February 28, 2014

American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U))

https://www.beynensonlaw.com/case-law/american-chiropractic-care-p-c-v-praetorian-ins-co-2014-ny-slip-op50346u/

Court: Appellate Term, Second Department
Decided: February 28, 2014
Citation: 2014 NY Slip Op 50346(U) · 42 Misc 3d 145(A)
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Followed in 2 later decisions (see Cited by)
Issues: Medical necessity
Legal questions: Lack of medical necessity · Proof of mailing (see the maps)

Cite as

American Chiropractic Care, P.C. v Praetorian Ins. Co., 42 Misc 3d 145(A), 2014 NY Slip Op 50346(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2014)

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 provider's treating chiropractor's sworn letter raised a factual issue on medical necessity despite the insurer's peer review. The insurer established timely mailing of denials based on lack of medical necessity and submitted a sworn chiropractic peer review supplying a factual basis and medical rationale for that determination. Those submissions established the insurer's prima facie entitlement to summary judgment. In opposition, however, the provider's sworn medical-necessity letter sufficiently demonstrated a factual dispute under Zuckerman v City of New York. The Appellate Term, Second Department, affirmed denial of the insurer's motion to dismiss the assigned no-fault claims by summary judgment.

Reported in New York Official Reports at American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U))

[*1]

American Chiropractic Care, P.C. v Praetorian Ins. Co.

2014 NY Slip Op 50346(U) [42 Misc 3d 145(A)]

Decided on February 28, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 February 28, 2014

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

PRESENT: : NICOLAI, P.J., IANNACCI and MARANO, JJ
2012-1613 N C.

American Chiropractic Care, P.C. as Assignee of MIGDALIA MORALES, Respondent,
against
Praetorian Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, First District (Andrea Phoenix, J.), dated June 4, 2012. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, without costs.

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

Defendant established that it had timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008] Richard Morgan Do, P.C. v State Farm Mut. Auto. Ins. Co., 22 Misc 3d 134[A], 2009 NY Slip Op 50242[U] [App Term, 9th & 10th Jud Dists 2009]) its denial of claim forms, which denied plaintiff’s claims on the ground of lack of medical necessity. The sworn peer review report of defendant’s chiropractor set forth a factual basis and medical rationale for the chiropractor’s determination that there was a lack of medical necessity for the services provided to plaintiff’s assignor (see Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co., 29 Misc 3d 139[A], 2010 NY Slip Op 52062[U] [App Term, 9th & 10th Jud Dists 2010]). Consequently, defendant established its prima facie entitlement to summary judgment (see Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co., 27 Misc 3d 136[A], 2010 NY Slip Op 50829[U] [App Term, 9th & 10th Jud Dists 2010]). However, in opposition to defendant’s motion, plaintiff submitted a sworn letter of medical necessity by its treating chiropractor which sufficiently demonstrated the existence of a question of fact as to medical necessity (see Zuckerman v City of New York, 49 NY2d 557 [1980]).

Accordingly, the order is affirmed.

Nicolai, P.J., Iannacci and Marano, JJ., concur.
Decision Date: February 28, 2014

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.

Lack of medical necessity

Open the full map

Did the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?

This decision: Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)

Held the insurer's sworn chiropractic peer review made a prima facie showing, but the treating chiropractor's sworn letter of medical necessity raised a question of fact, so summary judgment was denied.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decisionCites it or cited by itCited or followed

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 94 (this one included) are in the same category.

Proof of mailing

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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 established timely mailing of its denial of claim forms, but the result turned on the provider's medical-necessity rebuttal.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

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.

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
Richard Morgan Do, P.C. v State Farm Mut. Auto. Ins.Co. (2009 NY Slip Op 50242(U)) FollowedThe insurer's cross motion for summary judgment on IME nonappearance was upheld upon sufficient proof of mailing of the requests.
Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 52062(U)) FollowedThe insurer's chiropractor supplied a sufficient medical rationale and factual basis for finding the services medically unnecessary.
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2010 NY Slip Op 50829(U)) FollowedThe insurer's affirmed peer reviews raised a triable issue of medical necessity and defeated the provider's summary judgment motion.

Cited by

A label shows how the later decision treated this one.

Westcan Chiropractic, P.C. v Hertz Claim Mgt. (2015 NY Slip Op 51066(U)) FollowedThe provider's treating-doctor affidavit rebutted the peer review and raised a triable issue of medical necessity.
Excel Surgery Ctr., L.L.C. v Hertz Claim Mgt. Corp. (2017 NY Slip Op 51951(U)) FollowedThe provider's chiropractor raised a triable issue of medical necessity by sufficiently rebutting the insurer's peer review report.

Similar decisions

Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U))The provider's chiropractor affidavit raised a triable issue of medical necessity despite the insurer's supported peer review.
Northshore Chiropractic Diagnostics, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51646(U))The provider's doctor's affidavit raised a factual issue on medical necessity despite the insurer's supported peer review reports.
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.
Premier Health Choice Chiropractic, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 51802(U))The provider's unsworn medical report failed to rebut the insurer's sworn IME showing that chiropractic treatment lacked medical necessity.
AJS Chiropractic, P.C. v Travelers Ins. Co. (2009 NY Slip Op 52446(U))The insurer's unrebutted chiropractic peer review established lack of medical necessity for the provider's first cause of action.