July 1, 2008

Mega Supplies Billing, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51418(U))

https://www.beynensonlaw.com/case-law/mega-supplies-billing-inc-v-geico-ins-co-2008-ny-slip-op-51418u/

Court: Appellate Term, Second Department
Decided: July 1, 2008
Citation: 2008 NY Slip Op 51418(U) · 20 Misc 3d 130(A)
Posture: Summary judgment
Outcome: Insurer prevailed
Issues: Medical necessity
Legal questions: Lack of medical necessity (see the maps)

Cite as

Mega Supplies Billing, Inc. v GEICO Ins. Co., 20 Misc 3d 130(A), 2008 NY Slip Op 51418(U) (App Term, 2d Dept, 2d & 11th Jud Dists 2008)

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 insurer's denial was not fatally defective, and its unrebutted affirmed peer review established lack of medical necessity for the supplies. Although portions of the denial form were omitted, those sections were irrelevant to the claim. The form promptly and specifically identified the ground for denial, and the insurer established that the Department of Insurance had approved it. The insurer's sworn submissions, including the peer review, made a prima facie showing of medical nonnecessity that the provider did not rebut. The Appellate Term, Second Department, affirmed the order denying the provider's summary judgment motion and granting the insurer's cross motion dismissing the complaint.

Reported in New York Official Reports at Mega Supplies Billing, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51418(U))

[*1]

Mega Supplies Billing, Inc. v GEICO Ins. Co.

2008 NY Slip Op 51418(U) [20 Misc 3d 130(A)]

Decided on July 1, 2008

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This opinion is uncorrected and will not be published in the printed Official Reports.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 July 1, 2008

SUPREME COURT OF THE STATE OF NEW YORK

APPELLATE TERM: 2nd and 11th JUDICIAL DISTRICTS

PRESENT: : RIOS, J.P., PESCE and GOLIA, JJ
2007-950 K C.

Mega Supplies Billing, Inc. a/a/o Tameka Robinson, Appellant,
against
GEICO Insurance Co., Respondent.

Appeal from an order of the Civil Court of the City of New York, Kings County (Margaret A. Chan, J.), entered May 3, 2007. The order denied plaintiff’s motion for summary judgment and granted defendant’s cross motion for summary judgment dismissing the complaint.

Order affirmed without costs.
In this action by a provider to recover assigned first-party no-fault benefits, plaintiff’s motion for summary judgment was supported by an affirmation from plaintiff’s counsel, an affidavit by an employee of plaintiff and various documents annexed thereto. The affidavit executed by the employee stated in a conclusory manner that the documents annexed to plaintiff’s motion papers were plaintiff’s business records. Defendant cross-moved for summary judgment on the ground of lack of medical necessity. In support of its cross motion and in opposition to plaintiff’s motion for summary judgment, defendant submitted an affirmed peer review report and argued, inter alia, that the affidavit by plaintiff’s employee failed to demonstrate personal knowledge of the facts set forth therein and that, as a result, plaintiff failed to establish a prima facie case. The court below denied plaintiff’s motion and granted defendant’s cross motion, finding that plaintiff failed to establish its prima facie entitlement to summary judgment and defendant established its defense of lack of medical necessity. The instant appeal by plaintiff ensued.

Contrary to plaintiff’s contention, the denial of claim form submitted by defendant was not fatally defective. Although the defendant omitted certain sections from the denial of claim form, the sections were not relevant to the instant claim. The denial of claim form “promptly apprise[d] the claimant with a high degree of specificity of the ground . . . on which the disclaimer [wa]s predicated . . .” (New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. [*2]Co., 32 AD3d 458, 460 [2006] [internal quotations and citations omitted]), and defendant established that said denial of claim form was approved by the New York State Department of Insurance (id.).

Turning to the merits of defendant’s cross motion, the sworn papers submitted in support of same, including the affirmed peer review report, established prima facie that there was no medical necessity for the supplies provided by plaintiff, which evidence was unrebutted. As a result, the court below properly granted defendant’s cross motion for summary judgment (see Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co., 18 Misc 3d 128[A], 2007 NY Slip Op 52455[U] [App Term, 2d & 11th Jud Dists 2007]; A. Khodadadi Radiology, P.C. v N.Y. Cent. Mut. Fire Ins. Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d & 11th Jud Dists 2007]).

Rios, J.P., Pesce and Golia, JJ., concur.
Decision Date: July 1, 2008

Legal questions

A question 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

Open the full map

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

This decision: Insurer's proof established lack of medical necessity and the provider failed to rebut it

Affirmed summary judgment for the insurer because its sworn papers, including an affirmed peer review report, established prima facie that the supplies were not medically necessary and the provider offered no rebuttal.

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 612 decisions on this question in the Second Department courts and the Court of Appeals, 315 (this one included) are in the same category.

Cited in this decision

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

New York Univ. Hosp. Rusk Inst. v Hartford Acc. & Indem. Co. (2006 NY Slip Op 06223) FollowedThe insurers were precluded from contesting a hospital claim because they failed to establish that their denial letter met regulatory requirements.
Delta Diagnostic Radiology, P.C. v American Tr. Ins. Co. (2007 NY Slip Op 52455(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.
A Khodadadi Radiology, P.C. v NY Cent. Mut. Fire Ins. Co. (2007 NY Slip Op 51342(U))The insurer's unrebutted peer review established that the provider's MRIs lacked medical necessity.

Similar decisions

All Borough Group Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51417(U))The insurer's denial preserved its medical-necessity defense, and an unrebutted affirmed peer review established that the supplies were unnecessary.
Mega Supply & Billing, Inc. v Larendon Natl. Ins. Co. (2010 NY Slip Op 51452(U))The provider failed to rebut the insurer's peer review or justify deferring summary judgment to obtain the reviewer's underlying records.
Bath Med. Supply, Inc. v GEICO Ins. Co. (2010 NY Slip Op 52316(U))The insurer's peer reviews established lack of medical necessity, and the provider failed to justify delaying summary judgment for discovery.
Vista Surgical Supplies, Inc. v GEICO Ins. Co. (2009 NY Slip Op 50739(U))A denial form is not invalid for omitting irrelevant sections if it is approved and specifically identifies the medical-necessity defense.
New Way Med. Supply Corp. v GEICO Ins. Co. (2014 NY Slip Op 50880(U))The insurer's peer reviews were unrebutted because appellate review was limited to the papers Civil Court considered.