October 12, 2011

Five Boro Psychological Servs., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 51858(U))

Headnote

The court considered the denial of claim form that was timely mailed by the defendant, which denied the claim on the ground of lack of medical necessity. The defendant submitted a sworn peer review report, which provided a factual basis and medical rationale for the conclusion that there was a lack of medical necessity for the services at issue. As a result, the defendant established its prima facie entitlement to judgment as a matter of law, shifting the burden to the plaintiff to rebut the defendant's showing. The main issue decided was whether the defendant had established that the services were not medically necessary, and whether the plaintiff had rebutted this showing. The court held that the defendant's showing that the services were not medically necessary was unrebutted by the plaintiff, and as a result, the defendant's motion for summary judgment dismissing the complaint was granted.

Reported in New York Official Reports at Five Boro Psychological Servs., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 51858(U))

Five Boro Psychological Servs., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 51858(U)) [*1]

Five Boro Psychological Servs., P.C. v Clarendon Natl. Ins. Co.

2011 NY Slip Op 51858(U) [33 Misc 3d 129(A)]

Decided on October 12, 2011

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This opinion is uncorrected and will not be published in the printed Official Reports.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 October 12, 2011

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., RIOS and STEINHARDT, JJ
2010-1148 K C.

Five Boro Psychological Services, P.C. as Assignee of LAURA PURNELL, Respondent,
against
Clarendon National Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Wavny Toussaint, J.), entered March 2, 2010. The order, insofar as appealed from, denied defendant’s motion for summary judgment dismissing the complaint and, upon denying plaintiff’s cross motion for summary judgment, found, pursuant to CPLR 3212 (g), that plaintiff had “established its prima facie case.”

ORDERED that the order, insofar as appealed from, 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 appeals from so much of an order as denied its motion for summary judgment dismissing the complaint and as, upon denying plaintiff’s cross motion for summary judgment, found, pursuant to CPLR 3212 (g), that plaintiff had “established its prima facie case.”

Defendant established that it had timely mailed the denial of claim form (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]), which denied the claim on the ground of lack of medical necessity. 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 conclusion that there was a lack of medical necessity for the services at issue. Consequently, defendant established its prima facie entitlement to judgment as a matter of law (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op [*2]52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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]), thereby shifting the burden to plaintiff to rebut defendant’s showing (see Alur Med. Supply, Inc. v Clarendon Natl. Ins. Co., 27 Misc 3d 132[A], 2010 NY Slip Op 50700[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; sect f1 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]). Defendant’s showing that the services were not medically necessary was unrebutted by plaintiff. Accordingly, the order, insofar as appealed from, is reversed and defendant’s motion for summary judgment dismissing the complaint is granted. We reach no other issue.

Pesce, P.J., Rios and Steinhardt, JJ., concur.
Decision Date: October 12, 2011