July 13, 2016

DJS Med. Supplies, Inc. v Allstate Ins. Co. (2016 NY Slip Op 51123(U))

https://www.beynensonlaw.com/case-law/djs-med-supplies-inc-v-allstate-ins-co-2016-ny-slip-op51123u/

Court: Appellate Term, Second Department
Decided: July 13, 2016
Citation: 2016 NY Slip Op 51123(U)
Posture: Trial
Outcome: Split result
Issues: Medical necessity Other
Legal questions: Lack of medical necessity (see the maps)

Cite as

DJS Med. Supplies, Inc. v Allstate Ins. Co., 2016 NY Slip Op 51123(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2016)

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.

A trial decision controls over an inconsistent judgment, and the discrepancy may be corrected on appeal under CPLR 5019 (a). The Civil Court found the insurer's unrebutted medical testimony established lack of necessity for the supplies addressed by its witness, but awarded the provider recovery for a massager the witness did not discuss. The entered judgment nevertheless dismissed the entire complaint. The Appellate Term, Second Department, upheld the medical-necessity determination but reversed the judgment and remitted for entry of judgment awarding the provider recovery for the massager, with statutory interest and attorney's fees under Insurance Law § 5106 (a). The insurer prevailed as to the remaining supplies.

Reported in New York Official Reports at DJS Med. Supplies, Inc. v Allstate Ins. Co. (2016 NY Slip Op 51123(U))

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

DJS Medical Supplies, Inc., as Assignee of DENNIS JOHNSON, Appellant,
against
Allstate Insurance Company, Respondent.

Appeal from a judgment of the Civil Court of the City of New York, Kings County (Carol Ruth Feinman, J.), entered July 3, 2014. The judgment, after a nonjury trial, dismissed the complaint.

ORDERED that the judgment is reversed, without costs, and the matter is remitted to the Civil Court for the entry of a judgment in favor of plaintiff in the principal sum of $181.50, together with costs, plus statutory interest and attorney’s fees due pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

In this action by a provider to recover first-party no-fault benefits for medical supplies provided to its assignor, a nonjury trial was held, limited, pursuant to a stipulation, to defendant’s defense of lack of medical necessity. The parties further stipulated to defendant’s witness’s “medical expertise.” Defendant’s doctor stated that he had examined a peer review report prepared by a different doctor, and that he had also reviewed the assignor’s medical records which had been considered by the peer reviewer. The witness testified about the medical supplies at issue, with the exception of a massager, and stated that he agreed with the peer reviewer’s conclusion that the supplies lacked medical necessity. Plaintiff called no witness to rebut defendant’s doctor’s testimony.

In a decision after trial, the Civil Court directed the entry of judgment in favor of plaintiff in the principal sum of $181.50 for a massager, since it was undisputed that defendant’s medical witness had not testified about it. The Civil Court further found that defendant had demonstrated that the remaining supplies in question were not medically necessary, and that plaintiff had failed to rebut defendant’s showing. Thereafter, plaintiff submitted a proposed judgment, which stated only that judgment was rendered in favor of defendant and made no award to plaintiff. The judgment, entered in the Civil Court on July 3, 2014, dismissed the complaint. On appeal, plaintiff argues that the judgment that dismissed the complaint, “except for $181.50,” should be reversed. Defendant concedes that the Civil Court limited plaintiff’s recovery to the sum of $181.50, and defendant raises no issue with respect to that part of the court’s decision after trial.

In reviewing a determination made after a nonjury trial, the power of this court is as broad as that of the trial court, and this court may render the judgment it finds warranted by the facts, bearing in mind that the determination of a trier of fact as to issues of credibility is given substantial deference, as a trial court’s opportunity to observe and evaluate the testimony and [*2]demeanor of the witnesses affords it a better perspective from which to assess their credibility (see Northern Westchester Professional Park Assoc. v Town of Bedford, 60 NY2d 492, 499 [1983]; Hamilton v Blackwood, 85 AD3d 1116 [2011]; Zeltser v Sacerdote, 52 AD3d 824, 826 [2008]).

In the case at bar, the record supports the determination of the Civil Court, which was based upon its assessment of the credibility of defendant’s witness and its recognition that plaintiff had not called a rebuttal witness.

However, we note that, whereas the Civil Court, in its decision after trial, directed that plaintiff be awarded the principal sum of $181.50, together with interest, costs and legal fees, the judgment dismissed the complaint. “Where there is an inconsistency between a judgment and the decision upon which it is based, the decision controls” (Kim v Schiller, 112 AD3d 671, 674 [2013]; see Green v Morris, 156 AD2d 331 [1989]). Such an inconsistency may be corrected by way of a motion for resettlement, pursuant to CPLR 2221, or on appeal, pursuant to CPLR 5019 (a) (see Kim, 112 AD3d at 674; Green, 156 AD2d at 331). We therefore reverse the judgment and remit the matter to the Civil Court for the entry of a judgment in favor of plaintiff in the principal sum of $181.50, together with costs, plus statutory interest and attorney’s fees due pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder (see CPLR 5019 [a]).

Pesce, P.J., Solomon and Elliot, JJ., concur.

Decision Date: July 13, 2016

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.

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: Insurer's proof established lack of medical necessity and the provider failed to rebut it

Upheld the trial finding that the supplies other than the massager were unnecessary because the trial court credited the insurer's expert and the provider called no rebuttal witness.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decision

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.

Similar decisions

Ap Orthopedic & Rehabilitation, P.C. v Allstate Ins. Co. (2015 NY Slip Op 51656(U))The insurer failed at trial to prove lack of medical necessity, and the record supported the provider's recovery on the third cause of action.
Bay LS Med. Supplies, Inc. v Allstate Ins. Co. (2016 NY Slip Op 51244(U))The provider failed to establish its prima facie case, while the insurer proved timely denial of the second claim.
Greater NY Med. Care, P.C. v Allstate Ins. Co. (2017 NY Slip Op 51849(U))The provider's trial judgment was reversed because it contradicted findings that the insurer proved lack of medical necessity without rebuttal.
Progressive Med., Inc. v Allstate Ins. Co. (2010 NY Slip Op 50219(U))The provider was entitled to judgment because medical necessity was the sole agreed trial issue and the insurer's expert testimony was stricken.
Metropolitan Med. Supplies, LLC v GEICO Ins. Co. (2012 NY Slip Op 51490(U))An insurer's medical expert may testify without having prepared the peer review, but must stay within the denial's stated basis.