Much ado over something?

Dayan v Allstate Ins. Co., 2015 NY Slip Op 51751(U)(App. Term 2d Dept. 2015)

At issue in this case is which party bears the burden of proving at trial the medical necessity or the lack of medical necessity of the assignor’s right-shoulder surgery, i.e., whether the injury was causally related to the accident in question. This court has previously stated that where, in rebutting a presumption of medical necessity which attaches to a claim form, an insurer is [*2]successful in satisfying its burden at trial of demonstrating a lack of medical necessity, “it is ultimately plaintiff who must prove, by a preponderance of the evidence, that the services or supplies were medically necessary”

Here, the trial court went wrong when the following occurred: “The court further stated that “all things being equal,” it must find in favor of plaintiff, and, thus, the court awarded plaintiff the principal sum of $8,939.66.

Well, all things are not equal.  There is a presumption (an inference that must be rebutted) and sufficient evidence must be adduced to rebut the presumption.  Then, and only then, must the medical provider tender admissible proof to satisfy its ultimate burden, i.e., proof that the service is medically necessary, etc.

 

Run of the mill medical necessity case

Throgs Neck Multicare, P.C. v State Farm Mut. Auto. Ins. Co., 2015 NY Slip Op 51756(U)(App. Term 2d Dept. 2015)

The rebuttal affidavit was pretty poor.  Yet, I would note that except for the amount of paragraphs, the rebuttal was equally as deficient as that in another recent case.  In South Nassau , the Court found a triable issue of fact.  Here, the Court non-suited Plaintiff.  Sometimes, it really is a roll of the dice with how the Court’s will rule on particular deficient affidavits of merit.

Lost to Dr. Bhatt

Ap Orthopedic & Rehabilitation, P.C. v Allstate Ins. Co., 2015 NY Slip Op 51656(U)(App. Term 2d Dept. 2015)

“In reviewing a determination made after a nonjury trial, the power of this court is as broad as that of the trial court, and this court may render the judgment it finds warranted by the facts, bearing in mind that the determination of a trier of fact as to issues of credibility is given substantial deference, as a trial court’s opportunity to observe and evaluate the testimony and demeanor of the witnesses affords it a better perspective from which to assess their credibility (see Northern Westchester Professional Park Assoc. v Town of Bedford, 60 NY2d 492, 499 [1983]; Hamilton v Blackwood, 85 AD3d 1116 [2011]; Zeltser v Sacerdote, 52 AD3d 824, 826 [2008]).

In the present case, the record supports the determination of the Civil Court, based upon its assessment of the credibility of defendant’s witness and the proof adduced at trial, that defendant failed to demonstrate that the services rendered were not medically necessary. As we find no basis to disturb the Civil Court’s findings, the judgment, insofar as appealed from, is affirmed.”

A somewhat pro-defendant judge ruled in favor of the medical provider; the medical provider did not have a rebuttal; the Appellate Term affirmed.  Not good.

Medical necessity finding not sufficient upon search of record

Healing Art Acupuncture, P.C. v Allstate Ins. Co., 2015 NY Slip Op 51670(U)(App. Term 2d Dept. 2015)

“While the court has the power to award summary judgment to a nonmoving party predicated upon a motion for that relief by another party (see Dunham v Hilco Constr. Co., 89 NY2d 425 [1996]), here the issue of medical necessity was not the subject of plaintiff’s motion for summary judgment (see Mary Immaculate Hosp. v Allstate Ins. Co., 5 AD3d 742 [2004]). As a result, the court improvidently exercised its discretion when it searched the record and awarded defendant summary judgment dismissing the complaint insofar as it sought to recover for services rendered after November 20, 2009″

Search of the record was inappropriate.  It makes sense in this case as Plaintiff has no reason to believe (s) he had to proffer sufficient evidence to show the services were medically necessary,

The Reply that introduced a proper reply was itself proper

SAL Med., P.C. v Clarendon Natl. Ins. Co., 2015 NY Slip Op 51449(U)(App. Term 2d Dept. 2015)

“The defect in one of the peer review reports submitted by defendant with its original motion papers, in that it did not bear a signature, was properly and timely remedied when the identical peer review report, this time bearing a signature, was submitted by defendant in its reply papers, and there is no indication that plaintiff was prejudiced in opposing defendant’s motion by this defect in form”

Unsworn letters not enough

Innovative MR Imaging, P.C. v Praetorian Ins. Co., 2015 NY Slip Op 51402(U)(App. Term 1st Dept. 2015)

“In opposition to defendant’s motion, plaintiff submitted two letters of medical necessity. However, as neither letter of medical necessity was sworn or even signed, they were of no probative value (see Rivers v Birnbaum, 102 AD3d 26, 45 [2012]). As a result, defendant’s prima facie showing that the services were not medically necessary was unrebutted by plaintiff.”

3212(f) – motion denied

IDF Diagnostic Med., P.C. v New York Cent. Mut. Fire Ins. Co., 2015 NY Slip Op 51213(U)(App. Term 2d Dept. 2015)

“The Civil Court held that, since defendant had annexed its discovery responses to its reply papers, plaintiff’s cross motion to compel disclosure was moot and that there was an issue of fact as to medical necessity because defendant had failed to provide, in a timely manner, the medical records which plaintiff had sought, so that plaintiff could respond to the branch of defendant’s motion seeking summary judgment dismissing plaintiff’s first cause of action.”

“In opposition to defendant’s motion, and in support of its cross motion to compel discovery, plaintiff demonstrated that it had requested from defendant, but had not received in time to oppose defendant’s motion (see CPLR 3212 [f]), the peer review report, the complete set of medical documentation relating to the assignor received by defendant and the complete set of medical documentation provided to defendant’s peer reviewer. In light of the foregoing, defendant is not entitled to summary judgment dismissing plaintiff’s first cause of action”

In this case, the penalty for ambushing the Plaintiff with late discovery is to essentially lost the medical necessity branch of the motion.

Depositions of medical providers

Farshad D. Hannanian, M.D., P.C. v Allstate Ins. Co., 2015 NY Slip Op 51133(U)(App. Term 2d Dept. 2015)

“In this action by a provider to recover assigned first-party no-fault benefits, six days after plaintiff served a motion seeking summary judgment, defendant served a notice of deposition of plaintiff’s assignor’s treating provider. Plaintiff timely objected, arguing, among other things, that disclosure was stayed pursuant to CPLR 3214 (b). Immediately after plaintiff’s assignor’s treating provider failed to appear for the deposition, defendant moved to compel plaintiff to, among other things, produce plaintiff’s assignor’s treating provider for a deposition. Plaintiff cross-moved, inter alia, for a protective order pursuant to CPLR 3013 and to strike defendant’s notice to take deposition on the ground that the notice to take deposition was palpably improper. Insofar as is relevant to this appeal, by order entered January 7, 2014, the Civil Court granted the branch of defendant’s motion seeking to compel plaintiff’s treating provider to appear for a deposition and denied plaintiff’s cross motion. This appeal by plaintiff ensued.”

“CPLR 3101 (a) provides for “full disclosure of all matter material and necessary in the prosecution or defense of an action, regardless of the burden of proof.” Parties to an action are entitled to reasonable discovery “of any facts bearing on the controversy which will assist preparation for trial by sharpening the issues and reducing delay and prolixity” (Allen v Crowell-Collier Publ. Co., 21 NY2d 403, 406 [1968]; see Traditional Acupuncture, P.C. v State Farm Ins. Co., 24 Misc 3d 129[A], 2009 NY Slip Op 51335[U] [App Term, 2d, 11th & 13th Jud Dists 2009]). Where, as here, defendant is defending this action on the ground that the services rendered lacked medical necessity, the court’s determination that a deposition of plaintiff’s assignor’s treating provider was material and necessary to defendant’s defense was proper”(see Great Health Care Chiropractic, P.C. v Interboro Ins. Co., 41 Misc 3d 130[A], 2013 NY Slip Op 51737[U] [App Term, 2d, 11th & 13th Jud Dists 2013]; see also CPLR 3214 [b] [court may grant discovery notwithstanding service of a summary judgment motion”

Again, another division between the knee jerk notice of deposition that failed in Ralph Medical and the full breadth of disclosure that the Appellate Term Second Department will allow.

Objective evidence necessary

Easy Care Acupuncture, P.C. v A. Cent. Ins. Co., 2015 NY Slip Op 50973(U)(App. Term 1st Dept 2015)

That the assignor may have subjectively reported during the course of the peer review examination that he “feels worse” after two months of treatment did not, by itself and without any objective medical explanation by the peer reviewer, eliminate all triable issues regarding the medical necessity of continued acupuncture treatment, especially in view of the peer reviewer’s own positive findings (see Easy Care Acupuncture, P.C. v 21 Century Advantage Ins. Co., 46 Misc 3d 126[A], 2014 NY Slip Op 51766[U][App Term, 1st Dept]). In addition, the peer reviewer’s statement that “with respect to the [assignor’s] right shoulder complaints, further comment outside my area of expertise is deferred to the appropriate specialist,” was hardly sufficient to permit a summary determination as to the medical necessity of continued treatment related to this injury.”

Again, an objective standpoint is used to discuss the gambit of the propriety of an IME review.  Also, the “outside my expertise” argument furthermore spells disaster.

An insufficient rebuttal

Bronx Mega Care Med, PLLC v Federal Ins. Co., 2015 NY Slip Op 51060(U)(App. Term 2d Dept. 2015)

“In opposition, plaintiff failed to submit medical evidence sufficient to raise a triable issue of fact as to medical necessity (see e.g. Amato v State Farm Ins. Co., 40 Misc 3d 129[A], 2013 NY Slip Op 51113[U] [App Term, 9th & 10th Jud Dists 2013]). Contrary to the determination of the District Court, the opposing affirmation of plaintiff’s doctor failed to 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, defendant’s motion for summary judgment dismissing the complaint should have been granted”

What is the line between meaningfully refer to and not meaningfully referred?