July 3, 2013

Amato v State Farm Ins. Co. (2013 NY Slip Op 51113(U))

Headnote

The relevant facts considered by the court were that a chiropractor was seeking to recover assigned first-party no-fault benefits for services rendered to an individual's spine, and the insurance company had denied the claims on the grounds of lack of medical necessity based on an independent medical examination (IME). The main issue was whether the chiropractic services at issue were medically necessary. The court found that the insurance company had made a showing that the treatment was not medically necessary, and therefore the burden was on the chiropractor to demonstrate, by a preponderance of the credible evidence, that the treatment was indeed necessary. Since the chiropractor did not provide any evidence, the court held that a finding that the individual's condition had worsened after the IME would be speculative, at best. Therefore, the judgment was reversed and the matter was remitted to the District Court for the entry of judgment in favor of the insurance company, dismissing the complaint.

Reported in New York Official Reports at Amato v State Farm Ins. Co. (2013 NY Slip Op 51113(U))

Amato v State Farm Ins. Co. (2013 NY Slip Op 51113(U)) [*1]

Amato v State Farm Ins. Co.

2013 NY Slip Op 51113(U) [40 Misc 3d 129(A)]

Decided on July 3, 2013

Appellate Term, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected in part through July 16, 2013; it will not be published in the printed Official Reports.

Decided on July 3, 2013

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS

PRESENT: : NICOLAI, P.J., LaSALLE and MARANO, JJ
2011-2993 N C.

Richard E. Amato, D.C. as Assignee of SANDRA J. BURRELL, Respondent, —
against
State Farm Insurance Company, Appellant.

Appeals from a decision of the District Court of Nassau County, First District (Fred J. Hirsh, J.), dated October 13, 2010, and from a judgment of the same court entered January 11, 2012. The decision, after a nonjury trial, found that plaintiff was entitled to judgment. The judgment awarded plaintiff the principal sum of $1,920.90.

ORDERED that the appeal from the decision is dismissed as no appeal lies from a decision (UDCA 1702; see Greenfield v Tassinari, 8 AD3d 529 [2004]); and it is further,

ORDERED that the judgment is reversed, without costs, and the matter is remitted to the District Court for the entry of judgment in favor of defendant dismissing the complaint.

In this action by a provider to recover assigned first-party no-fault benefits for chiropractic services rendered to plaintiff’s assignor’s spine, the District Court, in a decision after a nonjury trial, found for plaintiff, stating that defendant had failed to prove a factual basis or medical rationale for defendant’s determination that the services at issue were not medically necessary. A judgment awarding plaintiff the principal sum of $1,920.90 was entered pursuant to [*2]the decision.

Prior to the trial, the parties stipulated that plaintiff had timely submitted its claim forms to defendant, that defendant had timely denied the claims and that the only issue for trial was the medical necessity of the services. The proof at trial showed that defendant had denied plaintiff’s claims on the ground of lack of medical necessity based upon an independent medical examination (IME) of the assignor’s spine. It is undisputed that the IME had been conducted on September 8, 2005 and that the services at issue had been provided from January 3, 2006 to January 30, 2007. Defendant’s IME chiropractor testified that there was a lack of medical necessity for the chiropractic treatment at issue, which had been rendered after the IME, because, at the time of the IME, plaintiff’s assignor had reached “status quo ante.” Contrary to the holding of the District Court, after defendant made such a showing, plaintiff bore the burden of demonstrating, by a preponderance of the credible evidence, that the treatment at issue was medically necessary. Since plaintiff proffered no evidence, a finding that the assignor’s condition had worsened after the IME would be speculative, at best.

Accordingly, the judgment is reversed and the matter is remitted to the District Court for the entry of judgment in favor of defendant dismissing the complaint (see Cohen v Hallmark Cards, 45 NY2d 493 [1978]; Specialty Surgical Servs. v Travelers Ins. Co., 27 Misc 3d 134[A], 2010 NY Slip Op 50715[U] [App Term, 9th & 10th Jud Dists 2010]; S.J. Pahng, M.D., P.C. v Progressive Northeastern Ins. Co., 20 Misc 3d 137[A], 2008 NY Slip Op 51537[U] [App Term, 2d & 11th Jud Dists 2008]).

Nicolai, P.J., LaSalle and Marano, JJ., concur.
Decision Date: July 03, 2013