April 14, 2015

Harmonic Physical Therapy, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50525(U))

https://www.beynensonlaw.com/case-law/harmonic-physical-therapy-p-c-v-praetorian-ins-co-2015-ny-slip-op50525u/

Court
Appellate Term, First Department
Decided
April 14, 2015
Citation
2015 NY Slip Op 50525(U) · 47 Misc 3d 137(A)
Posture
Summary judgment
Outcome
Insurer prevailed
Later treatment
Distinguished in 1 and followed in 4 later decisions (see Cited by)
Issues
Policy issues Priority, other coverage
Cite as
Harmonic Physical Therapy, P.C. v Praetorian Ins. Co., 47 Misc 3d 137(A), 2015 NY Slip Op 50525(U) (App Term, 1st Dept 2015)

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.

An insurer need not defer payment of other legitimate claims pending resolution of a claim it timely denied for lack of medical necessity. After timely denying the provider's claim, the insurer exhausted policy limits by paying no-fault benefits pursuant to arbitration awards favoring other providers. Its proof established compliance with the priority-of-payment regulation, 11 NYCRR 65-3.15. The provider raised no triable issue. Following Nyack Hosp. v General Motors Acceptance Corp., requiring payment delays on uncontested claims or binding awards would undermine prompt payment under the no-fault scheme. The Appellate Term, First Department, reversed the order, insofar as appealed from, granted the insurer's cross motion dismissing the complaint and directed entry of judgment.

Reported in New York Official Reports at Harmonic Physical Therapy, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50525(U))

[*1]
Harmonic Physical Therapy, P.C. v Praetorian Ins. Co.
2015 NY Slip Op 50525(U) [47 Misc 3d 137(A)]
Decided on April 14, 2015
Appellate Term, First Department
Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.
As corrected in part through March 9, 2016; it will not be published in the printed Official Reports.

Decided on April 14, 2015

SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT
PRESENT: Lowe, III, Schoenfeld, Hunter, Jr., JJ.
570555/14
Harmonic Physical Therapy, P.C., a/a/o Gladis Nunez, Plaintiff-Respondent,

against

Praetorian Insurance Company Defendant-Appellant.

Defendant, as limited by its briefs, appeals from so much of an order of the Civil Court of the City of New York, Bronx County (Donald A. Miles, J.), entered March 20, 2013, as denied its cross motion for summary judgment dismissing the complaint.

Per Curiam.

Order (Donald A. Miles, J.), entered March 20, 2013, insofar as appealed from, reversed, with $10 costs, and defendant’s motion for summary judgment dismissing the complaint is granted. The Clerk is directed to enter judgment accordingly.

The defendant-insurer made a prima facie showing of entitlement to summary judgment dismissing the action for first-party no-fault benefits. The evidentiary proof submitted by defendant established that, following the timely denial of plaintiff-provider’s claim on the ground of lack of medical necessity, the governing insurance policy’s coverage limits had been exhausted through payment of no-fault benefits in satisfaction of arbitration awards rendered in favor of other health care providers, and that such payments were made in compliance with the priority of payment regulation (see 11 NYCRR 65-3.15; Nyack Hosp. v General Motors Acceptance Corp., 8 NY3d 294 [2007]; New York and Presbyt. Hosp. v Allstate Ins. Co., 28 AD3d 528 [2006]).

In opposition, plaintiff failed to raise a triable issue. Contrary to plaintiff’s contention, defendant was not precluded by 11 NYCRR 65-3.15 from paying other providers’ legitimate claims subsequent to the denial of plaintiff’s claims. Adopting plaintiff’s position, which would require defendant to delay payment on uncontested claims, or, as here, on binding arbitration awards – pending resolution of plaintiff’s disputed claim – “runs counter to the no-fault regulatory scheme, which is designed to promote prompt payment of legitimate claims” (Nyack Hosp. v General Motors Accept. Corp., 8 NY3d at 300).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.


I concur I concurI concur
Decision Date: April 14, 2015

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