November 26, 2010

Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 52062(U))

Headnote

The relevant facts of the case involved a medical imaging company seeking to recover first-party no-fault benefits from an insurance company for services rendered to a patient. The insurance company denied the claims on the grounds of lack of medical necessity. The main issue decided by the court was whether the insurance company's denial of the claims on the basis of lack of medical necessity was justified. The court held that the insurance company had provided a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity for the services at issue, shifting the burden to the medical imaging company to rebut the insurance company's showing. As the medical imaging company failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity, the court granted the insurance company's motion for summary judgment dismissing the complaint.

Reported in New York Official Reports at Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 52062(U))

Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 52062(U)) [*1]

Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co.

2010 NY Slip Op 52062(U) [29 Misc 3d 139(A)]

Decided on November 26, 2010

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This opinion is uncorrected and will not be published in the printed Official Reports.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 November 26, 2010

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : IANNACCI, J.P., NICOLAI and MOLIA, JJ
2009-1836 N C.

Dynamic Medical Imaging, P.C. as Assignee of LIJIA ESPINAL, Respondent,
against
New York Central Mutual Fire Ins. Co., Appellant.

Appeal from an order of the District Court of Nassau County, First District (Gary Franklin Knobel, J.), dated June 11, 2009. The order denied defendant’s motion for summary judgment dismissing the complaint and, upon a search of the record, granted summary judgment to plaintiff.

ORDERED that the order is reversed, without costs, and defendant’s motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint on the ground that the services rendered were not medically necessary. The District Court denied defendant’s motion, finding that defendant’s peer reviewer failed to set forth a sufficient medical rationale and factual basis for his conclusion that the services performed were not medically necessary, and, upon a search of the record, granted summary judgment to plaintiff. The instant appeal by defendant ensued.

In support of its motion, defendant submitted an affidavit of its no-fault litigation examiner, which demonstrated that defendant had timely mailed the denial of claim forms, which denied the claims on the ground of lack of medical necessity, in accordance with defendant’s standard office practices and procedures (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]). Contrary to the conclusion of the District Court, we find that the affidavit of defendant’s chiropractor and his peer review report set forth a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity for the services at issue (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]; B.Y., M.D., P.C. v Progressive Cas. Ins. Co., 26 Misc 3d 135[A], 2010 NY Slip Op 50144[U] [App Term, 9th & 10th Jud Dists 2010]), so as to shift the burden to plaintiff to rebut defendant’s prima facie showing.

In opposition to defendant’s motion, plaintiff failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity (see Speciality Surgical Servs. v [*2]Travelers Ins. Co., 27 Misc 3d 134[A], 2010 NY Slip Op 50715[U] [App Term, 9th & 10th Jud Dists 2010]; A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]). Accordingly, the order is reversed and defendant’s motion for summary judgment dismissing the complaint is granted.

Iannacci, J.P., Nicolai and Molia, JJ., concur.
Decision Date: November 26, 2010