October 25, 2012

Quality Psychological Servs., P.C. v Travelers Ins. Co. (2012 NY Slip Op 52080(U))

Headnote

The relevant facts the court considered were that an insurance company appealed an order granting summary judgment to a provider seeking to recover assigned first-party no-fault benefits. The insurance company had submitted two sworn peer review reports, each of which set forth the factual basis and medical rationale for the psychologist's determination that there was a lack of medical necessity for the services at issue. In opposition, the provider submitted an affidavit by a psychologist which failed to meaningfully refer to, let alone rebut, the conclusions set forth in the peer review reports. The main issue decided was whether the insurance company's evidence was sufficient to establish the lack of medical necessity and justify the denial of the claim. The holding of the court was that the insurance company's cross motion for summary judgment should have been granted, and the provider's motion for summary judgment was denied.

Reported in New York Official Reports at Quality Psychological Servs., P.C. v Travelers Ins. Co. (2012 NY Slip Op 52080(U))

Quality Psychological Servs., P.C. v Travelers Ins. Co. (2012 NY Slip Op 52080(U)) [*1]

Quality Psychological Servs., P.C. v Travelers Ins. Co.

2012 NY Slip Op 52080(U) [37 Misc 3d 133(A)]

Decided on October 25, 2012

Appellate Term, Second Department

Published by New York State Law Reporting Bureau pursuant to Judiciary Law § 431.

As corrected in part through December 3, 2012; it will not be published in the printed Official Reports.

Decided on October 25, 2012

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

PRESENT: : PESCE, P.J., WESTON and RIOS, JJ
2010-3066 K C.

Quality Psychological Services, P.C. as Assignee of JOHNNY RIVERA, Respondent,
against
Travelers Insurance Company, Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Carolyn E. Wade, J.), entered August 6, 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, with $30 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 Civil Court which granted plaintiff’s motion for summary judgment and denied defendant’s cross motion for summary judgment dismissing the complaint.

Contrary to the finding of the Civil Court, the affidavit submitted by defendant was sufficient to establish the timely mailing of the denial of claim forms (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]), which [*2]denied plaintiff’s claims on the ground of lack of medical necessity. Defendant also submitted two sworn peer review reports, each of which set forth the factual basis and medical rationale for the psychologist’s determination that there was a lack of medical necessity for the services at issue. In opposition, plaintiff submitted an affidavit by a psychologist which failed to meaningfully refer to, let alone rebut, the conclusions set forth in the peer review reports (see 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]). Consequently, defendant’s cross motion should have been granted (see 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.

Pesce, P.J., Weston and Rios, JJ., concur.
Decision Date: October 25, 2012