May 18, 2015

Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50778(U))

Headnote

The relevant facts considered by the court were that a medical service provider was seeking first-party no-fault benefits from an automobile insurance company. The insurance company had reduced the amount billed for a specific code of medical services pursuant to the workers' compensation fee schedule. The main issue decided was whether the insurance company had properly applied the fee schedule and whether this defense was properly set forth in the denial of the claim form. The holding of the case was that the insurance company's affidavit was sufficient to demonstrate that the fee schedule was properly applied, and the denial of benefits referenced an attached "Explanation of Review," which supported the insurance company's defense. Therefore, the court affirmed the order granting the insurance company's motion for summary judgment and denying the medical service provider's cross motion for summary judgment.

Reported in New York Official Reports at Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50778(U))

Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50778(U)) [*1]

Alleviation Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co.

2015 NY Slip Op 50778(U) [47 Misc 3d 149(A)]

Decided on May 18, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 May 18, 2015

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

PRESENT: : PESCE, P.J., ALIOTTA and SOLOMON, JJ.
2012-2681 K C

Alleviation Medical Services, P.C. as Assignee of DEXTON ELLIS, 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 (Dawn Jimenez Salta, J.), entered October 12, 2012. The order granted defendant’s motion for summary judgment dismissing the complaint and denied plaintiff’s cross motion for summary judgment.

ORDERED that the order is affirmed, with $25 costs.

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

Plaintiff’s main argument on appeal with respect to defendant’s cross motion is that defendant failed to demonstrate that it had properly reduced the sum billed for CPT code 20553 from $4,000 to $645.90 pursuant to the workers’ compensation fee schedule. Contrary to plaintiff’s contention, the affidavit submitted by defendant was sufficient to demonstrate, prima facie, that Ground Rule 3 and Ground Rule 5 were appropriately applied to the services billed, and that defendant properly applied CPT code 20552 in order to determine the amount due, which it calculated to be $645.90. It is of no relevance to the determination of this appeal that defendant has described a potential alternate calculation which, had defendant used it, would have concluded that only $416.85 was due.

Although plaintiff further argues that defendant’s proffered defense was not set forth in its denial of claim form, a checked box on the form indicated that benefits were denied because the fees were not in accordance with the fee schedule, and the denial referenced an attached “Explanation of Review.”

In view of the foregoing, defendant’s motion for summary judgment dismissing the complaint was properly granted and plaintiff’s cross motion for summary judgment was properly denied.

Accordingly, the order is affirmed.

Pesce, P.J., Aliotta and Solomon, JJ., concur.

Decision Date: May 18, 2015