October 11, 2012

Ayoob Khodadadi, M.D.,MRI, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51968(U))

Headnote

The relevant facts the court considered in this case were that the defendant had timely mailed denial of claim forms, denying the claims on the ground of lack of medical necessity. The defendant also submitted the affirmed reports of its peer reviewer, which set forth a factual basis and medical rationale for the doctor's opinion that there was a lack of medical necessity for the services provided to the plaintiff's assignor. In response, the plaintiff failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity. The main issue decided by the court was whether the defendant established its prima facie entitlement to summary judgment, and whether the plaintiff submitted sufficient evidence to raise a triable issue of fact as to medical necessity. The holding of the court was that the order granting the plaintiff's motion for summary judgment was reversed, and the defendant's cross motion for summary judgment dismissing the complaint was granted.

Reported in New York Official Reports at Ayoob Khodadadi, M.D.,MRI, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51968(U))

Ayoob Khodadadi, M.D.,MRI, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51968(U)) [*1]

Ayoob Khodadadi, M.D.,MRI, P.C. v Clarendon Natl. Ins. Co.

2012 NY Slip Op 51968(U) [37 Misc 3d 130(A)]

Decided on October 11, 2012

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This opinion is uncorrected and will not be published in the printed Official Reports.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 October 11, 2012

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

PRESENT: : IANNACCI, J.P., MOLIA and LaCAVA, JJ
2010-915 N C.

Ayoob Khodadadi, M.D., MRI, P.C. as Assignee of DAVID PIERRE, Respondent, —
against
Clarendon National Insurance Company, Appellant.

Appeal from an order of the District Court of Nassau County, Third District (Fred J. Hirsh, J.), dated March 22, 2010. The order granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, without costs, plaintiff’s motion for summary judgment is denied and defendant’s cross motion for summary judgment dismissing the complaint is granted.

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

In support of its cross motion, defendant submitted an affidavit of its claims examiner, which demonstrated that defendant 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]; Chi Acupuncture, P.C. v Kemper Auto & Home Ins. Co., 14 Misc 3d 141[A], 2007 NY Slip Op 50352[U] [App Term, 9th & 10th Jud Dists 2007]) its denial of claim forms, which denied the claims on the ground of lack of medical necessity. The affirmed reports of defendant’s peer reviewer set forth a factual basis and medical rationale for the doctor’s opinion 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]; B.Y., M.D., P.C. v Progressive Cas. Ins. Co., 26 Misc 3d 135[A], 2010 NY Slip Op 50144[U] [App Term, 9th & 10th Jud Dists 2010]). In opposition to defendant’s cross motion, plaintiff failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity (see Specialty Surgical Servs. v Travelers Ins. Co., 27 Misc 3d 134[A], 2010 NY Slip Op 50715[U] [App Term, 9th & 10th Jud [*2]Dists 2010]; A. Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

Accordingly, the order is reversed, plaintiff’s motion for summary judgment is denied and defendant’s cross motion for summary judgment dismissing the complaint is granted.

Iannacci, J.P., Molia and LaCava, JJ., concur.
Decision Date: October 11, 2012