May 6, 2013

Jamaica Dedicated Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50752(U))

https://www.beynensonlaw.com/case-law/jamaica-dedicated-med-care-p-c-v-geico-gen-ins-co-2013-ny-slip-op50752u/

Court: Appellate Term, Second Department
Decided: May 6, 2013
Citation: 2013 NY Slip Op 50752(U) · 39 Misc 3d 141(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Fee schedule
Legal questions: Proving a fee schedule defense (see the maps)

Cite as

Jamaica Dedicated Med. Care, P.C. v GEICO Gen. Ins. Co., 39 Misc 3d 141(A), 2013 NY Slip Op 50752(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013)

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 insurer's affidavit omitted claims in the complaint and failed to substantiate its fee-schedule defense, defeating summary judgment. The Civil Court denied the provider's summary judgment motion but granted the insurer's cross motion dismissing the assigned no-fault benefits complaint. On appeal, the provider showed that the claims examiner's affidavit addressed several claims outside the complaint, did not address certain claims being sued upon, and did not substantiate the stated fee-schedule basis for one denial. The Appellate Term, Second Department, reversed the dismissal judgment, vacated the portion of the order granting the insurer's cross motion, and denied that cross motion. The denial of the provider's motion remained intact.

Reported in New York Official Reports at Jamaica Dedicated Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50752(U))

[*1]

Jamaica Dedicated Med. Care, P.C. v GEICO Gen. Ins. Co.

2013 NY Slip Op 50752(U) [39 Misc 3d 141(A)]

Decided on May 6, 2013

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This opinion is uncorrected and will not be published in the printed Official Reports.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 May 6, 2013

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

PRESENT: : PESCE, P.J., RIOS and SOLOMON, JJ
2011-564 K C.

Jamaica Dedicated Medical Care, P.C. as Assignee of BOBBY JOHNSON, Appellant, —
against
GEICO General Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Johnny Lee Baynes, J.), entered July 30, 2010, deemed from a judgment of the same court entered November 3, 2010 (see CPLR 5501 [c]). The judgment, entered pursuant to the July 30, 2010 order denying plaintiff’s motion for summary judgment and granting defendant’s cross motion for summary judgment, dismissed the complaint.

ORDERED that the judgment is reversed, with $30 costs, so much of the order entered July 30, 2010 as granted defendant’s cross motion for summary judgment dismissing the complaint is vacated, and defendant’s cross motion is denied.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see [*2]CPLR 5501 [c]).

As plaintiff argues on appeal, the affidavit of defendant’s claims examiner, submitted by defendant in support of its cross motion, failed to address certain of plaintiff’s claims and failed to substantiate the fee schedule defense which was the stated basis for one denial. Instead, the affidavit addressed several claims which were not part of plaintiff’s complaint. Thus, based on the record before us, we find that defendant failed to establish its entitlement to summary judgment dismissing the complaint.

Accordingly, the judgment is reversed, so much of the order entered July 30, 2010 as granted defendant’s cross motion for summary judgment dismissing the complaint is vacated, and defendant’s cross motion is denied.

Pesce, P.J., Rios and Solomon, JJ., concur.
Decision Date: May 06, 2013

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.

Proving a fee schedule defense

Open the full map

Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?

This decision: Insurer's proof did not establish the excess as a matter of law; question left for trial (rules on the question, but another ground decided the case)

Held the claims examiner's affidavit failed to substantiate the fee schedule defense underlying one denial, so the insurer was not entitled to summary judgment.

Excess shownNot established; openDefense rejectedSplit by chargeThis decision

Of the 285 decisions on this question in the Second Department courts and the Court of Appeals, 85 (this one included) are in the same category.

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Jamaica Dedicated Med. Care, P.C. v Tri State Consumer Ins. Co. (2017 NY Slip Op 51790(U))The insurer's summary judgment cross motion failed because medical necessity was triable and its fee schedule defense was unproved.
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