November 26, 2010

Triangle R, Inc. v GEICO Ins. Co. (2010 NY Slip Op 52060(U))

https://www.beynensonlaw.com/case-law/triangle-r-inc-v-geico-ins-co-2010-ny-slip-op-52060u/

Court: Appellate Term, Second Department
Decided: November 26, 2010
Citation: 2010 NY Slip Op 52060(U) · 29 Misc 3d 139(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Triangle R, Inc. v GEICO Ins. Co., 29 Misc 3d 139(A), 2010 NY Slip Op 52060(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 the equipment, and the provider did not rebut it. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted the insurer's cross motion for summary judgment dismissing the assigned no-fault complaint. Civil Court had designated medical necessity as the sole trial issue. The peer review supplied a factual basis and medical rationale for finding the equipment unnecessary. Together with Civil Court's CPLR 3212 (g) finding that the denial was timely and proper, which the provider did not dispute on appeal, the unrebutted report entitled the insurer to judgment.

Reported in New York Official Reports at Triangle R, Inc. v GEICO Ins. Co. (2010 NY Slip Op 52060(U))

[*1]

Triangle R, Inc. v GEICO Ins. Co.

2010 NY Slip Op 52060(U) [29 Misc 3d 139(A)]

Decided on November 26, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 26, 2010

SUPREME COURT OF THE STATE OF NEW YORK

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

PRESENT: : WESTON, J.P., RIOS and STEINHARDT, JJ
2009-1782 Q C.

Triangle R, Inc. as Assignee of ROY ENCARNACION, Respondent,
against
GEICO Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Diane A. Lebedeff, J.), entered March 18, 2009. The order, insofar as appealed from, in effect, denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is reversed, without costs, 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. Defendant opposed the motion and cross-moved for summary judgment dismissing the complaint. Insofar as is relevant to this appeal, the Civil Court found that defendant’s denial of claim form was “timely and proper,” and that the sole issue to be determined at trial was the medical necessity of the medical equipment at issue. Defendant appeals from so much of the order as, in effect, denied its cross motion for summary judgment dismissing the complaint.

In support of its cross motion, defendant submitted, among other things, a sworn peer review report, which set forth a factual basis and medical rationale for the peer reviewer’s determination that there was a lack of medical necessity for the medical equipment at issue. Defendant’s showing that the equipment was not medically necessary was unrebutted by plaintiff.

In light of the foregoing, and the Civil Court’s CPLR 3212 (g) finding that defendant’s denial was “timely and proper,” a finding which plaintiff has not disputed on appeal, defendant’s cross motion for summary judgment dismissing the complaint 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, 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 Dists 2007]).

Weston, J.P., Rios and Steinhardt, JJ., concur. [*2]
Decision Date: November 26, 2010

Legal questions

A question 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

Open the full map

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 insurer's sworn peer review report, with a factual basis and medical rationale, showed the medical equipment was not medically necessary, and the provider offered no rebuttal, entitling the insurer to summary judgment.

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.

Cited in this decision

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

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

Right Aid Diagnostic Medicine, P.C. v GEICO Ins. Co. (2013 NY Slip Op 52003(U))The insurer's unrebutted sworn peer review established lack of medical necessity for the billed services.
Advanced Med. Diagnostics of Queens, P.C. v GEICO Ins. Co. (2013 NY Slip Op 52004(U))The insurer's unrebutted sworn peer review established that the services lacked medical necessity.
Complete Radiology, P.C. v GEICO Ins. Co. (2010 NY Slip Op 52158(U))The insurer's affirmed peer review established lack of medical necessity, and the provider did not rebut that showing.
Diagnostic Radiographic Imaging v GEICO Gen. Ins. Co. (2014 NY Slip Op 50869(U))The insurer's unrebutted peer review reports established that the disputed services were not medically necessary.
New Life Med., P.C. v GEICO Ins. Co. (2012 NY Slip Op 51061(U))The provider's practitioner failed to meaningfully rebut two peer review reports establishing lack of medical necessity.