December 18, 2015

Easy Care Acupuncture, P.C. v Nationwide Gen. Ins. Co. (2015 NY Slip Op 51849(U))

Headnote

The court considered the evidence submitted by the defendant that established that it timely denied the plaintiff's no-fault claims for services rendered on certain dates, on the ground that the amounts charged were in excess of the fees set forth in the applicable worker's compensation fee schedule. The main issue decided was whether the defendant properly denied the plaintiff's claim for $61.43, billed under a specific CPT code, thus precluding summary judgment dismissing this claim. The holding of the court was that the order of the Civil Court, which granted the defendant partial summary judgment dismissing plaintiff's no-fault claims, was modified to reinstate plaintiff's claim for first-party no-fault benefits billed under the specific CPT code, and as modified, the order was affirmed. The court found triable issues as to whether defendant properly denied the specific claim, and therefore, summary judgment dismissing this claim was precluded.

Reported in New York Official Reports at Easy Care Acupuncture, P.C. v Nationwide Gen. Ins. Co. (2015 NY Slip Op 51849(U))

Easy Care Acupuncture, P.C., a/a/o Cheryl Browne Plaintiff-Appellant,
against
Nationwide General Ins. Co., Defendant-Respondent.

Plaintiff appeals from so much of an order of the Civil Court of the City of New York, New York County (David B. Cohen, J.), entered December 18, 2014, as granted defendant partial summary judgment dismissing plaintiff’s no-fault claims for services rendered April 9, 2009 through May 27, 2009, and June 25, 2009 through September 15, 2009.

Per Curiam.

Order (David B. Cohen, J.), entered December 18, 2014, insofar as appealed from, modified by reinstating plaintiff’s claim for first-party no-fault benefits billed under CPT code 99202; as modified, order affirmed, without costs.

The affidavits and other documentary evidence submitted by defendant established, prima facie, that it timely denied (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]) plaintiff’s no-fault claims billed under CPT codes 97810, 97811, 97813 and 97814 for services rendered April 9, 2009 through May 27, 2009 and June 25, 2009 through September 15, 2009, on the ground that the amounts charged were in excess of the fees set forth in the applicable worker’s compensation fee schedule (see Akita Med. Acupuncture, P.C. v Clarendon Ins. Co., 41 Misc 3d 134[A], 2013 NY Slip Op 51860[U][App Term, 1st Dept 2013]; Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 [App Term, 2d Dept 2009]). In opposition, plaintiff failed to raise a triable issue as to the efficacy of defendant’s mailing of the denial or the calculation of the fee pertaining to these claims.

However, triable issues remain as to whether defendant properly denied plaintiff’s claim for $61.43, billed under CPT code 99202 (initial evaluation), thus precluding summary judgment dismissing this claim (see Megacure Acupuncture, P.C. v Clarendon Natl. Ins. Co., 33 Misc 3d 141[A], 2011 NY Slip Op 52199[U][App Term, 2d, 11th & 13th Jud Dists 2011]; see also VS Care Acupuncture v State Farm Mut. Auto. Ins. Co., 46 Misc 3d 141[A], 2015 NY Slip Op 50164[U][App Term, 1st Dept 2015]).

THIS CONSTITUTES THE DECISION AND ORDER OF THE COURT.
I concur I concur I concur

Decision Date: December 18, 2015