February 28, 2014

American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U))

Headnote

The main issue in this case was whether the defendant, Praetorian Insurance Company, was entitled to summary judgment dismissing the complaint brought by the plaintiff, American Chiropractic Care, P.C., seeking to recover assigned first-party no-fault benefits. The defendant had timely mailed denial of claim forms based on lack of medical necessity and provided a sworn peer review report by their chiropractor to support their determination. The court found that the defendant had established its prima facie entitlement to summary judgment. However, the plaintiff submitted a sworn letter of medical necessity by its treating chiropractor, which created a question of fact as to medical necessity. As a result, the court affirmed the order denying the defendant's motion for summary judgment, without costs.

Reported in New York Official Reports at American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U))

American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U)) [*1]

American Chiropractic Care, P.C. v Praetorian Ins. Co.

2014 NY Slip Op 50346(U) [42 Misc 3d 145(A)]

Decided on February 28, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 February 28, 2014

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

PRESENT: : NICOLAI, P.J., IANNACCI and MARANO, JJ
2012-1613 N C.

American Chiropractic Care, P.C. as Assignee of MIGDALIA MORALES, Respondent,
against
Praetorian Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, First District (Andrea Phoenix, J.), dated June 4, 2012. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, without costs.

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

Defendant established that it had timely mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008] Richard Morgan Do, P.C. v State Farm Mut. Auto. Ins. Co., 22 Misc 3d 134[A], 2009 NY Slip Op 50242[U] [App Term, 9th & 10th Jud Dists 2009]) its denial of claim forms, which denied plaintiff’s claims on the ground of lack of medical necessity. The sworn peer review report of defendant’s chiropractor set forth a factual basis and medical rationale for the chiropractor’s determination that there was a lack of medical necessity for the services provided to plaintiff’s assignor (see Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co., 29 Misc 3d 139[A], 2010 NY Slip Op 52062[U] [App Term, 9th & 10th Jud Dists 2010]). Consequently, defendant established its prima facie entitlement to summary judgment (see Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co., 27 Misc 3d 136[A], 2010 NY Slip Op 50829[U] [App Term, 9th & 10th Jud Dists 2010]). However, in opposition to defendant’s motion, plaintiff submitted a sworn letter of medical necessity by its treating chiropractor which sufficiently demonstrated the existence of a question of fact as to medical necessity (see Zuckerman v City of New York, 49 NY2d 557 [1980]).

Accordingly, the order is affirmed.

Nicolai, P.J., Iannacci and Marano, JJ., concur.
Decision Date: February 28, 2014