Jesa Med. Supply, Inc. v Progressive Ins. Co. (2011 NY Slip Op 51603(U))

SUPREME COURT OF THE STATE OF NEW YORK

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

Appeal from an order of the Civil Court of the City of New York, Kings County (Alice Fisher Rubin, J.), entered February 6, 2009. The order, insofar as appealed from, granted the branches of plaintiff’s motion seeking summary judgment as to claims for the sums of $1,205.50 and $1,675 and denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, without costs, the branches of plaintiff’s motion seeking summary judgment as to the claims for the sums of $1,205.50 and $1,675 are denied, 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. Defendant opposed the motion and cross-moved for summary judgment dismissing the complaint on the ground that the action, insofar as it pertained to plaintiff’s claims seeking to recover the sums of $1,205.50 and $1,675, was premature because it was commenced before defendant had received responses to its outstanding verification requests, and on the ground of lack of medical necessity as to plaintiff’s claim for $502.63. The Civil Court granted the branches of plaintiff’s motion seeking summary judgment on the $1,205.50 and $1,675 claims, and denied defendant’s cross motion for summary judgment, finding that a triable issue of fact exists as to the medical necessity of plaintiff’s $502.63 claim. This appeal by defendant ensued.

The affidavit of defendant’s litigation representative established that defendant had timely mailed its request and follow-up request for verification in accordance with its standard office practices and procedures to plaintiff and to the doctor who had prescribed the medical supplies at [*2]issue (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant demonstrated that it had not received the requested verification, and plaintiff did not show that the verification had been provided to defendant prior to the commencement of the action. Consequently, the 30-day period within which defendant was required to pay the $1,205.50 and $1,675 claims did not begin to run (see Insurance Department Regulations [11 NYCRR] § 65-3.8 [a]; Central Suffolk Hosp. v New York Cent. Mut. Fire Ins. Co., 24 AD3d 492 [2005]; Hospital for Joint Diseases v State Farm Mut. Auto. Ins. Co., 8 AD3d 533 [2004]), and, thus, plaintiff’s action with respect to the $1,205.50 and $1,675 claims is premature.

With respect to the branch of defendant’s cross motion seeking summary judgment dismissing the complaint insofar as it sought to recover the sum of $502.63, defendant demonstrated that it had timely denied the $502.63 claim on the ground of lack of medical necessity based upon an affirmed independent medical examination (IME) report (see St. Vincent’s Hosp. of Richmond, 50 AD3d at 1124; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d at 17-18). The IME report set forth a factual basis and medical rationale for the doctor’s opinion that there was a lack of medical necessity for the supplies 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]). As plaintiff failed to submit any medical evidence to rebut defendant’s showing of lack of medical necessity, the branch of defendant’s cross motion seeking summary judgment dismissing the $502.63 claim should have been granted (see Delta Diagnostic Radiology, P.C. v Integon Nat. Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51502[U]; 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, the branches of plaintiff’s motion seeking summary judgment as to the claims for the sums of $1,205.50 and $1,675 are denied, and defendant’s cross motion for summary judgment dismissing the complaint is granted. Pesce, P.J., Rios and Steinhardt, JJ., concur.
Decision Date: August 16, 2011