Metro Psychological Servs., P.C. v Auto One Ins. Co. (2016 NY Slip Op 51376(U))

Reported in New York Official Reports at Metro Psychological Servs., P.C. v Auto One Ins. Co. (2016 NY Slip Op 51376(U))

Metro Psychological Servs., P.C. v Auto One Ins. Co. (2016 NY Slip Op 51376(U)) [*1]
Metro Psychological Servs., P.C. v Auto One Ins. Co.
2016 NY Slip Op 51376(U) [53 Misc 3d 131(A)]
Decided on September 21, 2016
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This opinion is uncorrected and will not be published in the printed Official Reports.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 September 21, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2014-1015 K C
Metro Psychological Services, P.C., as Assignee of SEYMON FEYGIN, Respondent,

against

Auto One Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Harriet L. Thompson, J.), entered February 11, 2014. The order, insofar as appealed from, denied the branch of defendant’s motion seeking summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is affirmed, with $25 costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant appeals from so much of an order of the Civil Court as denied the branch of defendant’s motion seeking summary judgment dismissing the complaint.

Upon a review of the record, we agree with the Civil Court’s determination that there is a triable issue of fact regarding the medical necessity of the services at issue (see Zuckerman v City of New York, 49 NY2d 557 [1980]).

We note that the Civil Court failed to determine the branch of defendant’s motion seeking to compel plaintiff to appear for a deposition, and, thus, that branch of defendant’s motion remains pending and undecided (see Creese v Long Is. Light. Co., 98 AD3d 708, 711 [2012]; W.W. Med., P.C. v Allstate Ins. Co., 41 Misc 3d 130[A], 2013 NY Slip Op 51743[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]).

Accordingly, the order, insofar as appealed from, is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 21, 2016
K.O. Med., P.C. v Allstate Ins. Co. (2016 NY Slip Op 51367(U))

Reported in New York Official Reports at K.O. Med., P.C. v Allstate Ins. Co. (2016 NY Slip Op 51367(U))

K.O. Med., P.C. v Allstate Ins. Co. (2016 NY Slip Op 51367(U)) [*1]
K.O. Med., P.C. v Allstate Ins. Co.
2016 NY Slip Op 51367(U) [53 Misc 3d 130(A)]
Decided on September 19, 2016
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 September 19, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2014-1013 K C
K.O. Medical, P.C., as Assignee of JAWARA MILLINGTON, Respondent,

against

Allstate Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin Kelly Sheares, J.), entered January 23, 2014. The order denied 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, defendant appeals from an order of the Civil Court which denied defendant’s motion for summary judgment dismissing the complaint.

Contrary to defendant’s contention, the Civil Court correctly found that defendant’s moving papers failed to establish as a matter of law that plaintiff’s assignor had failed to appear for duly scheduled independent medical examinations (see Alrof, Inc. v Safeco Natl. Ins. Co., 39 Misc 3d 130[A], 2013 NY Slip Op 50458[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]). In addition, defendant’s moving papers do not demonstrate timely mailing of defendant’s denial of claim forms (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]).

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
Arguelles, M.D., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51366(U))

Reported in New York Official Reports at Arguelles, M.D., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51366(U))

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

Arguelles, M.D., P.C., as Assignee of BETTY ST. FLEUR, Appellant,

against

American Transit Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Richard G. Latin, J.), entered March 26, 2014. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order is modified by providing that the branches of defendant’s cross motion seeking summary judgment dismissing the seventh through tenth causes of action are denied; as so modified, the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which denied plaintiff’s motion for summary judgment, and granted defendant’s cross motion for summary judgment dismissing the complaint on various grounds.

Contrary to plaintiff’s contention as to the first through sixth causes of action, plaintiff failed to submit admissible medical proof to rebut defendant’s prima facie showing that the services at issue were not medically necessary. Plaintiff’s remaining contention as to these causes of action lacks merit (see Ortho-Med Surgical Supply, Inc. v Mercury Cas. Co., 27 Misc 3d 128[A], 2010 NY Slip Op 50587[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2010]). Consequently, plaintiff has shown no basis to disturb so much of the order as granted the branches of defendant’s cross motion seeking summary judgment dismissing those causes of action.

However, as to the seventh cause of action, plaintiff correctly argues that defendant failed to submit proof by someone with personal knowledge attesting to the nonappearance of plaintiff’s assignor for independent medical examinations (IMEs) (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]; Bright Med. Supply Co. v IDS Prop. & Cas. Ins. Co., 40 Misc 3d 130[A], 2013 NY Slip Op 51123[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]; Alrof, Inc. v Safeco Natl. Ins. Co., 39 Misc 3d 130[A], 2013 NY Slip Op 50458[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]). Consequently, the branch of defendant’s cross motion seeking summary judgment dismissing that cause of action should have been denied. However, since plaintiff failed to demonstrate that its assignor had appeared for either of the IMEs, and thereby establish that defendant’s denial based on this ground lacked [*2]merit as a matter of law (see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]), the branch of plaintiff’s motion for summary judgment as to this cause of action was properly denied.

Contrary to plaintiff’s argument as to the eighth cause of action, while defendant failed to prove any defense as to the claim underlying this cause of action, the record does not demonstrate that defendant conceded owing this claim. Moreover, plaintiff failed to establish its prima facie entitlement to summary judgment on this cause of action, since the proof submitted by plaintiff failed to establish that this claim had not been timely denied (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]), or that defendant had issued a timely denial of claim form with respect thereto that was conclusory, vague or without merit as a matter of law (see Westchester Med. Ctr., 78 AD3d 1168; Ave T MPC Corp., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U]). Thus, we find that neither party was entitled to summary judgment as to this cause of action.

Finally, as to the ninth and tenth causes of action, we find that there is a triable issue of fact as to whether defendant received the claims underlying those causes of action (see Zuckerman v City of New York, 49 NY2d 557 [1980]).

Accordingly, the order is modified by providing that the branches of defendant’s cross motion seeking summary judgment dismissing the seventh through tenth causes of action are denied.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
Synergy First Med., P.L.L.C. v Allstate Ins. Co. (2016 NY Slip Op 51365(U))

Reported in New York Official Reports at Synergy First Med., P.L.L.C. v Allstate Ins. Co. (2016 NY Slip Op 51365(U))

Synergy First Med., P.L.L.C. v Allstate Ins. Co. (2016 NY Slip Op 51365(U)) [*1]
Synergy First Med., P.L.L.C. v Allstate Ins. Co.
2016 NY Slip Op 51365(U) [53 Misc 3d 130(A)]
Decided on September 19, 2016
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 September 19, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-2740 Q C
Synergy First Medical, P.L.L.C., as Assignee of KALEEL GODDETT, Respondent,

against

Allstate Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Carmen R. Velasquez, J.), entered November 13, 2013. The order denied 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, defendant appeals from an order of the Civil Court which denied defendant’s motion for summary judgment dismissing the complaint.

To establish its prima facie entitlement to summary judgment dismissing a complaint on the ground that the plaintiff’s assignor had failed to appear for an examination under oath (EUO), an insurer must demonstrate “as a matter of law that it twice duly demanded an [EUO] from the [provider’s] assignor, . . . that the assignor twice failed to appear, and that the [insurer] issued a timely denial of the claims arising from the [provider’s] treatment of the assignor” (Interboro Ins. Co. v Clennon, 113 AD3d 596, 597 [2014]). Here, defendant failed to establish as a matter of law that its denial of claim forms had been properly and timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). We reach no other issue.

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
Ortho Passive Motion, Inc. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51364(U))

Reported in New York Official Reports at Ortho Passive Motion, Inc. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51364(U))

Ortho Passive Motion, Inc. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51364(U)) [*1]
Ortho Passive Motion, Inc. v New York Cent. Mut. Fire Ins. Co.
2016 NY Slip Op 51364(U) [53 Misc 3d 130(A)]
Decided on September 19, 2016
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 September 19, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-2723 Q C
Ortho Passive Motion, Inc., as Assignee of PIERRE SOUFFRANT, Respondent,

against

New York Central Mutual Fire Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Queens County (Barry A. Schwartz, J.), entered October 23, 2013. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, with $30 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, defendant appeals from an order of the Civil Court which denied defendant’s motion for summary judgment dismissing the complaint on the ground that plaintiff’s assignor had failed to appear for duly scheduled independent medical examinations (IMEs).

In support of its motion, defendant established that, before receiving the claims at issue, it had mailed letters scheduling an initial and follow-up IME (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). Defendant also established that the assignor had failed to appear for the duly scheduled IMEs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]). Defendant further demonstrated that, upon receipt of the claims, it had timely mailed initial and follow-up requests for written verification (see 11 NYCRR 65-3.5 [b]; 65-3.8 [l]; St. Vincent’s Hosp. of Richmond, 50 AD3d 1123). Finally, defendant established that, upon receiving the requested verification, it had timely denied the claims at issue based upon the assignor’s failure to appear for IMEs (see 11 NYCRR 65-3.8 [l]; St. Vincent’s Hosp. of Richmond, 50 AD3d 1123; Alev Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co., 38 Misc 3d 143[A], 2013 NY Slip Op 50258[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2013]).

Accordingly, the order is reversed and defendant’s motion for summary judgment dismissing the complaint is granted.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
Prime Diagnostic Med., P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51363(U))

Reported in New York Official Reports at Prime Diagnostic Med., P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51363(U))

Prime Diagnostic Med., P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51363(U)) [*1]
Prime Diagnostic Med., P.C. v State Farm Mut. Auto. Ins. Co.
2016 NY Slip Op 51363(U) [53 Misc 3d 130(A)]
Decided on September 19, 2016
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 September 19, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-2709 Q C
Prime Diagnostic Medical, P.C., as Assignee of ERIKA PEREZ, Appellant,

against

State Farm Mutual Automobile Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (William A. Viscovich, J.), entered November 19, 2013. 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 appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint.

For the reasons stated in Metro Health Prods., Inc. v State Farm Mut. Auto. Ins. Co. (49 Misc 3d 130[A], 2015 NY Slip Op 51419[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2015]), the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
NYS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51362(U))

Reported in New York Official Reports at NYS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51362(U))

NYS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51362(U)) [*1]
NYS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co.
2016 NY Slip Op 51362(U) [53 Misc 3d 130(A)]
Decided on September 19, 2016
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 September 19, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-2706 Q C
NYS Acupuncture, P.C., as Assignee of BARBARA GREENE, Appellant,

against

State Farm Mutual Automobile Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (William A. Viscovich, J.), entered November 20, 2013. 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, defendant moved for summary judgment dismissing the complaint, arguing that it had fully paid plaintiff for the services at issue in accordance with the workers’ compensation fee schedule. The Civil Court granted defendant’s motion.

Plaintiff argues on appeal, as it did in the Civil Court, that defendant failed to establish that its fee schedule reductions were proper. We disagree and find that defendant demonstrated that it had fully paid plaintiff for the services at issue in accordance with the workers’ compensation fee schedule for acupuncture services performed by chiropractors (see Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23, 24 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009] [“we hold, as a matter of law, that an insurer may use the workers’ compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which a licensed acupuncturist is entitled to receive for such acupuncture services”]).

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
Compas Med., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51361(U))

Reported in New York Official Reports at Compas Med., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51361(U))

Compas Med., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51361(U)) [*1]
Compas Med., P.C. v American Tr. Ins. Co.
2016 NY Slip Op 51361(U) [53 Misc 3d 130(A)]
Decided on September 19, 2016
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 September 19, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-2673 Q C
Compas Medical, P.C., as Assignee of MAXENE ALFRENA, Appellant,

against

American Transit Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Jodi Orlow, J.), entered June 20, 2013. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross 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 appeals from an order of the Civil Court which denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Contrary to plaintiff’s only contentions, the proof submitted by defendant in support of its cross motion was sufficient to give rise to a presumption that the examination under oath (EUO) scheduling letters had been properly mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]), and to demonstrate that plaintiff’s assignor had failed to appear for the EUOs (see Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 35 AD3d 720 [2006]).

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
Compas Med., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51360(U))

Reported in New York Official Reports at Compas Med., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51360(U))

Compas Med., P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51360(U)) [*1]
Compas Med., P.C. v American Tr. Ins. Co.
2016 NY Slip Op 51360(U) [53 Misc 3d 129(A)]
Decided on September 19, 2016
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 September 19, 2016

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


PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2013-2591 Q C
Compas Medical, P.C., as Assignee of YVAN PLETEAU, Appellant,

against

American Transit Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Jodi Orlow, J.), entered June 18, 2013. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order is modified by providing that defendant’s cross motion for summary judgment dismissing the complaint is denied; as so modified, the order is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, plaintiff appeals from an order of the Civil Court which denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Defendant’s cross motion for summary judgment was predicated upon the defense that defendant had timely denied the claims at issue based upon plaintiff’s assignor’s failure to appear for duly scheduled examinations under oath (EUOs). In order to prove that the EUO letters had been timely mailed, defendant submitted two affidavits, each describing a portion of defendant’s practices and procedures. While the affidavit that describes defendant’s mail room practices and procedures alleges that defendant mailed EUO scheduling letters on October 1, 2010 and October 29, 2010, the other affidavit, which alleges, based upon a combination of personal knowledge and practices and procedures, that a scheduling letter was prepared for mailing on October 29, 2010, does not even mention the October 1, 2010 letter. Thus, defendant did not demonstrate its entitlement to summary judgment dismissing the complaint.

Plaintiff’s contention that its motion for summary judgment should have been granted lacks merit. Plaintiff’s moving papers failed to establish that the claims at issue had not been timely denied (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]), or that defendant had issued timely denials of claim that were conclusory, vague or without merit as a matter of law (see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]).

Accordingly, the order is modified by providing that defendant’s cross motion for summary judgment dismissing the complaint is denied.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016
Sama Physical Therapy, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51359(U))

Reported in New York Official Reports at Sama Physical Therapy, P.C. v American Tr. Ins. Co. (2016 NY Slip Op 51359(U))

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

Sama Physical Therapy, P.C., as Assignee of WILLIAM VOLQUEZ, Appellant,

against

American Transit Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Queens County (Larry Love, J.), entered October 4, 2013. The order, insofar as appealed from, denied plaintiff’s motion for summary judgment and granted the branches of defendant’s cross motion seeking summary judgment dismissing the first through third causes of action and so much of the fifth and sixth causes of action as sought to recover in excess of “the proper No-Fault rate” of $32.57 for each of the claims underlying those causes of action.

ORDERED that the order, insofar as appealed from, is modified by providing that the branches of defendant’s cross motion seeking summary judgment dismissing the first through third causes of action are denied; as so modified, the order, insofar as appealed from, is affirmed, without costs.

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. The Civil Court denied plaintiff’s motion and granted the branches of defendant’s cross motion seeking summary judgment dismissing plaintiff’s first through third causes of action. In denying the branches of defendant’s cross motion seeking summary judgment dismissing the fourth through sixth causes of action, the court stated that “the claims are hereby adjusted to reflect the proper No Fault rate of $315.10,” but found that there was a triable issue of fact with respect to the medical necessity of the services billed for. This adjustment reflects a reduction of the claims underlying the fifth and sixth causes of action from $66.10 to $32.57; the fourth cause of action was not affected.

Plaintiff argues that the Civil Court should not have granted the branches of defendant’s cross motion seeking summary judgment dismissing the first through third causes of action, and, in effect, that the court should not have reduced the amount recoverable upon the fifth and sixth causes of action, because defendant did not demonstrate that plaintiff had not billed in accordance with the fee schedule. Plaintiff also argues that its motion for summary judgment should have been granted.

For the claims underlying the first through third, fifth and sixth causes of action, defendant demonstrated that it had changed CPT code 97799 to CPT code 97140 and reduced the amount due in accordance with that change. (It is noted that plaintiff did not bill under CPT code 97799 on the claim form underlying the fourth cause of action.) For the claims underlying the [*2]first through third causes of action, defendant applied Ground Rule 11, which states, “When multiple physical medicine procedures and/or modalities are performed on the same day, reimbursement is limited to 8.0 units or the amount billed, whichever is less.”

Contrary to plaintiff’s argument, defendant’s submissions were sufficient to demonstrate, prima facie, that it had properly applied CPT code 97140 to the services that had been billed under CPT code 97799, and plaintiff failed to raise a triable issue of fact with respect to the coding. However, plaintiff correctly argues that defendant did not demonstrate that Ground Rule 11 was appropriately applied to the services underlying the first through third causes of action.

Thus, the branches of defendant’s cross motion seeking summary judgment dismissing the first through third causes of action should have been denied. The Civil Court properly reduced the amounts recoverable under the fifth and sixth causes of action, and plaintiff’s arguments on appeal with respect to defendant’s cross motion are not relevant to the fourth cause of action.

Contrary to plaintiff’s final contention, it failed to demonstrate its prima facie entitlement to summary judgment, as the affidavit plaintiff submitted in support of its motion failed to establish that the claims at issue had not been timely denied (see Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., 25 NY3d 498 [2015]), or that defendant had issued timely denials of claim that were conclusory, vague or without merit as a matter of law (see Westchester Med. Ctr. v Nationwide Mut. Ins. Co., 78 AD3d 1168 [2010]; Ave T MPC Corp. v Auto One Ins. Co., 32 Misc 3d 128[A], 2011 NY Slip Op 51292[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]).

Accordingly, the order, insofar as appealed from, is modified by providing that the branches of defendant’s cross motion seeking summary judgment dismissing the first through third causes of action are denied.

Pesce, P.J., Aliotta and Solomon, JJ., concur.


Decision Date: September 19, 2016