March 2, 2012

Medical Assoc., P.C. v Interboro Ins. Co. (2012 NY Slip Op 50392(U))

Headnote

The main issue in this case was whether the denial of a claim for first-party no-fault benefits by Interboro Ins. Co. on the grounds of lack of medical necessity was justified. The court considered evidence from both the defendant and the plaintiff, with the defendant submitting an affirmed peer review report stating that the treatment provided by the plaintiff was not medically necessary. The plaintiff submitted an unsworn medical report in opposition to the defendant's motion. Ultimately, the court held that the purpose of the peer review report was not to prove the injury or treatment of the plaintiff's assignor but to establish that the treatment provided was not medically necessary. The court found that the defendant was not required to demonstrate that the records fell within an exception to the rule against hearsay and granted the defendant's motion for summary judgment dismissing the complaint.

Reported in New York Official Reports at Medical Assoc., P.C. v Interboro Ins. Co. (2012 NY Slip Op 50392(U))

Medical Assoc., P.C. v Interboro Ins. Co. (2012 NY Slip Op 50392(U)) [*1]

Medical Assoc., P.C. v Interboro Ins. Co.

2012 NY Slip Op 50392(U) [34 Misc 3d 154(A)]

Decided on March 2, 2012

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This opinion is uncorrected and will not be published in the printed Official Reports.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 March 2, 2012

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

PRESENT: : PESCE, P.J., WESTON and RIOS, JJ
2010-1565 K C.

Medical Associates, P.C. as Assignee of SIU ONG LEE CHAN, Respondent, —
against
Interboro Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Peter Paul Sweeney, J.), entered October 2, 2009. The order, insofar as appealed from, denied the branch of defendant’s motion seeking summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, without costs, and the branch of defendant’s motion seeking summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from so much of an order as denied the branch of its motion seeking summary judgment dismissing the complaint.

The affidavit submitted by defendant in support of its motion for summary judgment established that defendant had timely denied (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]) the claim at issue on the ground of lack of medical necessity. Defendant annexed to its motion papers an affirmed peer review report which set forth a factual basis and medical rationale for the peer reviewer’s determination that there was a lack of medical necessity for the services rendered (see Delta [*2]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]). In opposition, plaintiff proffered an unsworn medical report (see CPLR 2106; 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]; cf. Continental Med., P.C. v Mercury Cas. Co., 22 Misc 3d 134[A], 2009 NY Slip Op 50234[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).

The purpose of the peer review report submitted by defendant was not to attempt to prove that plaintiff’s assignor was injured as documented in her medical records, or that she was treated as set forth in those records, but to establish that, assuming the facts set forth therein were true, the treatment allegedly provided by plaintiff was not medically necessary (Urban Radiology, P.C. v Tri-State Consumer Ins. Co., 27 Misc 3d 140[A], 2010 NY Slip Op 50987[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Consequently, defendant was not required to demonstrate that the records fell within an exception to the rule against hearsay (id.). Thus, the Civil Court should have granted the branch of defendant’s motion seeking summary judgment dismissing the complaint.

Accordingly, the order, insofar as appealed from, is reversed and the branch of defendant’s motion seeking summary judgment dismissing the complaint is granted.

Pesce, P.J., Weston and Rios, JJ., concur.
Decision Date: March 02, 2012