January 15, 2015

Healing Art Acupuncture, P.C. v Amica Mut. Ins. Co. (2015 NY Slip Op 50078(U))

https://www.beynensonlaw.com/case-law/healing-art-acupuncture-p-c-v-amica-mut-ins-co-2015-ny-slip-op50078u/

Court: Appellate Term, Second Department
Decided: January 15, 2015
Citation: 2015 NY Slip Op 50078(U)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Fee schedule Timeliness and preclusion
Legal questions: Proof of mailing · Proving a fee schedule defense (see the maps)

Cite as

Healing Art Acupuncture, P.C. v Amica Mut. Ins. Co., 2015 NY Slip Op 50078(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 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 out-of-state affidavit's missing certificate of conformity may be disregarded where no substantial right is prejudiced. The insurer's claims representative established timely mailing of denials despite noncompliance with CPLR 2309 (c) and Real Property Law § 299-a. Under CPLR 2001, the defect was nonfatal because the provider showed no prejudice. A fee schedule adjuster's affidavit also established proper reimbursement using the workers' compensation schedule for acupuncture performed by chiropractors, following Great Wall Acupuncture, P.C. v GEICO Ins. Co. The provider raised no triable issue. The Appellate Term, Second Department, affirmed the judgment dismissing the complaint following the grant of the insurer's summary judgment motion and denial of the provider's cross motion.

Reported in New York Official Reports at Healing Art Acupuncture, P.C. v Amica Mut. Ins. Co. (2015 NY Slip Op 50078(U))

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

Healing Art Acupuncture, P.C. as Assignee of TATIANA OBAEZ, Appellant,
against
Amica Mutual Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Harriet L. Thompson, J.), entered March 13, 2013, deemed from a judgment of the same court entered March 27, 2013 (see CPLR 5501 [c]). The judgment, entered pursuant to the March 13, 2013 order granting defendant’s motion for summary judgment and denying plaintiff’s cross motion for summary judgment, dismissed the complaint.

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

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint and denied plaintiff’s cross motion for summary judgment. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).

In support of its motion, defendant submitted an affidavit by its claims representative, which affidavit sufficiently established the timely mailing of the denial of claim forms (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]). Although the claims representative’s affidavit, which was notarized outside the State of New York, failed to conform to the requirements set forth in CPLR 2309 (c) and Real Property Law § 299-a regarding the submission of a certificate of conformity, the absence of a certificate of conformity is not a fatal defect (see Fuller v Nesbitt, 116 AD3d 999 [2014]; Fredette v Town of Southampton, 95 AD3d 940 [2012]; see also Gonzalez v Perkan Concrete Corp., 110 AD3d 955 [2013]; Smith v Allstate Ins. Co., 38 AD3d 522 [2007]; Active Chiropractic, P.C. v Praetorian Ins. Co., 43 Misc 3d 134[A], 2014 NY Slip Op 50634[U] [App Term, 2d, 11th & 13th Jud Dists 2014]), as the defect may be disregarded pursuant to CPLR 2001 where a substantial right of a party is not prejudiced (see Midfirst Bank v Agho, 121 AD3d 343 [2014]; Rivers v Birnbaum, 102 AD3d 26 [2012]). In the present case, plaintiff failed to make any showing of prejudice.

Defendant denied plaintiff’s claims on the grounds that they exceeded the amount permitted by the workers’ compensation fee schedule, and that defendant had fully paid for the billed-for services in accordance with the fee schedule for acupuncture services performed by chiropractors. Contrary to plaintiff’s assertion, the affidavit executed by a fee schedule adjuster [*2]for defendant’s vendor, Managed Care Network, established that defendant had properly used the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which plaintiff was entitled to receive for the services at issue (see Great Wall Acupuncture, P.C. v GEICO Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]). Plaintiff’s papers failed to raise a triable issue of fact in opposition to defendant’s motion. Consequently, the Civil Court properly granted defendant’s motion and denied plaintiff’s cross motion.

Accordingly, the judgment is affirmed.

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

Decision Date: January 15, 2015

Legal questions (2)

Questions 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.

Proof of mailing

Open the full map

Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?

This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice

Held the claims representative's affidavit sufficiently established timely mailing of the denials, and its lack of a certificate of conformity for out-of-state notarization was a disregardable defect absent prejudice.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 806 (this one included) are in the same category.

Proving a fee schedule defense

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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

Held the vendor fee schedule adjuster's affidavit established that the insurer properly applied the chiropractor acupuncture fee schedule and fully paid, and the provider raised no triable issue.

Excess shownNot established; openDefense rejectedSplit by chargeThis decisionCites it or cited by itCited or followed

Of the 284 decisions on this question in the Second Department courts and the Court of Appeals, 146 (this one included) are in the same category.

Cited in this decision

A label shows how this decision treated the case it cites.

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345) FollowedAn insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
Active Chiropractic, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50634(U))An out-of-state affidavit's lack of a certificate of conformity under CPLR 2309 (c) is not a fatal defect.
Great Wall Acupuncture, P.C. v Geico Ins. Co. (2009 NY Slip Op 29467) FollowedAn insurer may use the chiropractic acupuncture fee schedule to reimburse acupuncture services performed by a licensed acupuncturist.

Cited by

Healthy Way Acupuncture, P.C. v 21st Century Indem. Ins. Co. (2017 NY Slip Op 50204(U))The insurer's corrected summary judgment motion was timely, and its policy proof established an applicable personal injury protection deductible.

Similar decisions

Healing Art Acupuncture, P.C. v Maya Assur. Co. (2015 NY Slip Op 50387(U))The insurer failed to prove mailing of IME notices or that the provider's fee exceeded the workers' compensation fee schedule.
Gl Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 51748(U))The insurer established full payment at the workers' compensation fee-schedule rate for chiropractic acupuncture.
Health Needles Acupuncture, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 51831(U))A letter merely announcing delay pending an assignor's IME and EUO does not toll the time to pay or deny a no-fault claim.
Healing Art Acupuncture, P.C. v Allstate Ins. Co. (2017 NY Slip Op 51821(U))The insurer failed to prove timely denials preserving its fee-schedule defense, and the provider failed to establish entitlement to summary judgment.
Natural Therapy Acupuncture, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 50389(U))The insurer's affidavit and exhibits established full payment for the disputed services under the workers' compensation fee schedule.