Key Takeaway
NY court case on healthcare provider's right to recover reasonable value for medical services when insurance claims are improperly processed or denied.
This article is part of our ongoing fee schedule coverage, with 118 published articles analyzing fee schedule issues across New York State. Attorney Jason Tenenbaum brings 24+ years of hands-on experience to this analysis, drawing from his work on more than 1,000 appeals, over 100,000 no-fault cases, and recovery of over $100 million for clients throughout Nassau County, Suffolk County, Queens, Brooklyn, Manhattan, and the Bronx. For personalized legal advice about how these principles apply to your specific situation, contact our Long Island office at (516) 750-0595 for a free consultation.
Spanakos v Racanelli, 2021 NY Slip Op 50127(U)(App. Term 2d Dept. 2021)
(1) “Plaintiff, a chiropractor, brought this action to recover, among other things, the balance allegedly due him for healthcare services rendered to defendant. At a nonjury trial, plaintiff proffered evidence that he had submitted bills to defendant’s health plan requesting payment, which bills set forth a total charge of $ 1,756.81, which sum includes a co-payment of $ 480 due from defendant. Defendant presented evidence that plaintiff had failed to provide information necessary for the health plan to process plaintiff’s claim, but implicitly conceded that defendant was responsible for paying the $ 480 co-payment. After the trial, the Civil Court awarded plaintiff the principal sum of $ 480. Plaintiff appeals on the ground of inadequacy.”
(2) “It is well settled that a healthcare provider is entitled to recover for professional services rendered by him or her under an implied agreement by the patient to pay the reasonable value of the services (see Taranto v Abohwo, 45 Misc 3d 130, 3 N.Y.S.3d 287, 2014 NY Slip Op 51578 ; Brookhaven Mem. Hosp. Med. Ctr. v Lukashevskiy, 43 Misc 3d 128, 990 N.Y.S.2d 436, 2011 NY Slip Op 52557 ; Brottman v Crane, 11 Misc 3d 129, 815 N.Y.S.2d 493, 2006 NY Slip Op 50299 ). The performance and acceptance of such services give rise to the inference of an implied contract to pay for the reasonable value of the services (see Moors v Hall, 143 AD2d 336, 338, 532 N.Y.S.2d 412 ; Brookhaven Mem. Hosp. Med. Ctr. v Lukashevskiy, 43 Misc 3d 128, 990 N.Y.S.2d 436, 2011 NY Slip Op 52557; Long Is. Jewish Med. Ctr. v Budhu, 20 Misc 3d 131, 867 N.Y.S.2d 17, 2008 NY Slip Op 51436 ; Brottman v Crane, 11 Misc 3d 129, 815 N.Y.S.2d 493, 2006 NY Slip Op 50299).”
(3) “The terms of an agreement, if any, by plaintiff to seek recovery of his fees from defendant’s health plan is not part of the record. Assuming, without deciding, that plaintiff’s right to recover payment from defendant was not affected by plaintiff’s failure, if any, to properly pursue payment from defendant’s health plan, plaintiff, in any event, did not establish the reasonable value of the services he rendered, which proof is part of plaintiff’s prima facie case (see Castro v East End Plastic, Reconstructive & Hand Surgery, P.C., 47 AD3d 608, 610, 850 N.Y.S.2d 483 ). The sole proof submitted by plaintiff as to the reasonableness of the charges appearing on his bills was the bills themselves (see id.). Consequently, plaintiff failed to establish that the award in his favor was inadequate.”
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Legal Context
Why This Matters for Your Case
New York law is among the most complex and nuanced in the country, with distinct procedural rules, substantive doctrines, and court systems that differ significantly from other jurisdictions. The Civil Practice Law and Rules (CPLR) governs every stage of civil litigation, from service of process through trial and appeal. The Appellate Division, Appellate Term, and Court of Appeals create a rich and ever-evolving body of case law that practitioners must follow.
Attorney Jason Tenenbaum has practiced across these areas for over 24 years, writing more than 1,000 appellate briefs and publishing over 2,353 legal articles that attorneys and clients rely on for guidance. The analysis in this article reflects real courtroom experience — from motion practice in Civil Court and Supreme Court to oral arguments before the Appellate Division — and a deep understanding of how New York courts actually apply the law in practice.
About This Topic
Fee Schedule Issues in No-Fault Insurance
The New York no-fault fee schedule establishes the maximum reimbursement rates for medical treatment provided to injured motorists. Disputes over fee schedule calculations, coding, usual and customary charges, and the applicability of workers compensation fee schedules to no-fault claims are common. These articles analyze fee schedule regulations, court decisions on reimbursement disputes, and the practical challenges providers face in obtaining appropriate payment under the no-fault system.
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Disclaimer: This article is published by the Law Office of Jason Tenenbaum, P.C. for informational and educational purposes only. It does not constitute legal advice, and no attorney-client relationship is formed by reading this content. The legal principles discussed may not apply to your specific situation, and the law may have changed since this article was last updated.
New York law varies by jurisdiction — court decisions in one Appellate Division department may not be followed in another, and local court rules in Nassau County Supreme Court differ from those in Suffolk County Supreme Court, Kings County Civil Court, or Queens County Supreme Court. The Appellate Division, Second Department (which covers Long Island, Brooklyn, Queens, and Staten Island) and the Appellate Term (which hears appeals from lower courts) each have distinct procedural requirements and precedents that affect litigation strategy.
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