A.B. Med. Servs. PLLC v Electric Ins. Co. (2005 NYSlipOp 50542(U))

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

Appeal by plaintiffs, as limited by their brief on appeal, from so much of an order of the Civil Court, Kings County (E. Prus, J.), entered on April 20, 2004, as denied their motion for summary judgment.

Order unanimously modified by granting the motion for summary judgment by plaintiff Daniel Kim’s Acupuncture P.C. in the sum of $3,475.56 and matter remanded to the court below for the calculation of statutory interest and an assessment of attorney’s fees thereon, and for all further proceedings on the remaining claims; as so modified, affirmed without costs.

In this action to recover assigned first-party no-fault benefits, plaintiffs moved for summary judgment in the sum of $11,139.79. We note at the outset that in their brief on appeal, plaintiffs have effectively withdrawn the claim of plaintiff Square Synagogue Transportation Inc. in the sum of $425. Moreover, said plaintiff’s motion for summary judgment as to its claim for $100, which defendant denied receiving, was properly denied since plaintiff’s proof of mailing as to this claim indicates a post date which is prior to the date of the bill. In the absence of any explanation of the discrepancy, plaintiff’s proof is insufficient to establish prima facie entitlement to summary judgment as to this claim. [*2]

With regard to the remaining claims, plaintiffs established a prima facie entitlement to summary judgment by proof that they submitted the claims, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86 [App Term, 2d & 11th Jud Dists 2004]; Amaze Med. Supply v Eagle Ins. Co., 2 Misc 3d 128[A], 2003 NY Slip Op 51701[U] [App Term, 2d & 11th Jud Dists]).

In opposition to plaintiffs’ motion, defendant argued that the claims of A.B. Medical Services PLLC, D.A.V. Chiropractic P.C., Daniel Kim’s Acupuncture P.C. and Square Synagogue Transportation Inc., in the sum of $7,139.23, were properly denied on the ground that plaintiffs’ assignor failed to attend scheduled independent medical examinations (IMEs).

Where “an insurer timely asserts in its claim denial form an injured person’s failure to comply with a reasonable and proper pre-claim IME request, and establishes such failure in admissible form in opposition to a plaintiff’s motion for summary judgment, the presumption of medical necessity which attaches to the claim form is rebutted . . . and such proof defeats the motion” (Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., ___Misc 3d ___, 2004 NY Slip Op 24527 [App Term, 2d & 11th Jud Dists]; see also S&M Supply Inc. v Peerless Ins. Co., 6 Misc 3d 127[A], 2004 NY Slip Op 51683[U] [App Term, 2d & 11th Jud Dists]).

It is undisputed that defendant issued timely denials based on the nonattendance of plaintiffs’ assignor at pre-claim IMEs scheduled by defendant. Contrary to plaintiffs’ contention, the letter of Transcion Medical P.C., which schedules IMEs for defendant, and defendant’s denial of claim forms, which were submitted as part of plaintiffs’ moving papers, indicated that plaintiffs’ assignor did not appear for all of the scheduled IMEs listed in Transcion’s letter. Under the circumstances presented, in our opinion, such selective attendance by plaintiffs’ assignor established the assignors’ receipt of all IME requests listed in said letter. In the absence of any reasonable excuse for the nonappearance by plaintiffs’ assignor, defendant effectively rebutted the presumption of medical necessity which ordinarily attaches to the claim forms. This is so, even though it is uncontroverted that plaintiffs’ assignor attended some of the IMEs. Therefore, its defense of lack of medical necessity of the services provided to plaintiffs’ assignor was still viable and raised a triable issue with respect thereto. Accordingly, the court below properly denied said plaintiffs’ motion for summary judgment in the sum of $7,139.23 (see Stephen Fogel Psychological, P.C. v Progressive Casualty Ins. Co., Misc 3d , 2004 NY Slip Op 24527, supra).

With regard to the additional claims of Daniel Kim’s Acupuncture P.C. in the amount of $3,475.55, which were timely denied, the stated basis for denial was lack of medical necessity, rather than the failure to appear for an IME. In opposition to the motion for summary judgment, defendant was required to submit proof in admissible form to rebut plaintiff’s prima facie showing (A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86, supra). Defendant submitted an unsworn peer review report of an acupuncturist. Since said report was not in admissible form, it was insufficient to warrant denial of said plaintiff’s motion for summary judgment (see CPLR 2106; Alvarez v Prospect Hosp., 68 NY2d 320, 324 [1986]; A.B. Med. Servs. PLLC v Lumbermens Mut. Cas. Co., 4 Misc 3d 86, supra; A.B. Med. Servs. v New York Cent. Mut. Fire Ins. Co., 3 Misc 3d 136[A], 2004 NY Slip Op 50507[U] [App Term, 2d & [*3]11th Jud Dists]).

We note that to the extent that the decision of the court below rests on the lack of authentication of the assignments, it is erroneous. The lack of authentication of an assignor’s signature, in and of itself, does not constitute a defect in the absence of any statutory and regulatory requirement for the same (A.B. Med. Servs. PLLC v Nationwide Mut. Ins. Co., 6 Misc 3d 70 [App Term, 2d & 11th Jud Dists 2004]). Even assuming arguendo that a lack of authentication constitutes a cognizable defect, defendant’s failure to seek verification of the assignments and to allege any deficiency in the assignments in its denial of claim forms constitutes a waiver of any defenses with respect thereto (see id; see also New York Hosp. Med. Ctr. of Queens v New York Cent. Mut. Fire Ins. Co., 8 AD3d 640 [2004]; Presbyterian Hosp. in City of N. Y. v Aetna Cas. & Sur. Co., 233 AD2d 433 [1996]; Park Health Ctr. v Eveready Ins. Co., 2001 NY Slip Op 40665[U] [App Term, 2d & 11th Jud Dists]).

Accordingly, the order of the court below is modified by granting the motion for summary judgment by plaintiff Daniel Kim’s Acupuncture P.C. in the sum of $3,475.56, and remanding the matter for the calculation of statutory interest and an assessment of attorney’s fees thereon pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder, and for all further proceedings on the remaining claims.
Decision Date: April 13, 2005