May 24, 2006

Contempo Med. Care, P.C. v Travelers Indem. Ins. Co. (2006 NY Slip Op 51338(U))

https://www.beynensonlaw.com/case-law/contempo-med-care-p-c-v-travelers-indem-ins-co-2006-ny-slip-op-51338u/

Court: Appellate Term, Second Department
Decided: May 24, 2006
Citation: 2006 NY Slip Op 51338(U) · 12 Misc 3d 139(A)
Posture: Summary judgment
Outcome: Provider prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Medical necessity

Cite as

Contempo Med. Care, P.C. v Travelers Indem. Ins. Co., 12 Misc 3d 139(A), 2006 NY Slip Op 51338(U) (App Term, 2d Dept, 2d & 11th Jud Dists 2006)

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 vague medical-necessity denials did not establish entitlement to partial summary judgment. The insurer limited its appeal to claims denied for lack of medical necessity and relied on affirmed peer review reports. Even assuming timely mailing, the denial forms merely referred to IMEs, without indicating that the IME reports were attached or separately sent within the 30-day claim-determination period. A medical-necessity denial must state its factual basis and medical rationale with sufficient particularity. Because the insurer might be precluded from asserting that defense, the Appellate Term, Second Department, affirmed the order, insofar as appealed from, denying the insurer's cross motion. The provider's denied motion was outside the appeal.

Reported in New York Official Reports at Contempo Med. Care, P.C. v Travelers Indem. Ins. Co. (2006 NY Slip Op 51338(U))

[*1]

Contempo Med. Care, P.C. v Travelers Indem. Ins. Co.

2006 NY Slip Op 51338(U) [12 Misc 3d 139(A)]

Decided on May 24, 2006

Appellate Term, Second Department

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

As corrected in part through November 4, 2011; it will not be published in the printed Official Reports.

Decided on May 24, 2006

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., RIOS and BELEN, JJ
2005-1026 K C.

Contempo Medical Care, P.C., as Assignee of Hayrapetyan Asya, Respondent,
against
Travelers Indemnity Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin S. Garson, J.), entered May 11, 2005. The order, insofar as appealed from, denied defendant’s cross motion for summary judgment.

Order, insofar as appealed from, affirmed without costs.

Plaintiff commenced this action to recover first-party no-fault benefits for medical services rendered to its assignor. After plaintiff moved for summary judgment, defendant cross-moved, seeking summary judgment dismissing the action in its entirety or, in the alternative, partial summary judgment pursuant to CPLR 3212 (g). The Civil Court denied plaintiff’s motion and defendant’s cross motion, and this appeal by defendant ensued.

Defendant’s notice of appeal and appellate brief limit the issue before this court to whether the defendant was entitled to partial summary judgment upon the claims which it denied due to an alleged lack of medical necessity. Defendant argues that the affirmed peer review reports annexed to its cross motion and upon which said denials were based established defendant’s prima facie entitlement to judgment as a matter of law upon the issue of medical necessity and that plaintiff failed to present evidence in admissible form to demonstrate the existence of an issue of fact with regard to medical necessity.

Assuming arguendo that defendant’s cross motion was sufficient to establish that defendant mailed, within the 30-day claim determination period, the NF-10 denial of claim forms upon which defendant now seeks partial summary judgment, in any event, defendant’s appeal lacks merit. This court has repeatedly held that where a denial of claim form fails to set forth with sufficient particularity the factual basis and medical rationale for its denial based upon lack of medical necessity, the defendant is precluded from asserting said defense (see A.B. Med. [*2]Servs. PLLC v Liberty Mut. Ins. Co., 10 Misc 3d 128[A], 2005 NY Slip Op 51902[U] [App Term, 2d & 11th Jud Dists]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]). The denial of claim forms submitted herein were insufficient on their face for vagueness in that they merely indicated that the denials were based upon independent medical examinations (IMEs) with no indication that the reports of said IMEs were annexed thereto or sent to the plaintiff under separate cover within the 30-day claim determination period. In view of the foregoing, defendant is not entitled to partial summary judgment as a matter of law upon said claims because defendant may be precluded from asserting lack of medical necessity as a defense to such claims (see A.B. Med. Servs. PLLC, 10 Misc 3d 128[A], 2005 NY Slip Op 51902[U], supra; Amaze Med. Supply, 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U], supra).

Pesce, P.J., Rios and Belen, JJ., concur.
Decision Date: May 24, 2006

Cited in this decision

A label shows how this decision treated the case it cites.

A.B. Med. Servs. PLLC v Liberty Mut. Ins. Co. (2005 NY Slip Op 51902(U)) FollowedA sufficient peer review report cannot cure a denial that omits the factual basis and medical rationale for lack of medical necessity.
Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U)) FollowedA provider's completed claim forms establish its prima facie case without additional medical proof when the insurer is precluded.

Cited by

A label shows how the later decision treated this one.

Olympic Chiropractic, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 50011(U)) FollowedA timely but factually insufficient IME denial does not preserve a medical-necessity defense.

Similar decisions

Avenue N Med., P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 52174(U))The insurer's timely denials and affirmed peer review raised a medical-necessity issue defeating the provider's summary judgment motion.
Neomy Med., P.C. v Auto One Ins. Co. (2010 NY Slip Op 51727(U))The insurer's timely denial and supported peer review raised a medical necessity issue defeating summary judgment on the appealed claim.
NY Comprehensive Med., P.C. v Maryland Cas. Co. (2008 NY Slip Op 50521(U))The provider's summary judgment cross motion failed because conflicting medical affirmations raised a triable issue of medical necessity.
A.M. Med. Servs., P.C. v New York Cent. Mut. Ins. (2006 NY Slip Op 51662(U))The insurer proved mailing of one medical necessity denial but failed to prove verification mailing for four other claims.
Expo Med. Supplies, Inc. v St. Paul Fire & Mar. Ins. Co. (2006 NY Slip Op 52251(U))A timely denial may still preclude a medical-necessity defense if it is conclusory and the peer review is not timely supplied.