November 19, 2010

Richmond Pain Mgt., P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 52015(U))

https://www.beynensonlaw.com/case-law/richmond-pain-mgt-p-c-v-clarendon-natl-ins-co-2010-ny-slip-op52015u/

Court: Appellate Term, Second Department
Decided: November 19, 2010
Citation: 2010 NY Slip Op 52015(U) · 29 Misc 3d 136(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity · Proof of mailing (see the maps)

Cite as

Richmond Pain Mgt., P.C. v Clarendon Natl. Ins. Co., 29 Misc 3d 136(A), 2010 NY Slip Op 52015(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2010)

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 sworn peer review established lack of medical necessity for testing, and the practitioner's affidavit did not rebut it. The Appellate Term, Second Department, reversed the order and granted the insurer's unopposed motion for summary judgment dismissing the assigned no-fault complaint. Affidavits established timely mailing of the denials through standard office practices, and the peer review supplied a factual basis and medical rationale for finding the testing unnecessary. Although the insurer's motion papers included an affidavit from the provider's health care practitioner, that affidavit did not meaningfully address the peer review's conclusions and therefore did not defeat the insurer's showing.

Reported in New York Official Reports at Richmond Pain Mgt., P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 52015(U))

[*1]

Richmond Pain Mgt., P.C. v Clarendon Natl. Ins. Co.

2010 NY Slip Op 52015(U) [29 Misc 3d 136(A)]

Decided on November 19, 2010

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This opinion is uncorrected and will not be published in the printed Official Reports.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 November 19, 2010

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS

PRESENT: : RIOS, J.P., PESCE and GOLIA, JJ
2009-1440 RI C.

Richmond Pain Management, P.C. as Assignee of JUAN RODRIGUEZ, Respondent,
against
Clarendon National Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Richmond County (Katherine A. Levine, J.), entered May 15, 2009. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed without costs and defendant’s motion for summary judgment dismissing the complaint is granted.

In this action by a provider to recover assigned first-party no-fault benefits, the Civil Court denied defendant’s unopposed motion for summary judgment dismissing the complaint on the ground of lack of medical necessity. This appeal by defendant ensued.

The affidavits submitted by defendant were sufficient to establish that defendant’s denial of claim forms, which denied the claims at issue of the ground of lack of medical necessity, had been timely mailed in accordance with standard office practices and procedures (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Defendant also submitted, among other things, a sworn peer review report, which set forth a factual basis and medical rationale for the doctor’s conclusion that there was a lack of medical necessity for the testing at issue. As the affidavit from plaintiff’s health care practitioner, included in defendant’s motion papers, failed to meaningfully refer to, let alone rebut, the conclusions set forth in the peer review report (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]), defendant’s motion for summary judgment should have been 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, oftlineP.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]). [*2]

Rios, J.P., Pesce and Golia, JJ., concur.
Decision Date: November 19, 2010

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 proof established lack of medical necessity and the provider failed to rebut it

Held the sworn peer review set forth a factual basis and medical rationale, and the provider practitioner's affidavit failed to meaningfully refer to or rebut it, so the insurer's unopposed motion should have been granted.

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 617 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.

Proof of mailing

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Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?

This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)

Held the insurer's affidavits sufficiently established timely mailing of the denial forms in accordance with standard office practices and procedures.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

Of the 1,400 decisions on this question in the Second Department courts and the Court of Appeals, 809 (this one included) are in the same category.

Cited in this decision

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

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.
Delta Diagnostic Radiology, P.C. v Chubb Group of Ins. (2007 NY Slip Op 27345) FollowedAn insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
Pan Chiropractic, P.C. v Mercury Ins. Co. (2009 NY Slip Op 51495(U)) FollowedThe provider's conclusory disagreement with the insurer's supported peer review failed to raise a medical-necessity issue of fact.
Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U)) FollowedThe insurer's examining physician supplied an unrebutted factual basis and medical rationale that the billed MRI was unnecessary.
Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 52455(U)) FollowedThe insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U)) FollowedThe insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.

Similar decisions

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.
Richmond Radiology, P.C. v Travelers Ins. Co. (2010 NY Slip Op 51964(U))The insurer's peer review supplied a factual basis and medical rationale for finding the assignor's testing medically unnecessary.
Midtown Med. Assoc., P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51071(U))The insurer's summary judgment motion based on lack of medical necessity was denied because its peer review showing was insufficient.
Biobalance Med., P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52378(U))The insurer established lack of medical necessity through a supported peer review report that the provider failed to rebut.
Crotona Hgts. Med., P.C. v Clarendon Natl. Ins. Co. (2013 NY Slip Op 50473(U))The provider's claims failed because verification remained outstanding and its medical evidence did not rebut the insurer's peer reviews.