December 22, 2003

Park Health Ctr. v Peerless Ins. Co. (2003 NY Slip Op 51687(U))

Headnote

The main issues in the case were whether the plaintiff was entitled to recover for medical services provided to its assignor under the No-Fault Law, and whether the defendant's denial of the claims based on an affirmed peer review report submitted by its doctor was justified. The court considered the claim forms, denial of the claims, and the affirmed peer review report in making its decision. The court held that the plaintiff's prima facie showing was opposed by the affirmed medical report, which raised a triable issue of fact. It was determined that the defense of lack of medical necessity could be based on a sufficiently detailed peer review report, as implicitly provided by Insurance Regulation 11 NYCRR 65-3.8 (b) (4), and that the defendant's timely denial of the plaintiff's no-fault benefits claim was justified based on the file-based peer review. Therefore, the order denying the plaintiff's motion for summary judgment was affirmed.

Reported in New York Official Reports at Park Health Ctr. v Peerless Ins. Co. (2003 NY Slip Op 51687(U))

Park Health Ctr. v Peerless Ins. Co. (2003 NY Slip Op 51687(U)) [*1]

Park Health Ctr. v Peerless Ins. Co.

2003 NY Slip Op 51687(U)

Decided on December 22, 2003

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This opinion is uncorrected and will not be published in the Official Reports.

Decided on December 22, 2003

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM : 2nd and 11th JUDICIAL DISTRICTS

PRESENT:PESCE, P.J., PATTERSON and RIOS, JJ.
NO. 2001-231 Q C

PARK HEALTH CENTER a/a/o MATTHEW LEWIS, Appellant, –
against
PEERLESS INSURANCE COMPANY, Respondent.

Appeal by plaintiff from an order of the Civil Court, Queens County (P. O’Donoghue, J.), dated December 6, 2000, which denied its motion for summary judgment.

Order unanimously affirmed without costs.

The plaintiff instituted this action under the No-Fault Law to recover for medical services it provided to its assignor. In support of its motion for summary judgment, plaintiff submitted its claim forms and the defendant’s denial of the claims based upon an affirmed peer review report submitted by its doctor.

The order denying plaintiffs motion for summary judgment should be affirmed. The plaintiffs prima facie showing was opposed by an affirmed medical report raising a triable issue of fact. The defense of lack of medical necessity may be based either on a medical examination or a sufficiently detailed peer review report, as implicitly provided by Insurance Regulation 11 NYCRR 65-3.8 (b) (4). Here, defendant timely denied plaintiffs no-fault benefits claim following a file-based peer review which, in our view, set forth a factual basis and medical rationale sufficient to create a triable issue as to the treatment’s medical necessity (Rockawav Blvd. Medical P.C.. Park Health Ctr. v Allstate Ins. Co., NYLJ, Mar. 7, 2003 [App Term, 2d & 11th Jud Dists]).
Decision Date: December 22, 2003