December 10, 2010
Urban Radiology, P.C. v GEICO Gen. Ins. Co. (2010 NY Slip Op 52157(U))
https://www.beynensonlaw.com/case-law/urban-radiology-p-c-v-geico-gen-ins-co-2010-ny-slip-op-52157u/
- Decided
- December 10, 2010
- Citation
- 2010 NY Slip Op 52157(U) · 29 Misc 3d 142(A)
- Posture
- Summary judgment
- Outcome
- Insurer prevailed
- Issues
- Medical necessity
- Legal questions
- Lack of medical necessity · Proof of mailing (see the maps)
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.
Reported in New York Official Reports at Urban Radiology, P.C. v GEICO Gen. Ins. Co. (2010 NY Slip Op 52157(U))
| Urban Radiology, P.C. v GEICO Gen. Ins. Co. |
| 2010 NY Slip Op 52157(U) [29 Misc 3d 142(A)] |
| Decided on December 10, 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| This opinion is uncorrected and will not be published in the printed Official Reports. |
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., GOLIA and STEINHARDT, JJ
2009-2003 K C.
against
GEICO General Insurance Company, Appellant.
Appeal from an order of the Civil Court of the City of New York, Kings County (Lisa S. Ottley, J.), entered July 16, 2009. The order, insofar as appealed from, 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 and defendant cross-moved for summary judgment dismissing the
complaint. Although plaintiff did not submit written opposition
to the cross motion, the Civil Court denied both motions, holding that the sole issue to be
determined at trial was the medical necessity of the services at issue. The instant appeal by
defendant ensued.
The papers submitted in support of defendant’s cross motion for summary judgment included an affidavit of an employee of its claims division, which established that the denial of claim forms, which denied the claims at issue on the ground of lack of medical necessity, 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]; 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]). Also included were two affirmed peer review reports, both of which set forth a factual basis and medical rationale for the opinions of the peer reviewers that there was a lack of medical necessity for the medical services at issue. Since defendant established its prima facie entitlement to summary [*2]judgment, and plaintiff submitted no written opposition to the cross motion, plaintiff failed to rebut defendant’s prima facie showing that there was a lack of medical necessity for the services (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]). Accordingly, defendant’s cross motion for summary judgment dismissing the complaint should have been granted.
Pesce, P.J., Golia and Steinhardt, JJ., concur.
Decision Date: December 10, 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.
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 two affirmed peer reviews set forth a factual basis and medical rationale for lack of medical necessity, and the provider submitted no opposition, so the insurer's cross motion should have been granted.
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.
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 claims-division employee's affidavit established timely mailing of the denial forms in accordance with the insurer's standard office practices and procedures.
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
- St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072)The 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)An insurer may prove mailing by describing its standard procedure for properly addressing and mailing items.
- Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co. (2009 NY Slip Op 51502(U))The 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))The 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))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
Cited by
- MSSA Corp. v Redland Ins. Co. (2011 NY Slip Op 51606(U))The insurer's unrebutted peer review established a factual basis and medical rationale for denying the supplies as medically unnecessary.
Similar decisions
- 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.
- 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.
- Manhattan Med. Imaging, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51737(U))The insurer's timely denial and supported peer review raised a triable issue of medical necessity, defeating provider summary judgment.
- Richmond Radiology, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52210(U))The insurer's affirmed peer review raised a triable issue of medical necessity despite the provider's challenge to the information reviewed.