November 3, 2014

NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U))

https://www.beynensonlaw.com/case-law/nj-ny-pain-mgt-v-allstate-ins-co-2014-ny-slip-op-51569u/

Court: Appellate Term, First Department
Decided: November 3, 2014
Citation: 2014 NY Slip Op 51569(U) · 45 Misc 3d 130(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity · Claimant's prima facie case on motions (see the maps)

Cite as

NJ/NY Pain Mgt. v Allstate Ins. Co., 45 Misc 3d 130(A), 2014 NY Slip Op 51569(U) (App Term, 1st Dept 2014)

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 insurer failed to raise a medical necessity issue because it submitted neither the IME report supporting its denial nor other evidence. The providers established entitlement to summary judgment by showing that the necessary billing documents were mailed to and received by the insurer and that payment was overdue under Insurance Law § 5106 (a) and 11 NYCRR 65-3.8 (a) (1). Although the insurer demonstrated a timely medical necessity denial, it supplied no evidentiary proof supporting that defense. Without evidentiary facts establishing a bona fide dispute over the necessity of the services, the providers were entitled to judgment. The Appellate Term, First Department, affirmed the appealed grant of their cross motion for summary judgment.

Reported in New York Official Reports at NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U))

[*1]

NJ/NY Pain Mgt. v Allstate Ins. Co.

2014 NY Slip Op 51569(U) [45 Misc 3d 130(A)]

Decided on November 3, 2014

Appellate Term, First 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This opinion is uncorrected and will not be published in the printed Official Reports.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 November 3, 2014

SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT
PRESENT: Schoenfeld, J.P., Shulman, Ling-Cohan, JJ.
570565/14

NJ/NY Pain Management and Neal Goldsmith, D.C. a/a/o Christine Montanez, Plaintiffs-Respondents,
against
Allstate Insurance Company, Defendant-Appellant.

Defendant, as limited by its brief, appeals from so much of an order of the Civil Court of the City of New York, New York County (Ann E. O’Shea, J.), dated October 17, 2011, as granted plaintiffs’ cross motion for summary judgment on the complaint.

Per Curiam.

Order (Ann E. O’Shea, J.), dated October 17, 2011, affirmed, with $10 costs.

Plaintiffs-providers established prima facie their entitlement to judgment as a matter of law by demonstrating that the necessary billing documents were mailed to and received by defendant-insurer and that payment of the no-fault benefits was overdue (see Insurance Law § 5106[a]; 11 NYCRR 65-3.8 [a][1]; Countrywide Ins. Co. v 563 Grand Med., P.C., 50 AD3d 313 [2008]).

In opposition, defendant failed to raise a triable issue. Although defendant showed that it timely denied the claim on the ground of medical necessity, it failed to submit the IME report upon which its denial was based or any other evidentiary proof to support its defense of medical necessity (see Vista Surgical Supplies, Inc. v Travelers Ins. Co., 50 AD3d 778 [2008]; Mollins v Allstate Ins. Co., 20 Misc 3d 141[A], 2008 NY Slip Op 51616[U][App Term, 1st Dept 2008]; cf. NYU-Hospital for Joint Diseases v Esurance Ins. Co., 84 AD3d 1190 [2011]). In the absence of “evidentiary facts” showing that a “bona fide” issue exists (see Rotuba Extruders v Ceppos, 46 NY2d 223, 231 [1979]) as to the medical necessity of the services here at issue, plaintiff’s cross motion for summary judgment was properly granted.

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.

I concur I concur I concur
Decision Date: November 03, 2014

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.

Lack of medical necessity

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

This decision: Insurer's medical-necessity proof failed (conclusory, no factual basis or rationale, inadmissible, not credited)

Held the insurer raised no triable issue because, despite a timely denial, it failed to submit the IME report underlying the denial or any other evidence supporting its medical-necessity defense.

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 73 decisions on this question in the First Department courts and the Court of Appeals, 22 (this one included) are in the same category. One decision in other departments that cites or is cited by this one is on the full map.

Claimant's prima facie case on motions

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On summary judgment or another pretrial motion, what must a no-fault claimant show to establish its prima facie case?

This decision: Claimant's proof held to make out its prima facie case (rules on the question, but another ground decided the case)

Held the providers established prima facie entitlement by showing that the billing documents were mailed to and received by the insurer and that payment was overdue.

Proof sufficientMailing/receipt not shownOverdue not shownOther element missingThis decisionCites it or cited by itCited or followed

Of the 52 decisions on this question in the First Department courts and the Court of Appeals, 45 (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

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

Countrywide Ins. Co. v 563 Grand Med., P.C. (2008 NY Slip Op 03059) FollowedAn insurer need not state its medical rationale in the prescribed denial form, and a nurse's medical necessity review is not per se invalid.
Vista Surgical Supplies, Inc. v Travelers Ins. Co. (2008 NY Slip Op 03199)The insurer's peer review reports were inadmissible because their facsimile signatures lacked evidence of placement or authorization.
Mollins v Allstate Ins. Co. (2008 NY Slip Op 51616(U))The insurer failed to raise a medical-necessity issue because it submitted neither the IME report underlying its denials nor other supporting proof.
NYU-Hospital for Joint Diseases v Esurance Ins. Co. (2011 NY Slip Op 04436) Contrasted (cf., but see)The insurer raised factual issues about timely denial and whether the assignor's injury resulted from driving while intoxicated.

Similar decisions

Palisade Surgery Ctr. LLC v Allstate Prop. & Cas. Ins. Co. (2016 NY Slip Op 51824(U))The providers' medical-necessity cross motion failed because conflicting expert opinions raised a triable issue and collateral estoppel did not apply.
Neomy Med., P.C. v Auto One Ins. Co. (2010 NY Slip Op 51727(U))The insurer's timely denial and supported peer review raised a medical necessity issue defeating summary judgment on the appealed claim.
Westchester Neurodiagnostic, P.C. v Allstate Ins. Co. (2009 NY Slip Op 51385(U))The insurer failed to establish that its medical necessity defense was preserved by timely mailing of the denial.
A.B. Med. Servs., Pllc v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50550(U))An insurer opposing summary judgment on medical necessity must submit admissible proof even if unaffirmed reports supported a timely denial.
A.B. Med. Servs. v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50507(U))An insurer opposing summary judgment on medical necessity must submit admissible proof even if unaffirmed reports supported a timely denial.