April 7, 2014

SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 50630(U))

Headnote

The relevant facts the court considered in this case were that SK Prime Medical Supply, Inc. sought to recover $201.96 in first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. The issue before the court was whether State Farm's denial of $200 of the claim at issue due to a deductible was appropriate, and whether the remaining amount sought by SK Prime was accurate based on the Durable Medical Goods Fee Schedule for Workers' Compensation. The holding of the court was that State Farm demonstrated the timely mailing of the denial of claim form and that the denial of $200 of the claim due to the deductible was proper. Additionally, State Farm's submission of its claims representative's affidavit and a copy of the fee schedule was sufficient to demonstrate that SK Prime was only entitled to receive $22.04 for a specific medical code, not the $24.00 billed by SK Prime. Therefore, the order granting State Farm's motion for summary judgment dismissing the complaint was affirmed.

Reported in New York Official Reports at SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 50630(U))

SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 50630(U)) [*1]

SK Prime Med. Supply, Inc. v State Farm Mut. Auto. Ins. Co.

2014 NY Slip Op 50630(U) [43 Misc 3d 133(A)]

Decided on April 7, 2014

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This opinion is uncorrected and will not be published in the printed Official Reports.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 7, 2014

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ
2011-3103 K C.

SK Prime Medical Supply, Inc. as Assignee of JENNIFER DENOFRIO, Appellant,
against
State Farm Mutual Automobile Ins. Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Pamela L. Fisher, J.), entered November 2, 2011. 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 seeks to recover the sum of $201.96, representing the portion of a $472.30 claim that was not paid by defendant. Plaintiff appeals from an order of the Civil Court which granted defendant’s motion for summary judgment dismissing the complaint.

Contrary to plaintiff’s argument on appeal, the affidavits submitted by defendant sufficiently established the timely mailing of the denial of claim form (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008] Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). Furthermore, defendant demonstrated that the applicable insurance policy contained a $200 deductible (see Insurance Department Regulations [11 NYCRR] § 65-1.6) and that defendant had denied $200 of the claim at issue due to the deductible (see Insurance Law § 5102 [b] [3]). Consequently, the Civil Court properly granted defendant’s motion for summary judgment dismissing so much of the complaint as seeks $200 (see Innovative Chiropractic, P.C. v Progressive Ins. Co., 26 Misc 3d 135[A], 2010 NY Slip Op 50148[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Finally defendant’s submission of its claims representative’s affidavit, along with a copy of the “NYS Medicaid DME Services Fee Schedule,” which has been adopted as the Durable Medical Goods Fee Schedule for Workers’ Compensation (see 12 NYCRR 442.2 [a]), was sufficient to demonstrate that plaintiff was entitled to receive $22.04 for Code E0190, the sum defendant has already paid, and not $24.00, the sum that plaintiff had billed (see Great Wall Acupuncture, P.C. v GEICO Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]).

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur. [*2]
Decision Date: April 07, 2014