May 9, 2019
Matter of Global Liberty Ins. Co. v McMahon (2019 NY Slip Op 03692)
https://www.beynensonlaw.com/case-law/matter-of-global-liberty-ins-co-v-mcmahon-2019-ny-slip-op-03692/
- Decided
- May 9, 2019
- Citation
- 2019 NY Slip Op 03692 · 172 AD3d 500
- Posture
- Article 75 petition
- Outcome
- Insurer prevailed
- Later treatment
- Distinguished in 1 and followed in 1 later decisions (see Cited by)
- Legal questions
- Proving a fee schedule defense · Court review of arbitration awards (see the maps)
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.
Reported in New York Official Reports at Matter of Global Liberty Ins. Co. v McMahon (2019 NY Slip Op 03692)
| Matter of Global Liberty Ins. Co. v McMahon |
| 2019 NY Slip Op 03692 [172 AD3d 500] |
| May 9, 2019 |
| Appellate Division, First Department |
| Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431. |
[*1]
| In the Matter of Global Liberty Insurance Co.,
Appellant, v Mark S. McMahon, M.D., as Assignee of Rudy Corniel, Respondent. |
Law Office of Jason Tenenbaum, P.C., Garden City (Jason Tenenbaum of counsel), for appellant.
Samandarov & Associates, P.C., Floral Park (Eli Shmulik of counsel), for respondent.
Order, Supreme Court, Bronx County (Fernando Tapia, J.), entered November 11, 2018, which denied Global Liberty Insurance Co.’s (Global) petition to vacate the master arbitrator’s award, dated August 15, 2018, affirming the lower arbitrator’s award in favor of respondent, dated April 17, 2018, dismissed the proceeding and confirmed the award, unanimously reversed, on the law, without costs, the petition granted, the award vacated, and the matter remanded to the lower arbitrator for a new arbitration to be conducted consistent with this decision.
Respondent submitted to Global a claim for payment under the No-Fault Law (Insurance Law art 51) in the amount of $5,813,81 for arthroscopic surgery respondent had performed on Global’s insured. Global approved the claim only up to the amount of $2,980.44, basing its position on the American Medical Association’s CPT Assistant newsletter.[FN*] After Global partially paid the claim, respondent commenced a no-fault arbitration, seeking payment of the $1,342.52 balance. The lower arbitrator, in rendering an award to respondent in that amount, refused to consider CPT Assistant, on which Global had relied, based on the arbitrator’s view that CPT Assistant was “not authorized by statute or regulation applicable to the No-Fault Law.” On Global’s appeal, the master arbitrator affirmed the lower arbitrator’s award. Thereafter, Supreme Court denied Global’s petition to vacate the award. On Global’s appeal, we reverse and grant the petition.
The Official New York Workers’ Compensation Medical Fee Schedule, promulgated by the chair of the Workers’ Compensation Board, directs users to “refer to the CPT book for an explanation of coding rules and regulations not listed in this schedule.” The CPT book, in turn, expressly makes reference to CPT Assistant. By both statute and regulation, the fee schedules established by the chair of the Workers’ Compensation Board are expressly made applicable to claims under the No-Fault Law (see Insurance Law § 5108; 11 NYCRR 68.0, 68.1 [a] [1]; see generally Government Empls. Ins. Co. v Avanguard Med. Group, PLLC, 127 AD3d 60, 63-64 [2d Dept 2015], affd 27 NY3d 22 [2016]). Accordingly, because CPT Assistant is incorporated by reference into the CPT book, which is incorporated by reference into the Official New York Workers’ Compensation Medical Fee Schedule applicable to this claim under the No-Fault Law, the award rendered without consideration of CPT Assistant is incorrect as a matter of law (see 11 NYCRR 65-4.10 [a] [4]). We therefore grant the petition to vacate the award and remand the matter to the lower arbitrator for a new arbitral proceeding, at which relevant portions of CPT Assistant shall be given due consideration. Concur—Friedman, J.P., Renwick, Kapnick, Kahn, Oing, JJ.
Footnotes
Footnote *:CPT is an acronym for Current Procedural Terminology.
Legal questions (2)
Questions 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.
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
Vacated the award and remanded because the arbitrator wrongly refused to consider CPT Assistant, which is incorporated by reference into the workers' compensation fee schedule through the CPT book.
Of the 45 decisions on this question in the First Department courts and the Court of Appeals, 10 (this one included) are in the same category. 3 decisions in other departments that cite or are cited by this one are on the full map.
When does a court vacate, modify or confirm a no-fault arbitrator’s or master arbitrator’s award under CPLR article 75?
This decision: Award vacated or modified because it was irrational, arbitrary and capricious, without evidentiary support or contrary to settled law
Vacated the award and remanded for a new arbitration because refusing to consider CPT Assistant, which the fee schedule incorporates through the CPT book, made the award incorrect as a matter of law.
Of the 55 decisions on this question in the First Department courts and the Court of Appeals, 13 (this one included) are in the same category. 2 decisions in other departments that cite or are cited by this one are on the full map.
Cited in this decision
- Government Empls. Ins. Co. v Avanguard Med. Group, PLLC (2015 NY Slip Op 01413)An insurer need not pay facility fees for office-based surgery under Public Health Law § 230-d absent statutory or regulatory authorization.
- Government Empls. Ins. Co. v Avanguard Med. Group, PLLC (2016 NY Slip Op 02473)No-fault insurers are not required to reimburse facility fees charged by accredited office-based surgery practices.
Cited by
A label shows how the later decision treated this one.
- Atlantic Med. & Diagnostic, P.C. v State Farm Mut. Auto. Ins. Co. (2024 NY Slip Op 51785(U)) DistinguishedMultiple units of CPT code 76942 are reimbursable under the Workers' Compensation Medical Fee Schedule with trigger point injections.
- Demas v State Farm Fire & Cas. Co. (2022 NY Slip Op 50250(U)) FollowedThe insurer failed to justify recoding cupping or applying a vasopneumatic-device valuation under the fee schedule.
- American Tr. Ins. Co. v Right Choice Supply, Inc. (2023 NY Slip Op 23039)A no-fault arbitrator need not apply summary judgment rules requiring a provider's medical evidence to specifically rebut an insurer's peer review.
- American Tr. Ins. Co. v PDA NY Chiropractic, P.C. (2023 NY Slip Op 50938(U))A provider's substantial compliance with reasonable additional verification requests does not make its claims payable.
Similar decisions
- Matter of Global Liberty Ins. Co. v Therapeutic Physical Therapy, P.C. (2017 NY Slip Op 01833)An insurer preserves a fee-schedule defense by checking box 18 on the NF-10 denial form to assert noncompliance with the fee schedule.
- Matter of Global Liberty Ins. Co. v Professional Chiropractic Care, P.C. (2016 NY Slip Op 04156)A master arbitrator's award was irrational because it ignored the coverage effect of the assignor's failure to attend duly scheduled IMEs. The insurer presented authority establishing that the IME nonappearances rendered the no-fault policy void ab initio.
- Matter of Global Liberty Ins. Co. of N.Y. v Avangard Supply, Inc. (2020 NY Slip Op 06855)An insurer's vague IME-based denial supported a rational arbitration award of no-fault benefits to the providers.
- Golden Earth Chiropractic & Acupuncture, PLLC v Global Liberty Ins. Co. of N.Y. (2016 NY Slip Op 26395)A master arbitrator may correct an error of substantive law without independently weighing evidence or determining credibility.
- Matter of Global Liberty Ins. Co. v Coastal Anesthesia Servs., LLC (2016 NY Slip Op 08964)A no-fault arbitrator has discretion to refuse late submissions under 11 NYCRR 65-4.2 (b) (3).