December 1, 2009 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : RIOS, J.P., PESCE and GOLIA, JJ
2008-1832 Q C.
against
Travelers Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Queens County (Diane A. Lebedeff, J.), dated August 8, 2008. The order, insofar as appealed from as limited by the brief, implicitly denied defendant’s cross motion for summary judgment dismissing plaintiff’s first cause of action.
ORDERED that the order, insofar as appealed from, is reversed without costs, and defendant’s cross motion for summary judgment dismissing plaintiff’s first cause of action is granted.
In this action by a provider to recover assigned first-party no-fault benefits, insofar as relevant to this appeal, plaintiff moved for summary judgment upon its first cause of action and defendant cross-moved for summary judgment dismissing said cause of action. The Civil Court found that there is an issue of fact as to medical necessity and denied the motion and, implicitly, the cross motion. Defendant appeals, contending that its cross motion seeking the dismissal of the first cause of action should have been granted.
The affidavits submitted by defendant in opposition to plaintiff’s motion and in support of its cross motion established that defendant had timely denied the claim at issue on the ground of lack of medical necessity, in accordance with defendant’s standard office practice or procedure used to ensure that the denial of the claim form was properly addressed and mailed (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Moreover, defendant annexed to its motion papers the affidavit and peer review report of its chiropractor, that set forth a factual basis and medical rationale for the chiropractor’s determination that there was a lack of medical necessity for the services rendered, which [*2]assertions were unrebutted (see e.g. Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; 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]; A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]). Consequently, defendant established its prima facie entitlement to summary judgment with respect to plaintiff’s first cause of action, and plaintiff failed to raise a triable issue of fact with respect thereto. Accordingly, the order, insofar as appealed from, is reversed and defendant’s cross motion for summary judgment dismissing plaintiff’s first cause of action is granted.
Rios, J.P., Pesce and Golia, JJ., concur.
Decision Date: December 01, 2009
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 established lack of medical necessity and the provider failed to rebut it
Held the chiropractor's affidavit and peer review set forth a factual basis and medical rationale for lack of medical necessity, which was unrebutted, so the insurer won summary judgment.
Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.
Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?
This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)
Held the insurer's affidavits established timely denial through its standard office practice ensuring the denial was properly addressed and mailed, a predicate to the medical-necessity ruling.
Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (this one included) are in the same category.
Cited in this decision
A label shows how this decision treated the case it cites.
- Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345) FollowedAn insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
- Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U))The insurer's examining physician supplied an unrebutted factual basis and medical rationale that the billed MRI was unnecessary.
- Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 52455(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
- A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
Similar decisions
- Innovative Chiropractic, P.C. v Travelers Ins. Co. (2009 NY Slip Op 52447(U))The treating chiropractor's conclusory affidavit failed to rebut the insurer's peer review on the provider's fifth cause of action.
- AJS Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 50208(U))The insurer's chiropractic IME report and supporting affidavit established lack of medical necessity, and the provider offered no rebuttal evidence.
- BLR Chiropractic, P.C. v American Tr. Ins. Co. (2012 NY Slip Op 50882(U))The insurer's peer review report and reviewing chiropractor's affidavit established lack of medical necessity, which the provider failed to rebut.
- Innovative Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 50884(U))The treating doctor's conclusory reaffirmation of medical necessity failed to rebut the insurer's sworn peer review and IME reports.
- American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U))The provider's treating chiropractor's sworn letter raised a factual issue on medical necessity despite the insurer's peer review.