Optimum Health Acupuncture, P.C. v Integon Natl. Ins. Co. (2022 NY Slip Op 50068(U))

Index No. CV-1526-20/SM
James F. Matthews, J.

Upon the following papers numbered 1 to 65 read on this motion by defendant for an order seeking Summary Judgment of dismissal ; by Notice of Motion/Order to Show Cause and supporting papers 1-4,61 ; Notice of Cross Motion and supporting papers ; Answering Affidavits and supporting papers 62,63 ; Replying Affidavits and supporting papers 64,65 ; Filed papers; Other exhibits: 5-60, (and after hearing counsel in support of and opposed to the motion), it is

ORDERED that the motion by defendant for summary judgment dismissing plaintiff’s complaint pursuant to CPLR 3212(b), is granted.

Plaintiff medical provider seeks reimbursement from defendant insurer for assigned first party no-fault benefits for medical dates of service (“DOS”) rendered to plaintiff’s assignor from 02/06/2019 through 03/19/2020, for injuries sustained from a car accident of 01/28/2019, in the outstanding sum of $7,399.77, under New York’s No-Fault Law.

Defendant now moves for summary judgment dismissing the complaint pursuant to CPLR 3212(b), supported by the affidavit of its Claims Supervisor, Danuta Fudali, which asserts, inter alia, that defendant timely mailed its NF-10 Denial Of Claim forms (“denials”) and Explanation of Benefits (“EOB’s”) to plaintiff, pursuant to the practices and procedures it established to ensure timely deliver of its mailings to the intended recipient, thereby creating a presumption of receipt. The denials were based upon defendant’s payment in full for plaintiff’s submissions of excessive billing not compiled in accordance with the Workers’ Compensation [*2]Fee Schedule (“Fee Schedule”), pursuant to the findings in the affidavit of Carolyn Mallory, C.P.C. (“Certified Professional Coder”)^[FN1] , and the lack of medical necessity for certain chiropractic and acupuncture billing, as supported by the Independent Medical Examination (“IME”) and report of Dr. John Iozzio, D.C., L.Ac., dated 03/26/2019, the IME report of Dr. John Iozzio dated 05/02/2019, and the peer review report of Dr. Daniel Sposta, D.C., L.Ac., dated 05/15/2019, which cut off any further chiropractic and acupuncture treatments as of 04/22/2019 and 05/23/2019, respectively.

In opposition to the motion for summary judgment, plaintiff asserts it attached to its papers as an exhibit, the affidavit of Dr. Vadim Dolsky, L.Ac., to rebut the claims of Dr. Iozzio and Dr. Sposta, by demonstrating plaintiff’s assignor was symptomatic and required the treatments provided by the treating providers; that Dr. Iozzio’s IME reports concede that the evaluations and treatments prior to the IME dates were medically necessary; that defendant’s IME reports failed to demonstrate the disputed services were inconsistent with generally accepted medical or professional practices; and Dr. Dolsky’s professional opinion differs from that stated by defendant’s experts, thereby raising a question of fact requiring a trial.

In addition, plaintiff asserts it attached to its papers as an exhibit, the affidavit of Priti Kumar, C.P.C., to rebut the facts and opinions on the proper use of the fee schedule, in opposition to the opinion expressed by Carolyn Mallory, C.P.C. on behalf of defendant. Plaintiff contends the difference of opinion of each party’s expert raises a question of fact, which requires a trial.

In reply to plaintiff’s opposition papers, defendant urges the Court to ignore the purported findings of both Dr. Vadim Dolsky, L.Ac., and that of Priti Kumar, C.P.C., as there are no affidavits or exhibits attached to plaintiff’s papers as an exhibit. Indeed, a search by the Court for the existence of any exhibits or affidavits from plaintiff proved useless, as there is none to be found.

A proponent of a motion for summary judgment must make a prima facie showing of entitlement to judgment as a matter of law with proof in admissible form sufficient to establish the lack of any material issues of fact (see Alvarez v Prospect Hospital, 68 NY2d 320, 324 [1986]; Winegrad v New York Univ. Med. Ctr., 64 NY2d 851, 853 [1985]; Zuckerman v City of New York, 49 NY2d 557,562 [1980]; see also Manhattan Medical v State Farm Mut. Ins. Co., 20 Misc 3d 1144[A][Civ. Ct. Richmond Cty. 2008]).

Once a showing of entitlement to summary judgment has been made, the burden shifts to the party opposing the motion for summary judgment, to produce evidentiary proof in admissible form sufficient to establish the existence of material issues of fact which require a trial of the action (see CPLR 3212 [b]; Alvarez v Prospect Hospital, supra; Zuckerman v City of New York, supra).

An attorney’s affirmation which demonstrates no personal knowledge of the facts, is insufficient to defeat a motion for summary judgment, but may serve as a vehicle for the submission of acceptable attachments, which do provide evidentiary proof in admissible form (see Zuckerman v City of New York, supra).

Here, the Court determines defendant has satisfied its burden of demonstrating the existence and following of its standard office practices and procedures for the timely and proper mailing of its NF-10 denial of claim forms and EOR’s to plaintiff (see Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2nd Dept, 2007]). Defendant’s mailing methods were sufficient to create a rebuttable presumption of proper mailing (see St. Vincent’s Hosp. of Richmond v GEICO, 50 AD3d 1123, 1124 [2nd Dept 2008]; New York Presbyt. Hosp. v Allstate Ins. Co.,29 AD3d 547 [2nd Dept 2006]; Gentlecare Ambulatory Anesthesia Servs. v GEICO Ins. Co., 57 Misc 3d 150[A][App Term, 2d, 11th & 13th Jud Dists 2017]). “…Proof of proper mailing gives rise to a presumption that the item was received by the addressee” (see Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679, 680 [2nd Dept 2001]), which presumptions of receipt, were not refuted or denied by plaintiff in the instant matter. Plaintiff’s arguments in opposition are unavailing.

The Court further determines that defendant has made a prima facie showing of entitlement to summary judgment as a matter of law with proof in admissible form sufficient to establish the lack of any material issues of fact, which has not been refuted by plaintiff (see Alvarez v Prospect Hospital,supra]; Winegrad v New York Univ. Med. Center, supra; Zuckerman v City of New York, supra).

The failure to submit a rebuttal affidavit from plaintiff’s C.P.C. expert on the contested fee schedule issues, leaves only the opposition analysis of plaintiff’s attorney, with no personal knowledge of the facts, unsupported by expert witness testimony as to the use and interpretation of the fee schedules in the context of defendant’s components and calculations of the alleged maximum permissible fee (see Murali v Upton, 175 Misc 2d 186, 187-188 [Civ Ct, NY Cty, 1997]).

In addition, the failure to submit a rebuttal affidavit from plaintiff’s expert physician showing the medical necessity of its billing in a non-conclusory manner and meaningful way, rebutting the issues raised in the insurer’s IME and peer review reports, fails to demonstrate the existence of a triable issue of fact as to whether there was a lack of medical necessity for the medical services at issue (see Throgs Neck Multicare, P.C. v Mercury Ins. Co., 52 Misc 3d 138[a}[App Term, 2nd Dept, 9th & 10th Jud Dists 2016]), and leaves the conclusions of defendant’s medical experts un-refuted (see Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A][App Term, 2nd, 11th & 13th Jud Dists 2009]).

“The law is well settled that a party, in opposition to a motion for summary judgment, must assemble and lay bare affirmative proof to demonstrate that the matters alleged are real and capable of being established upon trial” (see Nelson v Lundy, 298 AD2d 689, 690 [3rd Dept 2002]; see also Wasson v Bond, 80 AD3d 1114 [3rd Dept 2011]). The plaintiff’s papers fail to meet this standard and accordingly, judgment is granted in favor of defendant and the complaint is dismissed (see Jamil M. Abraham, M.D., P.C. v Country Wide Ins. Co.,3 Misc 3d 130[A][App Term, 2nd & 11th Jud Dists 2004]; Murali v Upton, supra).

Accordingly, the motion for summary judgment by defendant pursuant to CPLR 3212(b), is granted. The foregoing constitutes the decision and order of this Court.

Dated: January 5, 2022
J.D.C.

Footnotes

Footnote 1:Defendant’s expert Coder states under oath that in the event medical necessity is found at a trial, the amounts to be allowed under the fee schedule would be $447.32 for Bills 1 through 6, and $3,798.60 for Bills 7 through 46 (see page 46 of Carolyn Mallory’s affidavit).