November 30, 2015

Throgs Neck Multicare, P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51756(U))

Headnote

The main issue in the case was whether the defendant's denial of the plaintiff's claims for medical services was justified. The defendant argued that the claims were denied based on lack of medical necessity and also on the grounds that some of the services were in excess of the workers' compensation fee schedule. The court considered the plaintiff's challenge to the denial of the claims and found that they had failed to rebut the conclusions set forth in the independent medical examination (IME) report. As a result, the court held that the plaintiff had not raised a triable issue of fact as to the medical necessity of the services and affirmed the order granting the defendant's motion for summary judgment. Ultimately, the decision of the court favored the defendant, as it was found that the denial of the claims based on lack of medical necessity was justified.

Reported in New York Official Reports at Throgs Neck Multicare, P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51756(U))

Throgs Neck Multicare, P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51756(U)) [*1]

Throgs Neck Multicare, P.C. v State Farm Mut. Auto. Ins. Co.

2015 NY Slip Op 51756(U) [49 Misc 3d 151(A)]

Decided on November 30, 2015

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This opinion is uncorrected and will not be published in the printed Official Reports.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 30, 2015

SUPREME COURT, APPELLATE TERM, SECOND DEPARTMENT, 9th and 10th JUDICIAL DISTRICTS

PRESENT: : MARANO, P.J., GARGUILO and CONNOLLY, JJ.
2014-1569 S C

Throgs Neck Multicare, P.C. as Assignee of Esther Arias, Appellant,
against
State Farm Mutual Automobile Insurance Company, Respondent.

Appeal from an order of the District Court of Suffolk County, Third District (C. Stephen Hackeling, J.), dated June 26, 2014. The order, insofar as appealed from as limited by the brief, granted the branch of defendant’s amended motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims which had been denied solely on the ground of lack of medical necessity.

ORDERED that the order, insofar as appealed from, is affirmed, without costs.

In this action by a provider to recover assigned first-party no-fault benefits, defendant moved for summary judgment dismissing the complaint, asserting that it had timely and properly denied all of the claims at issue for lack of medical necessity, based on an affirmed report of an independent medical examination (IME). Defendant also asserted that some of the services at issue had been timely and properly denied on the additional ground that the claims were in excess of the workers’ compensation fee schedule. The District Court found that defendant had established both grounds, and granted defendant’s motion. On appeal, plaintiff does not address defendant’s fee schedule defense and, thus, in effect, plaintiff fails to challenge the dismissal of the claims which had been denied on this ground.

Contrary to plaintiff’s sole contention on appeal, the opposing affirmation of plaintiff’s doctor failed to meaningfully refer to, let alone rebut, the conclusions set forth in the IME report. Therefore, plaintiff failed to raise a triable issue of fact as to medical necessity (see e.g. Bronx Mega Care Med, PLLC v Federal Ins. Co., 48 Misc 3d 132[A], 2015 NY Slip Op 51060[U] [App Term, 9th & 10th Jud Dists 2015]; Amato v State Farm Ins. Co., 40 Misc 3d 129[A], 2013 NY Slip Op 51113[U] [App Term, 9th & 10th Jud Dists 2013]; Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).

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

Marano, P.J., Garguilo and Connolly, JJ., concur.

Decision Date: November 30, 2015