May 11, 2012

BLR Chiropractic, P.C. v American Tr. Ins. Co. (2012 NY Slip Op 50882(U))

Headnote

In the case BLR Chiropractic, P.C. v American Tr. Ins. Co., the plaintiff, a provider seeking to recover first-party no-fault benefits, moved for summary judgment, while the defendant cross-moved for summary judgment dismissing the complaint. The defendant had timely denied the plaintiff's claim on the ground of lack of medical necessity and submitted evidence to support their decision, including a peer review report and affidavit executed by the chiropractor who performed the review. The court found that the evidence submitted by the defendant established a prima facie case of lack of medical necessity for the services at issue, shifting the burden to the plaintiff to rebut the defendant's showing, which they failed to do. As a result, the court reversed the order denying the defendant's cross motion and granted summary judgment dismissing the complaint.

Reported in New York Official Reports at BLR Chiropractic, P.C. v American Tr. Ins. Co. (2012 NY Slip Op 50882(U))

BLR Chiropractic, P.C. v American Tr. Ins. Co. (2012 NY Slip Op 50882(U)) [*1]

BLR Chiropractic, P.C. v American Tr. Ins. Co.

2012 NY Slip Op 50882(U) [35 Misc 3d 141(A)]

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This opinion is uncorrected and will not be published in the printed Official Reports.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

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

PRESENT: : WESTON, J.P., PESCE and RIOS, JJ
2011-68 K C.

BLR Chiropractic, P.C. as Assignee of JOSE RAMIREZ, Respondent, —
against
American Transit Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Margaret A. Pui Yee Chan, J.), entered June 16, 2010. The order denied defendant’s cross motion for summary judgment dismissing the complaint.

ORDERED that the order is reversed, without costs, 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, plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. Plaintiff’s motion was withdrawn, and defendant’s cross motion was denied.

The affidavits submitted by defendant were sufficient to establish that defendant had timely denied plaintiff’s claim (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]) on the ground of lack of medical necessity. Defendant also submitted a peer review report, which set forth the factual basis and medical rationale for the chiropractor’s determination that there was a lack of medical necessity for the services at issue, as well as an affidavit executed by the chiropractor who had performed the peer review. Contrary to the Civil Court’s finding and plaintiff’s argument on [*2]appeal, the annexed copy of the peer review report and the accompanying affidavit established, prima facie, a lack of medical necessity for the services at issue. Consequently, the burden shifted to plaintiff to rebut defendant’s prima facie showing (see Alur Med. Supply, Inc. v Clarendon Natl. Ins. Co., 27 Misc 3d 132[A], 2010 NY Slip Op 50700[U] [App Term, 2d, 11th & 13th Jud Dists 2010]; Pan Chiropractic, P.C. v Mercury Ins. Co., 24 Misc 3d 136[A], 2009 NY Slip Op 51495[U] [App Term, 2d, 11th & 13th Jud Dists 2009]), but plaintiff failed to do so.

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

Weston, J.P., Pesce and Rios, JJ., concur.
Decision Date: May 11, 2012