Gentlecare Ambulatory Anesthesia Servs. v American Ind. Ins. Co. (2019 NY Slip Op 50633(U))

Reported in New York Official Reports at Gentlecare Ambulatory Anesthesia Servs. v American Ind. Ins. Co. (2019 NY Slip Op 50633(U))

Gentlecare Ambulatory Anesthesia Servs. v American Ind. Ins. Co. (2019 NY Slip Op 50633(U)) [*1]
Gentlecare Ambulatory Anesthesia Servs. v American Ind. Ins. Co.
2019 NY Slip Op 50633(U) [63 Misc 3d 144(A)]
Decided on April 26, 2019
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This opinion is uncorrected and will not be published in the printed Official Reports.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 26, 2019

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


PRESENT: : MICHAEL L. PESCE, P.J., MICHELLE WESTON, THOMAS P. ALIOTTA, JJ
2017-967 K C
Gentlecare Ambulatory Anesthesia Services; Lyonel F. Paul, M.D., as Assignee of Ligene, Joanel, Respondent,

against

American Independent Ins. Co., Appellant.

Freiberg, Peck & Kang, LLP (Yilo J. Kang of counsel), for appellant. The Rybak Firm, PLLC (Damin J. Toell and Karina Barska of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin Kelly Sheares, J.), entered April 26, 2017. The order, insofar as appealed from, denied defendant’s motion to dismiss the complaint pursuant to CPLR 3211 (a) (8).

ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and defendant’s motion to dismiss the complaint is granted.

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 defendant’s motion which sought to dismiss the complaint pursuant to CPLR 3211 (a) (8) on the ground that the Civil Court lacked personal jurisdiction over defendant.

For the reasons stated in Pavlova v American Ind. Ins. Co. (60 Misc 3d 128[A], 2018 NY Slip Op 50943[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2018]), the order, insofar as appealed from, is reversed, and defendant’s motion to dismiss the complaint is granted (see also Matter of Government Empls. Ins. Co. v Basedow, 28 AD3d 766 [2006]; Matter of Eagle Ins. Co. v Gutierrez-Guzman, 21 AD3d 489 [2005]).

PESCE, P.J., WESTON and ALIOTTA, JJ., concur.



ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 26, 2019
Performance Plus Med., P.C. v American Ind. Ins. Co. (2019 NY Slip Op 50632(U))

Reported in New York Official Reports at Performance Plus Med., P.C. v American Ind. Ins. Co. (2019 NY Slip Op 50632(U))

Performance Plus Med., P.C. v American Ind. Ins. Co. (2019 NY Slip Op 50632(U)) [*1]
Performance Plus Med., P.C. v American Ind. Ins. Co.
2019 NY Slip Op 50632(U) [63 Misc 3d 143(A)]
Decided on April 26, 2019
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 26, 2019

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


PRESENT: : MICHAEL L. PESCE, P.J., MICHELLE WESTON, THOMAS P. ALIOTTA, JJ
2017-242 K C
Performance Plus Medical, P.C., as Assignee of Philiip, Nigel, Respondent,

against

American Independent Ins. Co., Appellant.

Freiberg, Peck & Kang, LLP (Yilo J. Kang of counsel), for appellant. The Rybak Firm, PLLC (Damin J. Toell and Karina Barska of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin Kelly Sheares, J.), entered January 6, 2017. The order, insofar as appealed from, denied defendant’s motion to dismiss the complaint pursuant to CPLR 3211 (a) (8).

ORDERED that the order, insofar as appealed from, is reversed, with $30 costs, and defendant’s motion to dismiss the complaint is granted.

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 defendant’s motion which sought to dismiss the complaint pursuant to CPLR 3211 (a) (8) on the ground that the Civil Court lacked personal jurisdiction over defendant.

For the reasons stated in Pavlova v American Ind. Ins. Co. (60 Misc 3d 128[A], 2018 NY Slip Op 50943[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2018]), the order, insofar as appealed from, is reversed, and defendant’s motion to dismiss the complaint is granted (see also Matter of Government Empls. Ins. Co. v Basedow, 28 AD3d 766 [2006]; Matter of Eagle Ins. Co. v Gutierrez-Guzman, 21 AD3d 489 [2005]).

PESCE, P.J., WESTON and ALIOTTA, JJ., concur.


ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 26, 2019
Allstate Ins. Co. v Gandron (2019 NY Slip Op 50562(U))

Reported in New York Official Reports at Allstate Ins. Co. v Gandron (2019 NY Slip Op 50562(U))

Allstate Ins. Co. v Gandron (2019 NY Slip Op 50562(U)) [*1]
Allstate Ins. Co. v Gandron
2019 NY Slip Op 50562(U) [63 Misc 3d 138(A)]
Decided on April 17, 2019
Appellate Term, First 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 17, 2019

SUPREME COURT, APPELLATE TERM, FIRST DEPARTMENT
PRESENT: Shulman, P.J., Ling-Cohan, Edmead, JJ.
570364/18
Allstate Insurance Company, Petitioner-Respondent,

against

Deborah Gandron, Respondent-Appellant.

Respondent appeals from an order of the Civil Court of the City of New York, New York County (Leticia M. Ramirez, J.), entered March 23, 2018, which granted the petition of Allstate Insurance Company to vacate a master arbitrator’s award and reinstated the original arbitrator’s award in favor of petitioner.

Per Curiam.

Order (Leticia M. Ramirez, J.), entered March 23, 2018, reversed, without costs, petition denied and the award of the master arbitrator is reinstated.

Civil Court erred in vacating the master arbitrator’s award on the ground of misconduct (see CPLR 7511[b][1]). The master arbitrator’s measured response to the self-represented respondent-appellant’s apparently unsolicited communication, wherein the master arbitrator, inter alia, directed appellant to serve a copy of her communication upon petitioner Allstate, and indicated that respondent “would be well advised to retain an attorney to advise you of what your rights and chances are,” did not rise to the level of misconduct so as to warrant vacatur of the arbitration award (see Matter of Travelers Ins. Co. v Job, 239 AD2d 289, 289—90 [1997]; cf. Matter of Goldfinger v Lisker, 68 NY2d 225, 227-228 [1986] [“private communication between the arbitrator and one party-litigant, which related to the credibility of the party-litigant and the validity of the amount in dispute, and occurred without the knowledge or consent of the other party-litigant, constitutes misconduct sufficient to warrant vacating the arbitration award”]).

Nor did the master arbitrator exceed his authority, and his determination that there were factual issues concerning whether Allstate complied with the relevant no-fault regulations (see American Tr. Ins. Co. v Clark, 131 AD3d 840 [2015]; 11 NYCRR § 65-3.6[b]) and whether respondent’s nonappearance for a scheduled independent medical examination was excusable (cf. Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., 7 Misc 3d 18 [App Term, 2d Dept 2004] affd 35 AD3d 720 [2006]), was not irrational.

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.


I concur I concur I concur
Decision Date: April 17, 2019
Sure Way NY, Inc. v Travelers Ins. Co. (2019 NY Slip Op 50601(U))

Reported in New York Official Reports at Sure Way NY, Inc. v Travelers Ins. Co. (2019 NY Slip Op 50601(U))

Sure Way NY, Inc. v Travelers Ins. Co. (2019 NY Slip Op 50601(U)) [*1]
Sure Way NY, Inc. v Travelers Ins. Co.
2019 NY Slip Op 50601(U) [63 Misc 3d 142(A)]
Decided on April 15, 2019
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 15, 2019

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


PRESENT: : MICHELLE WESTON, J.P., THOMAS P. ALIOTTA, DAVID ELLIOT, JJ
2017-9 K C
Sure Way NY, Inc., as Assignee of Dixin, Marla, Appellant,

against

Travelers Insurance Company, Respondent.

The Rybak Firm, PLLC (Damin J. Toell and Karina Barska of counsel), for appellant. Law Offices of Aloy O. Ibuzor (Duane Frankson of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Harriet L. Thompson, J.), entered May 17, 2016. The order granted defendant’s motion for summary judgment dismissing the complaint and denied plaintiff’s cross motion for summary judgment.

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 on the ground that plaintiff’s assignor does not qualify as an eligible injured person, as the assignor was not a “family member” of the insured as defined in the Florida insurance policy at issue. Plaintiff cross-moved for summary judgment, asserting that, at a minimum, it had established its prima facie case. By order entered May 17, 2016, the Civil Court granted defendant’s motion and denied plaintiff’s cross motion.

Upon the record presented, we find that defendant sufficiently established that plaintiff’s assignor did not reside in the household of the Florida policyholder, but, rather, in Brooklyn, and thus was not a “family member” of the insured as defined by the insurance policy at issue. In opposition, plaintiff failed to raise a triable issue of fact (see Zuckerman v City of New York, 49 NY2d 557 [1980]). Consequently, defendant’s motion for summary judgment dismissing the [*2]complaint was properly granted.

Accordingly, the order is affirmed.

WESTON, J.P., ALIOTTA and ELLIOT, JJ., concur.



ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 15, 2019
Sure Way NY, Inc. v Travelers Ins. Co. (2019 NY Slip Op 50600(U))

Reported in New York Official Reports at Sure Way NY, Inc. v Travelers Ins. Co. (2019 NY Slip Op 50600(U))

Sure Way NY, Inc. v Travelers Ins. Co. (2019 NY Slip Op 50600(U)) [*1]
Sure Way NY, Inc. v Travelers Ins. Co.
2019 NY Slip Op 50600(U) [63 Misc 3d 141(A)]
Decided on April 15, 2019
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 15, 2019

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


PRESENT: : MICHAEL L. PESCE, P.J., MICHELLE WESTON, BERNICE D. SIEGAL, JJ
2016-2079 K C
Sure Way NY, Inc., as Assignee of Fagan, Esther, Respondent,

against

Travelers Insurance Company, Appellant.

The Rybak Firm, PLLC (Duane Frankson of counsel), for appellant. Law Offices of Aloy O. Ibuzor (Damin J. Toell and Karina Barska of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Katherine A. Levine, J.), entered April 20, 2016. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, without 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.

For the reasons stated in Sure Way, Inc., as Assignee of Dixin, Marla v Travelers Ins. Co. (__ Misc 3d ___, 2019 NY Slip Op ______ [appeal No. 2017-9 K C], decided herewith), the order is reversed and defendant’s motion for summary judgment dismissing the complaint is granted.

The decision and order of this court dated July 13, 2018 (60 Misc 3d 139[A], 2018 NY Slip Op 51130[U]) is hereby recalled and vacated (see motion decided simultaneously herewith).

PESCE, P.J., WESTON and SIEGAL, JJ., concur.


ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 15, 2019
CPM Med Supply, Inc. v State Farm Fire & Cas. Ins. Co. (2019 NY Slip Op 50576(U))

Reported in New York Official Reports at CPM Med Supply, Inc. v State Farm Fire & Cas. Ins. Co. (2019 NY Slip Op 50576(U))

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

CPM Med Supply, Inc., as Assignee of Carlos Espinoza-Calle, Appellant,

against

State Farm Fire and Casualty Insurance Company, Respondent.

Fuld & Karp, P.C. (David Karp of counsel), for appellant. Richard T. Lau & Associates (Linda Filosa and Arthur Kontaxis of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Richard J. Montelione, J.), entered August 31, 2016. The order granted defendant’s motion for summary judgment dismissing the complaint as premature.

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 as premature, as plaintiff had failed to provide verification which defendant had requested.

Contrary to plaintiff’s argument, it was required to respond to defendant’s verification requests. As plaintiff did not respond to defendant’s verification requests with respect to plaintiff’s claim for the sum of $1,989.85, plaintiff failed to demonstrate a basis to disturb so much of the order as dismissed the complaint insofar as it sought to recover upon the $1,989.85 claim.

While plaintiff did respond in writing to defendant’s verification requests pertaining to the claim for $1,785, plaintiff neither provided the invoices requested by defendant nor stated that it was not in possession or control of those invoices. Rather, plaintiff merely set forth its opinion that the items requested were “not needed,” based upon its own interpretation of how the rate of reimbursement should be calculated. This is not a “reasonable justification for the failure to comply” with a verification request (11 NYCRR 65-3.8 [b] [3]), or a sufficient response (see Village Med. Supply, Inc. v Travelers Prop. Cas. Ins. Co., 61 Misc 3d 126[A], 2018 NY Slip Op 51311[U] [App Term, 1st Dept 2018]; D & R Med. Supply v American Tr. Ins. Co., 32 Misc 3d 144[A], 2011 NY Slip Op 51727[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2011]; Urban Radiology, P.C. v Tri-State Consumer Ins. Co., 27 Misc 3d 140[A], 2010 NY Slip Op 50987[U] [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2010]; cf. Mount Sinai Hosp. v Auto One Ins. Co., 121 AD3d 869 [2014]).

We note that while the Civil Court dismissed the complaint as premature, the claimed services were rendered after April 1, 2013, and defendant properly denied the claims at issue on the ground that plaintiff had failed to provide the requested verification within 120 days of the initial verification request in this action (see 11 NYCRR 65-3.5 [o]; 65-3.8 [b] [3]). Therefore, defendant was entitled to dismissal of plaintiff’s complaint with prejudice, but as defendant has not cross-appealed, the order is affirmed.

PESCE, P.J., ALIOTTA and ELLIOT, JJ., concur.



ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 12, 2019
GL Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50575(U))

Reported in New York Official Reports at GL Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50575(U))

GL Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50575(U)) [*1]
GL Acupuncture, P.C. v Progressive Ins. Co.
2019 NY Slip Op 50575(U) [63 Misc 3d 140(A)]
Decided on April 12, 2019
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 12, 2019

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


PRESENT: : MICHAEL L. PESCE, P.J., THOMAS P. ALIOTTA, DAVID ELLIOT, JJ
2017-303 K C
GL Acupuncture, P.C., as Assignee of Gibson, Darrell, Appellant,

against

Progressive Insurance Company, Respondent.

The Rybak Firm, PLLC (Damin J. Toell and Karina Barska of counsel), for appellant. McCormack & Mattei, P.C. (Jamila Shukry and Stafford Harmitt of counsel), for respondent.

Appeal, on the ground of inadequacy, from a judgment of the Civil Court of the City of New York, Kings County (Richard J. Montelione, J.), entered August 4, 2016. The judgment, after a nonjury trial, awarded plaintiff the principal sum of only $54.74.

ORDERED that the judgment 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 $178.58 for acupuncture services rendered by a licensed acupuncturist. At a nonjury trial, the parties stipulated that plaintiff had established its prima facie case, that defendant had timely denied the claims at issue andthat defendant’s witness was a certified coder. The Civil Court took judicial notice of the workers’ compensation chiropractic fee schedule. In her testimony, defendant’s coder explained how she had calculated the payments for the acupuncture services billed under CPT codes 97810 and 97811 based on the chiropractic fee schedule, and she testified that defendant was offering payment in the amount of $54.74 for an office visit billed under CPT code 99203. Plaintiff did not call a witness to rebut the coder’s testimony. The Civil Court, finding the testimony by defendant’s witness to be credible, determined that defendant had properly paid the claims billed under CPT codes 97810 and [*2]97811, and awarded plaintiff the principal sum of $54.74 for the office visit billed under CPT code 99203. A judgment was entered on August 4, 2016 pursuant to the decision.

Upon a review of the record, we find that the Civil Court properly determined that defendant had established that it had fully paid plaintiff for the services billed under CPT codes 97810 and 97811 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 [App Term, 2d Dept, 2d, 11th & 13th Jud Dists 2009]) and that plaintiff had failed to rebut defendant’s showing.

Accordingly, the judgment is affirmed.

PESCE, P.J., ALIOTTA and ELLIOT, JJ., concur.



ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 12, 2019
Healing Art Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50574(U))

Reported in New York Official Reports at Healing Art Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50574(U))

Healing Art Acupuncture, P.C. v Progressive Ins. Co. (2019 NY Slip Op 50574(U)) [*1]
Healing Art Acupuncture, P.C. v Progressive Ins. Co.
2019 NY Slip Op 50574(U) [63 Misc 3d 140(A)]
Decided on April 12, 2019
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 12, 2019

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


PRESENT: : MICHAEL L. PESCE, P.J., THOMAS P. ALIOTTA, DAVID ELLIOT, JJ
2017-116 K C
Healing Art Acupuncture, P.C., as Assignee of Andino, Giovanni, Appellant,

against

Progressive Insurance Company, Respondent.

The Rybak Firm, PLLC (Damin J. Toell and Karina Barska of counsel), for appellant. McCormack & Mattei, P.C. (Jamila Shukry and Erin O’Neill of counsel), for respondent.

Appeal from a judgment of the Civil Court of the City of New York, Kings County (Richard J. Montelione, J.), entered August 4, 2016. The judgment, after a nonjury trial, dismissed the complaint.

ORDERED that the judgment is affirmed, with $25 costs.

At the commencement of a nonjury trial in this action by a provider to recover assigned first-party no-fault benefits, the parties stipulated that plaintiff had established its prima facie case and that defendant had timely denied the claim in question. The issue for trial was whether defendant had properly paid the bill in accordance with the workers’ compensation fee schedule. The Civil Court consolidated for trial the case at bar with GL Acupuncture, P.C., as Assignee of Gibson, Darrell v Progressive Ins. Co. ( Misc 3d , 2019 NY Slip Op [appeal No. 2017-303 K C], decided herewith). At the trial, the court took judicial notice of the workers’ compensation chiropractic fee schedule and the parties stipulated that defendant’s witness was a certified medical coder. The witness testified that she had applied the workers’ compensation chiropractic fee schedule to determine payment for the services, which had been provided by a licensed acupuncturist. In the GL Acupuncture trial, the court, finding that the testimony of defendant’s witness was credible and, noting that plaintiff had failed to rebut the testimony, [*2]determined, insofar as is relevant, that defendant had properly paid the claims for services billed under CPT codes 97810 and 97811. In the case at bar, plaintiff’s attorney told the court that he agreed with defense counsel’s statement that defendant’s witness would similarly testify that she had applied the chiropractic rate to the services, which had been provided by a licensed acupuncturist. The court found, as it did in GL Acupuncture, that defendant had correctly applied the fee schedule codes. Consequently, a judgment was entered on August 4, 2016 dismissing the complaint.

We find that defendant established that it had fully paid plaintiff for the services billed 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”]) and that plaintiff failed to rebut defendant’s showing.

Accordingly, the judgment is affirmed.

PESCE, P.J., ALIOTTA and ELLIOT, JJ., concur.



ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 12, 2019
Success Rehab P.T., P.C. v NY Cent. Mut. Fire Ins. Co. (2019 NY Slip Op 50572(U))

Reported in New York Official Reports at Success Rehab P.T., P.C. v NY Cent. Mut. Fire Ins. Co. (2019 NY Slip Op 50572(U))

Success Rehab P.T., P.C. v NY Cent. Mut. Fire Ins. Co. (2019 NY Slip Op 50572(U)) [*1]
Success Rehab P.T., P.C. v NY Cent. Mut. Fire Ins. Co.
2019 NY Slip Op 50572(U) [63 Misc 3d 140(A)]
Decided on April 12, 2019
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 12, 2019

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


PRESENT: : MICHAEL L. PESCE, P.J., MICHELLE WESTON, DAVID ELLIOT, JJ
2016-2884 K C
Success Rehab P.T., P.C., as Assignee of Carlos Ponce, Appellant,

against

NY Central Mutual Fire Ins. Co., Respondent.

Gary Tsirelman, P.C. (Irena Golodkeyer of counsel), for appellant. Gullo & Associates, LLP (Cristina Carollo of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin Kelly Sheares, J.), entered August 10, 2016. The order, insofar as appealed from, granted the branches of defendant’s motion seeking summary judgment dismissing so much of the complaint as sought to recover upon seven claims for services provided from March 1, 2010 through September 22, 2010.

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 moved for summary judgment dismissing the complaint. Plaintiff appeals from so much of an order of the Civil Court entered August 10, 2016 as granted the branches of defendant’s motion seeking summary judgment dismissing seven claims for services provided from March 1, 2010 through September 22, 2010, which claims had been denied on the ground of lack of medical necessity.

Contrary to plaintiff’s assertion, the proof submitted by defendant in support of its motion was sufficient to give rise to a presumption that the denial of claim forms at issue had been timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d [*2]1123 [2008]). In support of its motion, defendant proffered an affirmed report by the doctor who had performed an independent medical examination, which report set forth a factual basis and medical rationale for the doctor’s determination that the assignor’s injuries had resolved and that there was no medical necessity for the rendered services. Defendant’s prima facie showing was not rebutted by plaintiff. Plaintiff’s remaining arguments were improperly raised for the first time on appeal (see Joe v Upper Room Ministries, Inc., 88 AD3d 963 [2011]) and, in any event, lack merit.

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

PESCE, P.J., WESTON and ELLIOT, JJ., concur.


ENTER:
Paul Kenny
Chief Clerk
Decision Date: April 12, 2019
North Val. Med., P.C. v Allstate Ins. Co. (2019 NY Slip Op 50904(U))

Reported in New York Official Reports at North Val. Med., P.C. v Allstate Ins. Co. (2019 NY Slip Op 50904(U))

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

North Valley Medical, P.C., as Assignee of Genevia Fisher and Benny Francis, Respondent,

against

Allstate Insurance Company, Appellant.

Peter C. Merani, P.C. (Eric M. Wahrburg of counsel), for appellant. Petre and Zabokritsky, P.C. (Mark Petre of counsel), for respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (John J. Kelley, J.), entered January 26, 2017. The order denied defendant’s motion to dismiss the complaint or, in the alternative, to compel plaintiff to produce its owner for an examination before trial, and granted plaintiff’s cross motion for summary judgment.

ORDERED that the order is modified by providing that the branch of defendant’s motion seeking to compel plaintiff to produce its owner for an examination before trial is granted and plaintiff’s cross motion for summary judgment 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, defendant moved to dismiss the complaint, pursuant to CPLR 3211, arguing, among other things, that plaintiff had been reimbursed pursuant to the fee schedule of the practitioner provider option (PPO) agreement entered into between plaintiff and MultiPlan, Inc. (MultiPlan) and that plaintiff had failed to name Multiplan as a necessary party. In the alternative, defendant sought to compel plaintiff to produce its owner for an examination before trial (EBT). Plaintiff cross-moved for summary judgment. By order entered January 26, 2017, the Civil Court denied defendant’s motion and granted plaintiff’s cross motion for summary judgment.

A review of the record indicates that the Civil Court properly denied the branch of defendant’s motion seeking, pursuant to CPLR 3211, to dismiss the complaint. The affidavits and documents annexed to defendant’s moving papers failed to establish that the corporate plaintiff was a party to the PPO contract, dated October 1998, which states that it is between Emerth L. Coburn, M.D., as an “individual practitioner,” and MultiPlan.

With respect to the branch of defendant’s motion seeking, in the alternative, to compel plaintiff to produce its owner for an EBT, it is noted that CPLR 3101 (a) provides for the “full disclosure of all matter material and necessary in the prosecution or defense of an action.” What is “material and necessary” is left to the sound discretion of the court (see Matter of U.S. Pioneer Elecs. Corp. [Nikko Elec. Corp. of Am.], 47 NY2d 914, 916 [1979]; Gillen v Utica First Ins. Co., 41 AD3d 647 [2007]). Here, according to defendant, Dr. Coburn explicitly requested Multiplan to include within the scope of his individual PPO contract with Multiplan all bills submitted to [*2]Multiplan bearing plaintiff’s name and taxpayer identification number. Consequently, the Civil Court improvidently exercised its discretion in denying defendant’s alternate relief of compelling an EBT of Dr. Coburn, since defendant is seeking material and necessary evidence to support its defense, as defendant paid plaintiff’s claims in accordance with the provisions of the PPO contract.

Furthermore, plaintiff failed to establish its prima facie entitlement to summary judgment, as the affidavit and annexed documentation submitted in support of its cross motion do not establish that the claims in question 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 denial of claim forms 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]). In view of the foregoing, plaintiff’s cross motion should have been denied.

Accordingly, the order is modified by providing that the branch of defendant’s motion seeking to compel plaintiff to produce its owner for an examination before trial is granted and plaintiff’s cross motion for summary judgment is denied.

PESCE, P.J., ALIOTTA and ELLIOT, JJ., concur.


ENTER:
Paul Kenny
Chief Clerk
Decision Date: March 29, 2019