October 16, 2007

Matter of Health & Endurance Med., P.C. v Deerbrook Ins. Co. (2007 NY Slip Op 07844)

https://www.beynensonlaw.com/case-law/matter-of-health-endurance-med-p-c-v-deerbrook-ins-co-2007-ny-slip-op07844/

Court: Appellate Division, Second Department
Decided: October 16, 2007
Citation: 2007 NY Slip Op 07844 · 44 AD3d 857
Posture: Article 75 petition
Outcome: Provider prevailed
Later treatment: Distinguished in 2, contrasted (cf., but see) in 1 and followed in 3 later decisions (see Cited by)
Issues: CPLR article 75 (arbitration awards)

Cite as

Matter of Health & Endurance Med., P.C. v Deerbrook Ins. Co., 44 AD3d 857 (2d Dept 2007)

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.

An arbitrator impermissibly raised provider eligibility sua sponte when the insurer disputed only the need for the services. The Appellate Division, Second Department, reversed the order denying the provider's CPLR article 75 petition and confirming the master arbitrator's award, vacated both arbitration awards, and remitted to the arbitrator. Payment for services furnished by an independent contractor had been denied because the provider was deemed ineligible for direct payment under 11 NYCRR 65-3.11 (a). Under the circumstances, raising that issue sua sponte violated 11 NYCRR 65-4.4 (e). The arbitrator had not decided the insurer's medical-necessity issue, which required determination on remittal.

Reported in New York Official Reports at Matter of Health & Endurance Med., P.C. v Deerbrook Ins. Co. (2007 NY Slip Op 07844)

Matter of Health & Endurance Med., P.C. v Deerbrook Ins. Co.

2007 NY Slip Op 07844 [44 AD3d 857]

October 16, 2007

Appellate Division, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected through Wednesday, December 12, 2007

In the Matter of Health & Endurance Medical, P.C., as Assignee of Stanley Cummings, Appellant,
v
Deerbrook Insurance Company, Respondent.

—[*1] Gary Tsirelman, P.C., Brooklyn, N.Y. (Max Valerio of counsel), for appellant.

Marshall & Marshall, Jericho, N.Y. (Craig B. Marshall of counsel), for respondent.

In a proceeding pursuant to CPLR article 75 to vacate an award of a master arbitrator dated September 15, 2005, confirming an award of an arbitrator dated June 24, 2005 denying payment of no-fault insurance benefits, the appeal is from an order of the Supreme Court, Kings County (Ruchelson, J.), dated June 22, 2006, which denied the petition and granted the respondent’s cross petition to confirm the award of the master arbitrator.

Ordered that the order is reversed, on the law, with costs, the awards of the master arbitrator and arbitrator are vacated, and the matter is remitted to the arbitrator for further proceedings consistent herewith.

The petitioner, Health & Endurance Medical, P.C. (hereinafter HEM), as assignee, sought payment of no-fault insurance benefits from the respondent, Deerbrook Insurance Company (hereinafter Deerbrook) for medical services provided to an insured by an independent contractor. After arbitration, payment was denied on the ground that HEM was not a provider of health care services within the meaning of the no-fault regulations and, therefore, was not entitled to direct payment of such benefits. That award was confirmed by a master arbitrator. The Supreme Court, inter alia, denied HEM’s petition to vacate the award of the master arbitrator. We reverse.

In relevant part, the no-fault regulations provide for direct payments of no-fault benefits to “providers of health care services” (11 NYCRR 65-3.11 [a]). Under the circumstances [*2]of this case, the applicability of 11 NYCRR 65-3.11 (a) was impermissibly raised, sua sponte, by the arbitrator (see 11 NYCRR 65-4.4 [e]). Since the arbitrator never ruled on the only issue raised by Deerbrook relating to the need for the services in question, this matter must be remitted to the arbitrator for a determination of this issue. Miller, J.P., Ritter, Goldstein and Dickerson, JJ., concur.

Cited by

A label shows how the later decision treated this one.

A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co. (2012 NY Slip Op 06902) DistinguishedAn insurer's independent contractor defense is subject to preclusion if not asserted in a timely denial of claim.
Acuhealth Acupuncture, PC v Country-Wide Ins. Co. (2015 NY Slip Op 51256(U)) DistinguishedA no-fault arbitrator may subpoena a provider's claimed owner on the arbitrator's own initiative to resolve disputed ownership.
Metropolitan Radiological Imaging, P.C. v Country-Wide Ins. Co. (2008 NY Slip Op 50539(U)) Contrasted (cf., but see)A provider's prima facie no-fault showing does not require additional evidence establishing medical necessity.
Matter of 563 Grand Med., P.C. v Country-Wide Ins. Co. (2026 NY Slip Op 04292) FollowedAn arbitrator may not raise a standing defense that the insurer failed to assert in the arbitration proceeding.
Rj Professional Acupuncturist, P.C. v MVAIC (2008 NY Slip Op 51472(U)) FollowedMVAIC's verification request more than a year after receipt of the claims did not toll the 30-day determination period.
R.J. Professional Acupuncturist, P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 50541(U)) FollowedA provider establishes its prima facie no-fault claim by submitting complete proof of the fact and amount of loss and showing payment is overdue.
A.M. Med. Servs., P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 28528)A provider cannot correct during litigation claim forms identifying the treating professionals as independent contractors.
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.
Queens Community Med., P.C. v Motor Veh. Acc. Indem. Corp. (2008 NY Slip Op 50089(U))A no-fault arbitrator may raise any issue the arbitrator deems relevant under 11 NYCRR 65-4.4 (e) and 65-4.5 (o).
563 Grand Med., P.C. v Progressive Northeastern Ins. Co. (2008 NY Slip Op 50090(U))A no-fault arbitrator may raise any issue the arbitrator deems relevant under 11 NYCRR 65-4.4 (e) and 65-4.5 (o).

Similar decisions

Matter of Mercury Cas. Co. v Healthmakers Med. Group, P.C. (2009 NY Slip Op 08826)A court denying vacatur or modification of a no-fault arbitration award must confirm the award under CPLR 7511 (e).
T.S. Med. P.C. v Country Wide Ins. Co. (2005 NY Slip Op 50581(U))A provider need not prove medical necessity as part of its prima facie claim; the insurer bears the burden of proving its absence.
Matter of New Millennium Pain & Spine Medicine, P.C. v Progressive Cas. Ins. Co. (2023 NY Slip Op 05369)An insurer's duties cease upon payment of the contractual limit of its no-fault policy.
Health & Endurance Med. P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51191(U))A billing provider cannot recover assigned no-fault benefits for services rendered by an independent contractor rather than its employees.
American Tr. Ins. Co. v Beach Med. Rehabilitation, P.C. (2026 NY Slip Op 03771)The insurer failed to raise a triable issue on timely denials or causation in its action for de novo review of no-fault claims.