Devonshire Surgical Facility, Carnegie Hill Orthopedic Servs., P.C. v American Tr. Ins. Co., 2011 NY Slip Op 50513(U)(App. Term 1st Dept. 20110
“Even assuming that defendant issued timely denials of plaintiffs’ claims (see Country-Wide Ins. Co. v Zablozki, 257 AD2d 506 [1999], lv denied 93 NY2d 809 [1999]), the peer review report relied upon by defendant to deny plaintiffs’ claims is conclusory and fails to set forth sufficient facts to raise triable issues with respect to its defense of lack of medical necessity (see East Coast Acupuncture Servs., P.C. v American Tr. Ins. Co., 14 Misc 3d 135[A], 2007 NY Slip Op 50213[U][2007]).”
A peer review in the First Department presents three options: (1) Insufficient; (2) Sufficient to raise an issue of fact only; and (3) Sufficient to demonstrate lack of medical necessity prima facie.
In the Second Department, it is usually option (3) and rarely option (1). Never option (2)
One Response
Darn the App Term First for acknowledging the vast range of the quality of a Peer Review Report. We all got into the law to be cookie cutters.
This is this … that is that … this is not that … [it is getting to complex here] Let us stick with the first two