June 4, 2010

Innovative Chiropractic, P.C. v Travelers Ins. Co. (2010 NY Slip Op 50994(U))

Headnote

The court considered the denial of a claim for first-party no-fault benefits by the defendant insurance company, which was based on the lack of medical necessity for the services in question. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint brought by the plaintiff, a provider seeking to recover assigned first-party no-fault benefits. The holding of the case was that the defendant insurance company had established its prima facie entitlement to summary judgment by timely mailing denial of claim forms and submitting an affidavit and peer review report demonstrating the lack of medical necessity for the services. The plaintiff failed to raise a triable issue of fact, and therefore the defendant's cross motion for summary judgment dismissing the complaint should have been granted.

Reported in New York Official Reports at Innovative Chiropractic, P.C. v Travelers Ins. Co. (2010 NY Slip Op 50994(U))

Innovative Chiropractic, P.C. v Travelers Ins. Co. (2010 NY Slip Op 50994(U)) [*1]

Innovative Chiropractic, P.C. v Travelers Ins. Co.

2010 NY Slip Op 50994(U) [27 Misc 3d 141(A)]

Decided on June 4, 2010

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This opinion is uncorrected and will not be published in the printed Official Reports.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 4, 2010

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : PESCE, P.J., WESTON and GOLIA, JJ
2009-617 Q C.

Innovative Chiropractic, P.C. as assignee of YOLANDA TORRES, Respondent,
against
Travelers Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Diane A. Lebedeff, J.), entered November 5, 2008. The order, insofar as appealed from, denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed without costs and defendant’s cross motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The Civil Court denied both motions. Defendant appeals from so much of the order as denied its cross motion for summary judgment dismissing the complaint.

Defendant established that it had timely mailed (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]) the denial of claim forms, which denied the claims at issue on the ground of lack of medical necessity. In support of its cross motion for summary judgment, defendant also submitted, among other things, an affidavit from its peer review chiropractor and a peer review report, which set forth a factual basis and medical rationale for the conclusion that there was a lack of medical necessity for the services at issue (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). Defendant’s showing that the services were not medically necessary was unrebutted by plaintiff. Consequently, defendant established its prima facie entitlement to summary judgment and plaintiff failed to raise a triable issue of fact.
Accordingly, defendant’s cross motion for summary judgment dismissing the complaint should have been granted.

Pesce, P.J., Weston and Golia, JJ., concur.
Decision Date: June 04, 2010