July 13, 2015

Huntington Regional Chiropractic, P.C. v Truck Ins. Exch. (2015 NY Slip Op 51068(U))

https://www.beynensonlaw.com/case-law/huntington-regional-chiropractic-p-c-v-truck-ins-exch-2015-ny-slip-op-51068u/

Court: Appellate Term, Second Department
Decided: July 13, 2015
Citation: 2015 NY Slip Op 51068(U)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Huntington Regional Chiropractic, P.C. v Truck Ins. Exch., 2015 NY Slip Op 51068(U) (App Term, 2d Dept, 9th & 10th 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.

The providers' medical affidavits raised a triable issue of medical necessity despite the insurer's sufficient IME reports. The providers appealed dismissal of their first through eighteenth and twenty-first through thirty-sixth causes of action for assigned no-fault benefits. The insurer submitted reports from a chiropractor and an orthopedist that supplied factual bases and medical rationales for finding the respective services unnecessary. The providers' opposing medical affidavits nevertheless created a factual dispute requiring denial of summary judgment. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and denied the branches of the insurer's motion seeking dismissal of those causes of action.

Reported in New York Official Reports at Huntington Regional Chiropractic, P.C. v Truck Ins. Exch. (2015 NY Slip Op 51068(U))

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS

Huntington Regional Chiropractic, P.C. as Assignee of TANIA HERNANDEZ Also Known as TANIA R. HERNANDEZ and ORTHOMED CARE, P.C. as Assignee of TANIA R. HERNANDEZ, Appellants, July 13, 2015
against
Truck Insurance Exchange, Respondent.

Appeal from an order of the District Court of Nassau County, Third District (Michael A. Ciaffa, J.), dated January 23, 2014. The order, insofar as appealed from, granted the branches of defendant’s motion seeking summary judgment dismissing plaintiffs’ first through eighteenth, and twenty-first through thirty-sixth causes of action.

ORDERED that the order, insofar as appealed from, is reversed, without costs, and the branches of defendant’s motion seeking summary judgment dismissing plaintiffs’ first through eighteenth, and twenty-first through thirty-sixth causes of action are denied.

In this action by providers to recover assigned first-party no-fault benefits, plaintiffs appeal from so much of an order as granted the branches of defendant’s motion seeking summary judgment dismissing plaintiffs’ first through eighteenth, and twenty-first through thirty-sixth causes of action.

In support of its motion, defendant submitted, among other things, two independent medical examination reports, one from a chiropractor and one from an orthopedist, which set forth a factual basis and a medical rationale for the examiners’ determination that there was a lack of medical necessity for the respective services provided (see Total Equip., LLC v Praetorian Ins. Co., 34 Misc 3d 145[A], 2012 NY Slip Op 50155[U] [App Term, 9th & 10th Jud Dists 2012]). However, the medical affidavits submitted by plaintiffs in opposition were sufficient to raise a triable issue of fact as to the medical necessity of the claims at issue (see Huntington Med. Plaza, P.C. v Travelers Indem. Co., 43 Misc 3d 129[A], 2014 NY Slip Op 50527[U] [App Term, 2d, 11th & 13th Jud Dists 2014]; Brooklyn Chiropractic & Sports Therapy, P.C. v A. Cent. Ins. Co., 39 Misc 3d 148[A], 2013 NY Slip Op 50904[U] [App Term, 9th & 10th Jud Dists 2013]).

Accordingly, the order, insofar as appealed from, is reversed, and the branches of defendant’s motion seeking summary judgment dismissing plaintiffs’ first through eighteenth and twenty-first through thirty-sixth causes of action are denied.

Tolbert, J.P., Marano and Connolly, JJ., concur.

Decision Date: July 13, 2015

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.

Lack of medical necessity

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Did the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?

This decision: Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)

Held that the chiropractic and orthopedic IME reports made a prima facie showing, but the providers' medical affidavits raised a triable issue of fact as to medical necessity, so the insurer's motion was denied.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decisionCites it or cited by itCited or followed

Of the 612 decisions on this question in the Second Department courts and the Court of Appeals, 95 (this one included) are in the same category.

Cited in this decision

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

Total Equip., LLC v Praetorian Ins. Co. (2012 NY Slip Op 50155(U))The insurer's affirmed IME report established lack of medical necessity for the supplies, and the provider failed to rebut that showing.
Huntington Med. Plaza, P.C. v Travelers Indem. Compan (2014 NY Slip Op 50527(U)) FollowedThe insurer failed to establish that prior medical-necessity determinations collaterally estopped the providers' claims for later treatment.
Brooklyn Chiropractic & Sports Therapy, P.C. v A. Cent. Ins. Co. (2013 NY Slip Op 50904(U)) FollowedThe insurer established lack of medical necessity for one claim and outstanding verification for two, but obtained no dismissal of twelve others.

Similar decisions

Bay Plaza Chiropractic, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52315(U))The provider's chiropractor affidavit raised a triable issue of medical necessity despite the insurer's supported peer review.
AJS Chiropractic, P.C. v Travelers Ins. Co. (2009 NY Slip Op 52446(U))The insurer's unrebutted chiropractic peer review established lack of medical necessity for the provider's first cause of action.
American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U))The provider's treating chiropractor's sworn letter raised a factual issue on medical necessity despite the insurer's peer review.
Theracare & Wellness, P.T., P.C. v Great N. Ins. Co. (2016 NY Slip Op 51429(U))The insurer's unrebutted IME report established a lack of medical necessity for the treatment at issue.
A.B. Med. Servs., PLLC v New York Cent. Mut. Fire Ins. Co. (2009 NY Slip Op 50331(U))The insurer's evidence established a founded belief that the assignors' injuries did not arise from an insured incident.