Olga Bard Acupuncture, P.C. v Geico Ins. Co.

[*1] Olga Bard Acupuncture, P.C. v Geico Ins. Co. 2010 NY Slip Op 51898(U) [29 Misc 3d 132(A)] Decided on November 8, 2010 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 This opinion is uncorrected and will not be published in the printed Official Reports.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 November 8, 2010
SUPREME COURT OF THE STATE OF NEW YORK
APPELLATE TERM: 2nd, 11th and 13th JUDICIAL DISTRICTS
PRESENT: : PESCE, P.J., RIOS and STEINHARDT, JJ
2009-1575 K C.

Olga Bard Acupuncture, P.C. as Assignee of KEVIN WHITTAKER, Respondent,

against

Geico Ins. Co., Appellant.

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin D. Garson, J.), entered June 8, 2009. The order, insofar as appealed from, granted plaintiff's motion for summary judgment as to the first three causes of action and denied defendant's cross motion for summary judgment dismissing the complaint.

ORDERED that the order, insofar as appealed from, is modified by providing that so much of plaintiff's motion as sought summary judgment as to the second and third causes of action and as to claims bearing codes 97810 and 97811 included in the first cause of action is denied, and so much of defendant's cross motion as sought summary judgment dismissing the second, third, fourth and fifth causes of action as well as so much of the first cause of action as sought to recover for claims bearing codes 97810 and 97811 is granted; as so modified, the order, insofar as appealed from, is affirmed without costs and the matter is remitted to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees on the remaining award to plaintiff in the principal sum of $109.34.

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. Defendant alleged that it had properly paid for the services at issue in the first three causes of action at a rate reduced pursuant to the workers' compensation fee schedule and that it had denied reimbursement for the services at issue in the fourth and fifth causes of action for lack of medical necessity based upon an independent medical examination (IME). The Civil Court granted plaintiff's motion as to the first three causes of action only and denied defendant's cross motion in its entirety, finding that the only issue for trial was the medical necessity of the services that are the subject of the fourth and fifth causes of action. The instant appeal by defendant ensued.

Plaintiff established its prima facie entitlement to summary judgment (see Insurance Law § 5106 [a]; Art of Healing Medicine, P.C. v Travelers Home & Mar. Ins. Co., 55 AD3d 644 [2008]; Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]; Dan Med., P.C. v New York Cent. Mut. Fire Ins. Co., 14 Misc 3d 44 [App Term, 2d & 11th Jud Dists 2006]). The [*2]burden then shifted to defendant to raise a triable issue of fact (see Zuckerman v City of New York, 49 NY2d 557 [1980]).

The affidavit submitted by defendant in opposition to plaintiff's motion and in support of defendant's cross motion was sufficient to establish that the denial of claim forms were timely mailed in accordance with defendant's standard office practices and procedures (see St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co., 50 AD3d 1123, 1124 [2008]; Residential Holding Corp. v Scottsdale Ins. Co., 286 AD2d 679 [2001]; Delta Diagnostic Radiology, P.C. v Chubb Group of Ins., 17 Misc 3d 16 [App Term, 2d & 11th Jud Dists 2007]). However, defendant did not proffer sufficient evidence to warrant the dismissal of plaintiff's claim in the sum of $109.34 for the initial acupuncture visit, which claim was included in plaintiff's first cause of action (see Raz Acupuncture, P.C. v AIG Indem. Ins. Co., 28 Misc 3d 127[A], 2010 NY Slip Op 51177[U] [App Term, 2d, 11th & 13th Jud Dists 2010]). As a result, plaintiff was entitled to summary judgment upon so much of the first cause of action as sought to recover the sum of $109.34.

For the reasons stated in Great Wall Acupuncture v GEICO Gen. Ins. Co. (16 Misc 3d 23 [App Term, 2d & 11th Jud Dists 2007]; see also Great Wall Acupuncture, P.C. v Geico Ins. Co., 26 Misc 3d 23 [App Term, 2d, 11th & 13th Jud Dists 2009]), it was proper for defendant to use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which plaintiff was entitled to receive for the acupuncture services rendered by its licensed acupuncturist. Consequently, so much of plaintiff's motion as sought summary judgment on the second and third causes of action as well as the remaining portion of the first cause of action should have been denied, and so much of defendant's cross motion as sought summary judgment dismissing the second and third causes of action and the remaining portion of the first cause of action should have been granted, as these causes of action sought to recover upon claims that were paid pursuant to the workers' compensation fee schedule (see Great Wall Acupuncture, P.C., 26 Misc 3d 23; Great Wall Acupuncture, 16 Misc 3d 23).

With respect to the claims at issue in plaintiff's fourth and fifth causes of action, which were denied on the ground of lack of medical necessity, defendant, in support of its cross motion, annexed a report written by the acupuncturist who had performed the IME, as well as the acupuncturist's affidavit attesting to the truth of the report, which established, prima facie, a lack of medical necessity for the services performed after the examination took place. In opposition to defendant's cross motion, plaintiff failed to raise a triable issue of fact. The affidavit of the treating acupuncturist did not meaningfully refer to, let alone rebut, the conclusions set forth in the IME report (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, so much of defendant's cross motion as sought to dismiss the fourth and fifth causes of action should have been granted (see Innovative Chiropractic, P.C. v Mercury Ins. Co., 25 Misc 3d 137[A], 2009 NY Slip Op 52321[U] [App Term, 2d, 11th & 13th Jud Dists 2009]).

Accordingly, so much of plaintiff's motion as sought summary judgment as to the second and third causes of action and as to claims bearing codes 97810 and 97811 included in the first cause of action is denied, so much of defendant's cross motion as sought summary judgment dismissing the second, third, fourth and fifth causes of action as well as so much of the first cause of action as sought to recover for claims bearing codes 97810 and 97811 is granted, and the [*3]matter is remitted to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees on the remaining award to plaintiff in the principal sum of $109.34.

Pesce, P.J., Rios and Steinhardt, JJ., concur.
Decision Date: November 08, 2010