December 13, 2012
Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U))
https://www.beynensonlaw.com/case-law/bay-plaza-chiropractic-p-c-v-praetorian-ins-co-2012-ny-slip-op52315u/
- Decided
- December 13, 2012
- Citation
- 2012 NY Slip Op 52315(U) · 38 Misc 3d 126(A)
- Posture
- Summary judgment
- Outcome
- Provider prevailed
- Issues
- Medical necessity
- Legal questions
- Lack of medical necessity (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 Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U))
| Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. |
| 2012 NY Slip Op 52315(U) [38 Misc 3d 126(A)] |
| Decided on December 13, 2012 |
| 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| This opinion is uncorrected and will not be published in the printed Official Reports.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, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : RIOS, J.P., ALIOTTA and SOLOMON, JJ
2011-866 Q C.
against
Praetorian Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Queens County (Maureen A. Healy, J.), entered February 2, 2011. The order, insofar as appealed from as limited by the brief, denied defendant’s motion for summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.
In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint and plaintiff cross-moved for summary judgment. The Civil Court found that plaintiff and defendant had established their prima facie cases and that the sole issue for trial was the medical necessity of the services rendered to plaintiff’s assignor. Defendant appeals, as limited by its brief, from so much of the order as denied its motion.
In support of its motion, defendant submitted, among other things, a sworn peer review report which set forth a factual basis and medical rationale for the doctor’s determination that there was a lack of medical necessity for the chiropractic services rendered. In opposition to the motion, plaintiff submitted an affidavit by its chiropractor which was sufficient to demonstrate that there was an issue of fact as to the medical necessity of the services at issue (see Quality Psychological Servs., P.C. v Mercury Ins. Group, 27 Misc 3d 129[A], 2010 NY Slip Op 50601[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; cf. Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).
Accordingly, the order, insofar as appealed from, is affirmed.
Rios, J.P., Aliotta and Solomon, JJ., concur.
Decision Date: December 13, 2012
Legal questions
A question 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: Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)
Affirmed denial of the insurer's motion: its sworn peer review set forth a factual basis and medical rationale, but the provider's chiropractor's affidavit raised an issue of fact as to medical necessity.
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.
Cited in this decision
A label shows how this decision treated the case it cites.
- Quality Psychological Servs., P.C. v Mercury Ins. Group (2010 NY Slip Op 50601(U)) FollowedThe insurer's timely denial and peer review report supported its defense, but the provider raised a medical-necessity fact issue.
- Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) Contrasted (cf., but see)The provider's conclusory disagreement with the insurer's supported peer review failed to raise a medical-necessity issue of fact.
Cited by
- American Tr. Ins. Co. v Right Choice Supply, Inc. (2023 NY Slip Op 23039)A no-fault arbitrator need not apply summary judgment rules requiring a provider's medical evidence to specifically rebut an insurer's peer review.
Similar decisions
- 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.
- 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.
- Baybenson Chiropractic, LLC v Clarendon Natl. Ins. (2013 NY Slip Op 50756(U))The provider's chiropractor failed to rebut the insurer's peer review and IME findings that the chiropractic services were unnecessary.
- 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.