August 8, 2014

Quality Health Prods., Inc. v Geico Ins. Co. (2014 NY Slip Op 51268(U))

Headnote

In the case of Quality Health Products, Inc. v Geico Ins. Co., the main issue was whether the medical supplies at issue were medically necessary and therefore covered under the first-party no-fault benefits. Quality Health Products, Inc. as Assignee of the individuals involved, had moved for summary judgment to recover these benefits, while Geico Ins. Co. had cross-moved for summary judgment to dismiss the complaint, arguing that the claims had been denied due to a lack of medical necessity. The court considered the peer review reports submitted by Geico, which provided a factual basis and medical rationale for the determination that there was a lack of medical necessity for the supplies at issue. In opposition, Quality Health Products, Inc. submitted an affidavit from a doctor that did not sufficiently rebut the conclusions set forth in the peer review reports. As a result, the court held that the only remaining issue for trial was medical necessity, and reversed the order in favor of Geico, granting their motion for summary judgment dismissing the complaint.

Reported in New York Official Reports at Quality Health Prods., Inc. v Geico Ins. Co. (2014 NY Slip Op 51268(U))

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

Quality Health Products, Inc. as Assignee of FAUSTIN DJIADEU and SEBASTIEN MOUWA, Respondent,
against
Geico Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Carol Ruth Feinman, J.), entered December 12, 2011. The order, insofar as appealed from, upon denying plaintiff’s motion for summary judgment, made, in effect, CPLR 3212 (g) findings in plaintiff’s favor, and denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, the CPLR 3212 (g) findings in plaintiff’s favor are vacated, and defendant’s cross motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment, and defendant cross-moved for summary judgment dismissing the complaint on the ground that it had timely and properly denied

the claims at issue based on a lack of medical necessity. Insofar as is relevant to this appeal, the Civil Court, upon denying plaintiff’s motion, made, in effect, CPLR 3212 (g) findings in plaintiff’s favor, denied defendant’s cross motion, and held that the only remaining issue for trial was medical necessity.

In support of its cross motion, defendant submitted three affirmed peer review reports which set forth a factual basis and medical rationale for the reviewers’ determinations that there was a lack of medical necessity for the supplies at issue. In opposition to the cross motion, plaintiff submitted an affidavit from a doctor which failed to meaningfully refer to, let alone sufficiently rebut, the conclusions set forth in the peer review reports (see 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]). In view of the foregoing, and as plaintiff has not challenged the Civil Court’s finding, in effect, that defendant is otherwise entitled to judgment, the order, insofar as appealed from, is reversed and defendant’s cross motion for summary judgment dismissing the complaint is granted (see Delta 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 [*2]Dists 2007]).

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

Decision Date: August 08, 2014