May 25, 2018

Compas Med., P.C. v 21st Century Ins. Co. (2018 NY Slip Op 50773(U))

https://www.beynensonlaw.com/case-law/compas-med-p-c-v-21st-century-ins-co-2018-ny-slip-op-50773u/

Court: Appellate Term, Second Department
Decided: May 25, 2018
Citation: 2018 NY Slip Op 50773(U) · 59 Misc 3d 147(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Fee schedule Timeliness and preclusion
Legal questions: Proving a fee schedule defense · Proof of mailing (see the maps)

Cite as

Compas Med., P.C. v 21st Century Ins. Co., 59 Misc 3d 147(A), 2018 NY Slip Op 50773(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2018)

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 motion for summary judgment based on full payment under the workers' compensation fee schedule was granted. The claims concerned services rendered before April 1, 2013. The Appellate Term, Second Department, affirmed, finding sufficient proof to presume proper mailing of the denials and to establish proper use of the fee schedule.

Reported in New York Official Reports at Compas Med., P.C. v 21st Century Ins. Co. (2018 NY Slip Op 50773(U))

[*1]

Compas Med., P.C. v 21st Century Ins. Co.

2018 NY Slip Op 50773(U) [59 Misc 3d 147(A)]

Decided on May 25, 2018

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This opinion is uncorrected and will not be published in the printed Official Reports.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 May 25, 2018

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 2d, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : MICHAEL L. PESCE, P.J., THOMAS P. ALIOTTA, DAVID ELLIOT, JJ
2016-146 K C

Compas Medical, P.C., as Assignee of Icart, Lisanda, Appellant,
against
21st Century Insurance Company, Respondent.

The Rybak Firm, PLLC (Damin J. Toell of counsel), for appellant. Law Offices of Buratti, Rothenberg & Burns (Maryana Feigen of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Reginald A. Boddie, J.), entered September 8, 2015. The order granted defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint on the ground that it had fully paid plaintiff for the services at issue, which had been rendered prior to April 1, 2013, in accordance with the workers’ compensation fee schedule.

Contrary to plaintiff’s contention, the proof submitted by defendant in support of its motion was sufficient to give rise to a presumption that the denial of claim forms had been properly mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]) and to demonstrate that defendant had properly used the workers’ compensation fee schedule to determine the amount which plaintiff was entitled to receive for the services at issue.

Accordingly, the order is affirmed.

PESCE, P.J., ALIOTTA and ELLIOT, JJ., concur.

ENTER:
Paul Kenny
Chief Clerk
Decision Date: May 25, 2018

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.

Proving a fee schedule defense

Open the full map

Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?

This decision: Insurer proved the billed amount exceeded the applicable fee schedule

Held the insurer showed it properly used the workers' compensation fee schedule for pre-April 2013 services and fully paid, so dismissal was affirmed.

Excess shownNot established; openDefense rejectedSplit by chargeThis decision

Of the 285 decisions on this question in the Second Department courts and the Court of Appeals, 147 (this one included) are in the same category.

Proof of mailing

Open the full map

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)

Rejected the provider's contention and held the insurer's proof sufficient to raise a presumption that the denial of claim forms had been properly mailed.

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.

Similar decisions

Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51142(U))The insurer failed to establish full payment under the workers' compensation fee schedule for the claim underlying the first cause of action.
Compas Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51417(U))The insurer established proper mailing of verification requests and denials and timely denial after receipt of verification.
Compas Med., P.C. v Geico Ins. Co. (2014 NY Slip Op 51259(U))The provider failed to establish its prima facie case, but the insurer also failed to obtain dismissal on its three defenses.
Compas Med., P.C. v Nationwide Ins. (2014 NY Slip Op 51826(U))The insurer proved mailing of IME notices and denials but failed to establish its fee schedule defense to two claims.
Compas Med., P.C. v Allstate Ins. Co. (2017 NY Slip Op 51463(U))The insurer's affidavit failed to establish timely mailing of its denial forms through a sufficient office practice or procedure.