February 19, 2013

Jamaica Dedicated Med. Care, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50259(U))

https://www.beynensonlaw.com/case-law/jamaica-dedicated-med-care-p-c-v-praetorian-ins-co-2013-ny-slip-op50259u/

Court: Appellate Term, Second Department
Decided: February 19, 2013
Citation: 2013 NY Slip Op 50259(U) · 38 Misc 3d 143(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Jamaica Dedicated Med. Care, P.C. v Praetorian Ins. Co., 38 Misc 3d 143(A), 2013 NY Slip Op 50259(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 provider failed to rebut the insurer's IME report establishing lack of medical necessity for the services rendered. Civil Court denied the parties' summary judgment applications but found the provider's prima facie showing and the timely, proper mailing of denials established, leaving medical necessity as the sole trial issue. The insurer's affirmed IME report supplied a factual basis and medical rationale for finding the services unnecessary. The provider did not meaningfully address its conclusions or challenge the finding that the insurer was otherwise entitled to judgment. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted the insurer's cross motion for summary judgment dismissing the complaint.

Reported in New York Official Reports at Jamaica Dedicated Med. Care, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50259(U))

[*1]

Jamaica Dedicated Med. Care, P.C. v Praetorian Ins. Co.

2013 NY Slip Op 50259(U) [38 Misc 3d 143(A)]

Decided on February 19, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 February 19, 2013

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

PRESENT: : PESCE, P.J., RIOS and SOLOMON, JJ
2011-1563 K C.

Jamaica Dedicated Medical Care, P.C. as Assignee of MATTHEW BAXTER, Respondent, —
against
Praetorian Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Carolyn E. Wade, J.), entered April 13, 2011. The order, insofar as appealed from as limited by the brief, in effect, denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, with $30 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, in effect, denied the motions but found that plaintiff had established its prima facie entitlement to summary judgment, that defendant had “established timely and proper mailing of its denial(s),” and that “[t]he sole issue for trial is the defense of lack of medical necessity.” Defendant appeals, as limited by its brief, from so much of the order as, in effect, denied its cross motion for summary judgment dismissing the complaint.

In support of its cross motion, defendant submitted an affirmed medical report by the doctor who had performed the independent medical examination (IME) on defendant’s behalf, which set forth a factual basis and medical rationale for the doctor’s determination that there was [*2]a lack of medical necessity for the services rendered. In opposition to the cross motion, plaintiff failed to meaningfully refer to, let alone rebut, the conclusions set forth in the IME report (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). As plaintiff has not challenged the Civil Court’s finding, in effect, that defendant is otherwise entitled to judgment, defendant’s cross motion for summary judgment dismissing the complaint is granted (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]; Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; 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, insofar as appealed from, is reversed, and defendant’s cross motion for summary judgment dismissing the complaint is granted.

Pesce, P.J., Rios and Solomon, JJ., concur.
Decision Date: February 19, 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.

Lack of medical necessity

Open the full map

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

This decision: Insurer's proof established lack of medical necessity and the provider failed to rebut it

Granted the insurer's cross motion because its affirmed IME report set forth a factual basis and medical rationale for lack of necessity and the provider failed to meaningfully refer to, let alone rebut, its conclusions.

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 617 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.

Cited in this decision

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

Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) FollowedThe provider's conclusory disagreement with the insurer's supported peer review failed to raise a medical-necessity issue of fact.
Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U))The insurer's examining physician supplied an unrebutted factual basis and medical rationale that the billed MRI was unnecessary.
Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 52455(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.

Similar decisions

Jamaica Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50760(U))The provider's doctor's affirmation failed to rebut the insurer's peer review establishing lack of medical necessity for the equipment.
Jamaica Med. Plaza, P.C. v Interboro Ins. Co. (2013 NY Slip Op 50475(U))The insurer was entitled to a provider deposition material and necessary to its defense, but factual disputes barred summary judgment.
Five S & A Rehab Pt, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51724(U))The insurer's affirmed IME report established lack of medical necessity, and the provider failed to rebut that showing.
Manhattan Med. Imaging, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 51541(U))The insurer's unrebutted peer review supplied a factual basis and medical rationale establishing lack of medical necessity.
Jamaica Dedicated Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50752(U))The insurer's affidavit omitted claims in the complaint and failed to substantiate its fee-schedule defense, defeating summary judgment.