December 23, 2011

Hilltop Med. Diagnostic & Treatment Ctr. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52388(U))

Headnote

The relevant facts in the case include a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company timely denied the claim on the ground of lack of medical necessity. The main issue decided in this case was whether the insurance company's peer reviewer's report demonstrated a lack of medical necessity for the services at issue, which would shift the burden to the provider to rebut the insurance company's showing. The holding of the court was that the insurance company's peer reviewer's report did set forth a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity, and the provider failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity. Therefore, the court reversed the order denying the insurance company's motion for summary judgment and granted the motion for summary judgment dismissing the complaint.

Reported in New York Official Reports at Hilltop Med. Diagnostic & Treatment Ctr. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52388(U))

Hilltop Med. Diagnostic & Treatment Ctr. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52388(U)) [*1]

Hilltop Med. Diagnostic & Treatment Ctr. v Clarendon Natl. Ins. Co.

2011 NY Slip Op 52388(U) [34 Misc 3d 135(A)]

Decided on December 23, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 December 23, 2011

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 9th and 10th JUDICIAL DISTRICTS

PRESENT: : NICOLAI, P.J., MOLIA and IANNACCI, JJ
2010-2532 N C.

Hilltop Medical Diagnostic & Treatment Center as Assignee of FRANTZ GUILLAME, Respondent,
against
Clarendon National Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, Second District (Michael A. Ciaffa, J.), dated July 7, 2010. The order denied defendant’s motion for summary judgment dismissing the complaint.

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 appeals from an order denying its motion for summary judgment dismissing the complaint.

In support of its motion, defendant submitted an affidavit of an employee of its claims division, which demonstrated that defendant had timely denied the claim on the ground of lack of medical necessity (see Richard Morgan Do, P.C. v State Farm Mut. Auto. Ins. Co., 22 Misc 3d 134[A], 2009 NY Slip Op 50242[U] [App Term, 9th & 10th Jud Dists 2009]; Chi Acupuncture, P.C. v Kemper Auto & Home Ins. Co., 14 Misc 3d 141[A], 2007 NY Slip Op 50352[U] [App Term, 9th & 10th Jud Dists 2007]). Contrary to the conclusion of the District Court, the affirmed report of defendant’s peer reviewer set forth a sufficient medical rationale and factual [*2]basis to demonstrate a lack of medical necessity for the services at issue (see 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]; see also A.B. Med. Servs., PLLC v Country-Wide Ins. Co., 23 Misc 3d 140[A], 2009 NY Slip Op 51016[U] [App Term, 9th & 10th Jud Dists 2009]), 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 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.

Nicolai, P.J., Molia and Iannacci, JJ., concur.
Decision Date: December 23, 2011