May 1, 2015

Lenox Hill Radiology & MIA, P.C. v Great N. Ins. Co. (2015 NY Slip Op 50680(U))

https://www.beynensonlaw.com/case-law/lenox-hill-radiology-mia-p-c-v-great-n-ins-co-2015-ny-slip-op50680u/

Court: Appellate Term, Second Department
Decided: May 1, 2015
Citation: 2015 NY Slip Op 50680(U) · 47 Misc 3d 143(A)
Posture: Summary judgment
Outcome: Provider prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity · Proof of mailing (see the maps)

Cite as

Lenox Hill Radiology & MIA, P.C. v Great N. Ins. Co., 47 Misc 3d 143(A), 2015 NY Slip Op 50680(U) (App Term, 2d Dept, 9th & 10th Jud Dists 2015)

Posture, outcome, issues and treatment by other decisions are Beynenson Law’s classification. Treatment labels are assigned by a language model reading the citing decision; negative and appeal-history labels are checked by a second reader.

Summary

Editorial summary by Beynenson Law, not part of the court’s decision.

The provider's doctor's affirmation raised a triable issue of medical necessity in response to the insurer's peer review report. The insurer moved for summary judgment dismissing assigned no-fault claims and established timely and proper mailing of its medical-necessity denials. Its affirmed peer review supplied a factual basis and medical rationale for finding the services unnecessary. The opposing doctor's affirmation nevertheless raised a factual dispute as to whether the services were medically necessary, precluding dismissal on summary judgment. The Appellate Term, Second Department, affirmed the order of District Court, Nassau County, denying the insurer's motion.

Reported in New York Official Reports at Lenox Hill Radiology & MIA, P.C. v Great N. Ins. Co. (2015 NY Slip Op 50680(U))

[*1]

Lenox Hill Radiology & MIA, P.C. v Great N. Ins. Co.

2015 NY Slip Op 50680(U) [47 Misc 3d 143(A)]

Decided on May 1, 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This opinion is uncorrected and will not be published in the printed Official Reports.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 1, 2015

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

PRESENT: : GARGUILO, J.P., MARANO and CONNOLLY, JJ.
2013-2049 N C

Lenox Hill Radiology and MIA, P.C. as Assignee of SAMIR GEMAYEL, Respondent,
against
Great Northern Insurance Company Doing Business as CHUBB GROUP OF INSURANCE COMPANIES, Appellant.

Appeal from an order of the District Court of Nassau County, First District (Fred J. Hirsh, J.), dated July 31, 2013. The order denied defendant’s motion for summary judgment dismissing the complaint.

ORDERED that the order is affirmed, without costs.

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

Defendant established that the denial of claim forms, which denied the claims on the ground of lack of medical necessity, had been timely and properly mailed (see St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123 [2008]). While the affirmed peer review report by defendant’s doctor set forth a factual basis and medical rationale for the doctor’s opinion that there was a lack of medical necessity for the services at issue, plaintiff proffered a doctor’s affirmation in opposition, which affirmation was sufficient to raise a triable issue of fact as to whether the services were medically necessary (see Zuckerman v City of New York, 49 NY2d 557 [1980]). Consequently, defendant’s motion for summary judgment dismissing the complaint was properly denied.

Accordingly, the order is affirmed.

Garguilo, J.P., Marano and Connolly, JJ., concur.

Decision Date: May 01, 2015

Legal questions (2)

Questions of no-fault law this decision rules on, from our Legal Questions pages. Bars count the decisions on the question by year and court, coloured by category; circles are this decision and the decisions on the question it cites or that cite it. Point at a bar or circle for details. The categories and summaries are Beynenson Law’s classification, made by a language model and checked by a second reading.

Lack of medical necessity

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Did the insurer’s proof establish lack of medical necessity, and did the provider’s evidence rebut it?

This decision: Provider's evidence rebutted the insurer's showing (triable issue, or necessity found at trial)

Although the insurer's affirmed peer review set forth a factual basis and medical rationale, the provider's doctor's affirmation raised a triable issue on medical necessity, so the insurer's motion was properly denied.

Unrebutted, insurer prevailsProvider's rebuttal sufficientInsurer raised triable issueInsurer's proof insufficientTrial error, new trialThis decisionCites it or cited by itCited or followed

Of the 617 decisions on this question in the Second Department courts and the Court of Appeals, 94 (this one included) are in the same category.

Proof of mailing

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Did a party’s evidence establish that it mailed a no-fault claim, denial, verification request or examination notice?

This decision: The insurer's (or its agent's) proof established mailing of its denial, verification request or IME/EUO notice (rules on the question, but another ground decided the case)

Held the insurer established that its medical-necessity denials were timely and properly mailed.

Insurer proved mailingInsurer failed to proveProvider proved mailingProvider failed to proveTriable issue on mailingMixed rulingsThis decisionCites it or cited by itCited or followed

Of the 1,384 decisions on this question in the Second Department courts and the Court of Appeals, 806 (this one included) are in the same category.

Cited in this decision

A label shows how this decision treated the case it cites.

St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072) FollowedThe insurer raised factual issues concerning a proper timely denial and its entitlement to deny the hospital's claim.

Cited by

Heavenly Points Acupuncture v Integon Natl. Ins. Co. (2021 NY Slip Op 50895(U))The insurer established lack of medical necessity, and the provider's conclusory expert affidavit failed to raise a triable issue.

Similar decisions

Lenox Hill Radiology v Great N. Ins. Co. (2016 NY Slip Op 50206(U))The provider's mailing affidavit raised a triable issue over submission of the claim form despite the insurer's proof of nonreceipt.
Bronx Mega Care Med, PLLC v Federal Ins. Co. (2015 NY Slip Op 51060(U))The provider's doctor's affirmation failed to meaningfully address or rebut the insurer's IME conclusions on medical necessity.
Medical Assoc., P.C. v Unitrin Advantage Ins. Co. (2013 NY Slip Op 50757(U))The provider's medical affirmations raised factual issues concerning MRI necessity, requiring denial of both sides' summary judgment requests.
Manhattan Med. Imaging, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51737(U))The insurer's timely denial and supported peer review raised a triable issue of medical necessity, defeating provider summary judgment.
Bronx Park Med., P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 51832(U))The insurer's unrebutted peer review established a factual basis and medical rationale for denying the services as medically unnecessary.