Appeal from an order of the Civil Court of the City of New York, Kings County (Peter Paul Sweeney, J.), entered September 30, 2009.
Neomy Med., P.C. v GEICO Ins. Co.
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This opinion is uncorrected and will not be published in the printed Official Reports.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 August 4, 2011
PRESENT: WESTON, J.P., PESCE and RIOS, JJ
The order, insofar as appealed from, denied defendant's cross motion for summary judgment dismissing the complaint.
ORDERED that the order, insofar as appealed from, 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. The Civil Court held that there is an issue of fact with respect to the medical necessity of the services rendered to plaintiff's assignor because defendant had not annexed the medical records upon which the peer review relied and defendant had failed to establish a foundation for the admission of the records. Defendant appeals from so much of the order as denied its cross motion for summary judgment dismissing the complaint.
Defendant established that it had timely mailed the denial of claim
form (see St. Vincent's Hosp. of Richmond v Government Empls. Ins.
Co., 50 AD3d 1123 ; Delta Diagnostic Radiology, P.C. v Chubb
Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]),
which denied the claim at issue on the ground of lack of medical necessity. In support of its cross
motion for summary judgment, defendant also submitted, among other things, a peer review report,
which set forth a factual basis and medical rationale for the conclusion that there was a lack of
medical necessity for the services at issue. Contrary to the determination of the Civil Court,
there was no need for defendant to annex the medical records examined by the peer review doctor
(cf. Matter of State of New York v Wilkes, 77 AD3d 1451 ). Furthermore, since the purpose of
the peer review report submitted by defendant was not to attempt to prove that plaintiff's assignor was
injured as documented in his medical records, or that she was treated as set forth in those records,
but to establish that, assuming the facts set forth therein were true, the treatment allegedly provided by
plaintiff was not medically necessary, defendant was not required to demonstrate that the records fell within
an exception to the rule against hearsay (see id.; Urban Radiology, P.C. v
Tri-State Consumer Ins. Co., 27 Misc 3d 140[A], 2010 NY Slip Op
50987[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). Consequently, defendant established its prima facie
entitlement to summary judgment (see Delta Diagnostic Radiology, P.C. v Integon Natl. Ins. Co., 24 Misc 3d
136[A], 2009 NY Slip Op 51502[U] [App Term, 2d, 11th & 13th Jud Dists 2009]; Delta Diagnostic Radiology,
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 NY Cent. Mut. Fire Ins.
Co., 16 Misc 3d 131[A], 2007 NY Slip Op 51342[U] [App Term, 2d
& 11th Jud Dists 2007]). Defendant's showing that the services rendered to plaintiff's assignor were
not medically necessary was unrebutted by plaintiff. Accordingly, defendant's cross motion for summary
judgment dismissing the complaint should have been granted.
Weston, J.P., and Pesce, J., concur.
Rios, J., concurs in a separate memorandum.
Rios, J., concurs in the following memorandum:
Contrary to the finding of the majority, in my opinion, the affidavit of defendant's representative failed to describe on personal knowledge the mailing procedure ...