July 1, 2008

All Borough Group Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51417(U))

https://www.beynensonlaw.com/case-law/all-borough-group-med-supply-inc-v-geico-ins-co-2008-ny-slip-op51417u/

Court
Appellate Term, Second Department
Decided
July 1, 2008
Citation
2008 NY Slip Op 51417(U) · 20 Misc 3d 130(A)
Posture
Summary judgment
Outcome
Insurer prevailed
Issues
Medical necessity
Legal questions
Lack of medical necessity (see the maps)
Cite as
All Borough Group Med. Supply, Inc. v GEICO Ins. Co., 20 Misc 3d 130(A), 2008 NY Slip Op 51417(U) (App Term, 2d Dept, 2d & 11th Jud Dists 2008)

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 denial preserved its medical-necessity defense, and an unrebutted affirmed peer review established that the supplies were unnecessary. The provider challenged the denial because portions of the form were omitted. The omitted sections were irrelevant to the claim, the form specifically identified lack of medical necessity based on a peer review, and the insurer proved Department of Insurance approval of the form. The defense was therefore not precluded. The insurer's cross-motion papers established medical nonnecessity without rebuttal. The Appellate Term, Second Department, affirmed denial of the provider's summary judgment motion and the grant of the insurer's cross motion dismissing the complaint.

Reported in New York Official Reports at All Borough Group Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51417(U))

[*1]
All Borough Group Med. Supply, Inc. v GEICO Ins. Co.
2008 NY Slip Op 51417(U) [20 Misc 3d 130(A)]
Decided on July 1, 2008
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This opinion is uncorrected and will not be published in the printed Official Reports.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 July 1, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS


PRESENT: : PESCE, P.J., GOLIA and STEINHARDT, JJ
2007-930 K C.
All Borough Group Medical Supply, Inc. a/a/o Altagrace Petit-Frere, Appellant,

against

GEICO Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Margaret A. Chan, J.), entered May 3, 2007. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Order affirmed without costs.
In this action by a provider to recover assigned first-party no-fault benefits, plaintiff’s motion for summary judgment was supported by an affirmation from plaintiff’s counsel, an affidavit by an employee of plaintiff and various documents annexed thereto. The affidavit executed by the employee stated in a conclusory manner that the
documents annexed to plaintiff’s motion papers were plaintiff’s business records. Defendant cross-moved for summary judgment on the ground of lack of medical necessity. In support of its cross motion and in opposition to plaintiff’s motion for summary judgment, defendant argued, inter alia, that the affidavit by plaintiff’s employee failed to demonstrate personal knowledge of the facts set forth therein and that, as a result, plaintiff failed to establish a prima facie case. The court below denied plaintiff’s motion and granted defendant’s cross motion, finding that plaintiff failed to establish its prima facie entitlement to summary judgment and defendant established its defense of lack of medical necessity. The instant appeal by plaintiff ensued.

Contrary to plaintiff’s contention, the denial of claim form submitted by defendant, which included a defense of lack of medical necessity as per a peer review report, was not fatally defective. Although defendant omitted certain sections from the denial of claim form, the sections were not relevant to the instant claim. The denial of claim form “promptly apprise[d] the claimant with a high degree of specificity of the ground . . . on which the disclaimer [wa]s [*2]predicated . . .” (New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co., 32 AD3d 458, 460 [2006] [internal quotations and citations omitted]) and defendant established that said denial of claim form was approved by the New York State Department of Insurance (id.). Consequently, defendant’s defense of lack of medically necessity was not precluded.

Defendant’s cross motion papers, including the affirmed peer review report, established prima facie that there was no medical necessity for the supplies provided by plaintiff, which evidence was unrebutted. As a result, the court below properly granted defendant’s cross motion for summary judgment (see 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 N.Y. Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

Pesce, P.J., Golia and Steinhardt, JJ., concur.
Decision Date: July 1, 2008

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