June 3, 2016

GBI Acupuncture, P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50859(U))

https://www.beynensonlaw.com/case-law/gbi-acupuncture-p-c-v-tri-state-consumers-ins-co-2016-ny-slip-op50859u/

Court: Appellate Term, Second Department
Decided: June 3, 2016
Citation: 2016 NY Slip Op 50859(U) · 51 Misc 3d 150(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Fee schedule
Legal questions: Proving a fee schedule defense (see the maps)

Cite as

GBI Acupuncture, P.C. v Tri State Consumers Ins. Co., 51 Misc 3d 150(A), 2016 NY Slip Op 50859(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.

The insurer's summary judgment dismissing the provider's claims on a full-payment fee schedule defense was affirmed. The Appellate Term, Second Department, upheld the Civil Court's order for the reasons stated in the companion appeal, Renelique v Tri State Consumers Ins. Co., decided the same day, No. 2013-1709 Q C.

Reported in New York Official Reports at GBI Acupuncture, P.C. v Tri State Consumers Ins. Co. (2016 NY Slip Op 50859(U))

[*1]

GBI Acupuncture, P.C. v Tri State Consumers Ins. Co.

2016 NY Slip Op 50859(U) [51 Misc 3d 150(A)]

Decided on June 3, 2016

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This opinion is uncorrected and will not be published in the printed Official Reports.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 June 3, 2016

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-1419 K C

GBI Acupuncture, P.C., as Assignee of SOFIA GJONBALAJ, Appellant,
against
Tri State Consumers Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Harriet L. Thompson, J.), entered April 12, 2013. The order granted defendant’s motion for summary judgment.

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

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint, arguing that it had fully paid plaintiff in accordance with the workers’ compensation fee schedule. The Civil Court granted defendant’s motion.

For the reasons stated in Renelique, as Assignee of Yvon Delgado v Tri State Consumers Ins. Co. (___ Misc 3d ___, 2016 NY Slip Op _____ [appeal No. 2013-1709 Q C], decided herewith), the order is affirmed.

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

Decision Date: June 03, 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.

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

Upheld summary judgment for the insurer on its showing that it had fully paid the acupuncture provider under the workers' compensation fee schedule, for the reasons given in the companion appeal.

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.

Similar decisions

GBI Acupuncture, P.C. v Allstate Ins. Co. (2016 NY Slip Op 51412(U))The insurer failed to establish timely mailing of denials supporting its fee-schedule payment defense.
GBI Acupuncture, P.C. v 21st Century Ins. Co. (2015 NY Slip Op 51235(U))The insurer established timely denials and proper reimbursement under the workers' compensation fee schedule for the acupuncture services.
GBI Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 50329(U))The insurer established full payment for acupuncture services under the workers' compensation fee schedule applicable to chiropractors.
GBI Acupuncture, P.C. v GEICO Ins. Co. (2017 NY Slip Op 51237(U))The insurer's summary judgment dismissal of fee-schedule claims was affirmed after the provider's mailing and fee-schedule challenges were rejected.
GL Acupuncture, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51698(U))The insurer established timely denial and full payment under the fee schedule for acupuncture services performed by chiropractors.