May 26, 2011

Rogy Med., P.C. v Geico Ins. Co. (2011 NY Slip Op 50990(U))

Headnote

The relevant facts of this legal case are that a provider, Rogy Medical, P.C., sought to recover first-party no-fault benefits from GEICO Insurance Company. Rogy Medical moved for summary judgment in the Civil Court of the City of New York, which was granted on November 19, 2009. GEICO Insurance Company opposed the motion, arguing that the services provided lacked medical necessity and that the provider billed in excess of the workers' compensation fee schedule. The main issue decided by the Appellate Term was whether there was a triable issue of fact with respect to the lack of medical necessity for the services and the amount billed in excess of the fee schedule. The holding of the case was that GEICO Insurance Company demonstrated the existence of a triable issue of fact with respect to both causes of action, and therefore the judgment in favor of Rogy Medical, P.C. was reversed, the order was vacated, and the motion for summary judgment was denied.

Reported in New York Official Reports at Rogy Med., P.C. v Geico Ins. Co. (2011 NY Slip Op 50990(U))

Rogy Med., P.C. v Geico Ins. Co. (2011 NY Slip Op 50990(U)) [*1]
Rogy Med., P.C. v Geico Ins. Co.
2011 NY Slip Op 50990(U) [31 Misc 3d 149(A)]
Decided on May 26, 2011
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This opinion is uncorrected and will not be published in the printed Official Reports.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 May 26, 2011

SUPREME COURT OF THE STATE OF NEW YORK

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


PRESENT: : PESCE, P.J., GOLIA and STEINHARDT, JJ
2010-40 Q C.
Rogy Medical, P.C. as Assignee of RICARDO CADICHON, Respondent,

against

GEICO Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Diane A. Lebedeff, J.), entered November 19, 2009, deemed from a judgment of the same court entered December 23, 2009 (see CPLR 5501 [c]). The judgment, entered pursuant to the November 19, 2009 order granting plaintiff’s motion for summary judgment, awarded plaintiff the principal sum of $2,971.57.

ORDERED that the judgment is reversed, without costs, the order entered November 19, 2009 is vacated and plaintiff’s motion for summary judgment is denied.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff moved for summary judgment. Defendant opposed the motion on the grounds that the services rendered lacked medical necessity and that the provider billed in excess of the workers’ compensation fee schedule. By order entered November 19, 2009, the Civil Court granted plaintiff’s motion for summary judgment, and this appeal by defendant ensued. A judgment was subsequently entered, from which the appeal is deemed to have been taken (see CPLR 5501 [c]).

Inasmuch as defendant raises no issue on appeal with respect to plaintiff’s prima facie case, we do not pass upon the propriety of the Civil Court’s determination with respect thereto.

Defendant established that the denial of claim forms at issue were timely mailed in accordance with defendant’s standard office practices and procedures (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). With respect to the claim at issue in plaintiff’s first cause of action, which was denied on the ground of lack of medical necessity, defendant submitted an affirmed peer review report which set forth a [*2]factual basis and medical rationale for the doctor’s conclusion that there was a lack of medical necessity for the services at issue. As a result, defendant demonstrated the existence of a triable issue of fact with respect to plaintiff’s first cause of action (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]). Similarly, with respect to the claim at issue in the second cause of action, an issue of fact was presented as to whether plaintiff is seeking to recover in excess of the amount permitted by the worker’s compensation fee schedule. Accordingly, the judgment is reversed, the order entered November 19, 2009 is vacated and plaintiff’s motion for summary judgment is denied.

Pesce, P.J., Golia and Steinhardt, JJ., concur.
Decision Date: May 26, 2011