August 5, 2015

North Bronx Med. Health Care v Praetorian Ins. Co. (2015 NY Slip Op 51231(U))

https://www.beynensonlaw.com/case-law/north-bronx-med-health-care-v-praetorian-ins-co-2015-ny-slip-op51231u/

Court: Appellate Term, Second Department
Decided: August 5, 2015
Citation: 2015 NY Slip Op 51231(U) · 48 Misc 3d 140(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

North Bronx Med. Health Care v Praetorian Ins. Co., 48 Misc 3d 140(A), 2015 NY Slip Op 51231(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015)

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's motion for summary judgment dismissing the provider's claims on medical necessity grounds was denied. The Appellate Term, Second Department, affirmed the order in this action for assigned no-fault benefits. It found triable issues of fact regarding the insurer's lack of medical necessity defense upon reviewing the record and relied on Zuckerman v City of New York.

Reported in New York Official Reports at North Bronx Med. Health Care v Praetorian Ins. Co. (2015 NY Slip Op 51231(U))

[*1]

North Bronx Med. Health Care v Praetorian Ins. Co.

2015 NY Slip Op 51231(U) [48 Misc 3d 140(A)]

Decided on August 5, 2015

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This opinion is uncorrected and will not be published in the printed Official Reports.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 August 5, 2015

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-994 Q C

North Bronx Medical Health Care as Assignee of JENNIFER PAREDES, Respondent, August 5, 2015
against
Praetorian Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Barry A. Schwartz, J.), entered March 28, 2013. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from an order of the Civil Court which denied defendant’s motion for summary judgment dismissing the complaint.

A review of the record reveals that there are triable issues of fact regarding defendant’s defense of lack of medical necessity. Consequently, defendant’s motion was properly denied (see Zuckerman v City of New York, 49 NY2d 557 [1980]).

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.

Decision Date: August 05, 2015

Legal questions

A question 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

Open the full map

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

This decision: Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)

Affirmed denial of the insurer's summary judgment motion because the record presented triable issues of fact on its lack of medical necessity defense.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decision

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 94 (this one included) are in the same category.

Similar decisions

Lynbrook Med. of NY, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51226(U))The insurer's peer review established lack of medical necessity, and the provider submitted no medical evidence to rebut it.
Northshore Chiropractic Diagnostics, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51646(U))The provider's doctor's affidavit raised a factual issue on medical necessity despite the insurer's supported peer review reports.
North Bronx Med. Health Care v NY Cent. Mut. Ins. Co. (2012 NY Slip Op 51658(U))The provider's medical affirmation failed to rebut the insurer's IME and peer review conclusions that the disputed services were unnecessary.
New Quality Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51697(U))The insurer proved IME and EUO nonappearance on six claims, while medical necessity remained disputed on two others.
Bronx Park Med., P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 51832(U))The insurer's unrebutted peer review established a factual basis and medical rationale for denying the services as medically unnecessary.