April 7, 2014

SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 50630(U))

https://www.beynensonlaw.com/case-law/sk-prime-med-supply-inc-v-state-farm-mut-auto-ins-co-2014-ny-slipop-50630u/

Court: Appellate Term, Second Department
Decided: April 7, 2014
Citation: 2014 NY Slip Op 50630(U) · 43 Misc 3d 133(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Later treatment: Followed in 1 later decision (see Cited by)
Issues: Policy issues Fee schedule Timeliness and preclusion
Legal questions: Proof of mailing · Proving a fee schedule defense (see the maps)

Cite as

SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co., 43 Misc 3d 133(A), 2014 NY Slip Op 50630(U) (App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2014)

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 established that a $200 deductible and the applicable fee schedule justified the unpaid balance of the provider's claim. Its affidavits established timely mailing of the denial, contrary to the provider's challenge. The policy contained the deductible under 11 NYCRR 65-1.6, and the insurer denied that portion under Insurance Law § 5102 (b) (3). A claims representative's affidavit and the Medicaid DME schedule, adopted for workers' compensation under 12 NYCRR 442.2 (a), established that Code E0190 allowed $22.04, already paid, rather than the billed $24.00. The Appellate Term, Second Department, affirmed summary judgment for the insurer dismissing the complaint.

Reported in New York Official Reports at SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 50630(U))

[*1]

SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co.

2014 NY Slip Op 50630(U) [43 Misc 3d 133(A)]

Decided on April 7, 2014

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This opinion is uncorrected and will not be published in the printed Official Reports.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 April 7, 2014

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ
2011-3103 K C.

SK Prime Medical Supply, Inc. as Assignee of JENNIFER DENOFRIO, Appellant,
against
State Farm Mutual Automobile Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Pamela L. Fisher, J.), entered November 2, 2011. The order granted 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, plaintiff seeks to recover the sum of $201.96, representing the portion of a $472.30 claim that was not paid by defendant. Plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint.

Contrary to plaintiff’s argument on appeal, the affidavits submitted by defendant sufficiently established the timely mailing of the denial of claim form (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]). Furthermore, defendant demonstrated that the applicable insurance policy contained a $200 deductible (see Insurance Department Regulations [11 NYCRR] § 65-1.6) and that defendant had denied $200 of the claim at issue due to the deductible (see Insurance Law § 5102 [b] [3]). Consequently, the Civil Court properly granted defendant’s motion for summary judgment dismissing so much of the complaint as seeks $200 (see Innovative Chiropractic, P.C. v Progressive Ins. Co., 26 Misc 3d 135[A], 2010 NY Slip Op 50148[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Finally defendant’s submission of its claims representative’s affidavit, along with a copy of the “NYS Medicaid DME Services Fee Schedule,” which has been adopted as the Durable Medical Goods Fee Schedule for Workers’ Compensation (see 12 NYCRR 442.2 [a]), was sufficient to demonstrate that plaintiff was entitled to receive $22.04 for Code E0190, the sum defendant has already paid, and not $24.00, the sum that plaintiff had billed (see Great Wall Acupuncture, P.C. v GEICO Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]).

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur. [*2]
Decision Date: April 07, 2014

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.

Proof of mailing

Open the full map

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

Rejected the provider's argument and held the insurer's affidavits sufficiently established timely mailing of the denial of claim form.

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 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 806 (this one included) are in the same category.

Proving a fee schedule defense

Open the full map

Did the insurer prove that the amount billed exceeded the applicable workers’ compensation fee schedule?

This decision: Insurer proved the billed amount exceeded the applicable fee schedule (rules on the question, but another ground decided the case)

Held the claims representative's affidavit and the Medicaid DME fee schedule adopted for workers' compensation showed the insurer's payment for code E0190 was the full scheduled amount, below what was billed.

Excess shownNot established; openDefense rejectedSplit by chargeThis decisionCites it or cited by itCited or followed

Of the 284 decisions on this question in the Second Department courts and the Court of Appeals, 146 (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.
Innovative Chiropractic, P.C. v Progressive Ins. Co. (2010 NY Slip Op 50148(U)) FollowedThe insurer established a policy deductible but failed to support its duplicative-billing defense to a separate bill.
Great Wall Acupuncture, P.C. v Geico Ins. Co. (2009 NY Slip Op 29467) FollowedAn insurer may use the chiropractic acupuncture fee schedule to reimburse acupuncture services performed by a licensed acupuncturist.

Cited by

A label shows how the later decision treated this one.

High Quality Med. Supplies, Inc. v Mercury Ins. Group (2016 NY Slip Op 51444(U)) FollowedOmission of durable medical equipment from the applicable fee schedule does not itself bar reimbursement.

Similar decisions

Dilon Med. Supply Corp. v State Farm Mut. Ins. Co. (2006 NY Slip Op 51344(U))An insurer's fraud defense based on excessive billing or lack of medical necessity is subject to the 30-day denial preclusion rule.
Skymed Med., P.C. v Tri-State Consumer Ins. (2014 NY Slip Op 51833(U))The provider's action was premature because the insurer proved timely verification requests and nonreceipt of the requested material.
Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50778(U))The insurer established that the workers' compensation fee schedule supported reducing the billed reimbursement using CPT code 20552.
SK Prime Med. Supply v Country Wide Ins. Co. (2021 NY Slip Op 51204(U))The insurer's underwriting affidavit established that it had issued no policy covering the accident, and the provider raised no triable issue.
AKS Med., P.C. v Progressive Ins. Co. (2009 NY Slip Op 51494(U))The provider failed to prove claim submission because its billing-manager affidavit contradicted the post office ledger on which it relied.