MEDICAL SERVICES PLLC v. GEICO CASUALTY INSURANCE CO (2006)

Appeal from an order of the Civil Court of the City of New York, Kings County (Robin S. Garson, J.), entered on March 20, 2004.   The order granted plaintiff's motion for summary judgment in the principal sum of $4,061.96.

Order modified by providing that plaintiff's motion for summary judgment is granted to the extent of awarding plaintiff partial summary judgment in the sum of $3,971.20 and matter remanded to the court below for the calculation of statutory interest and assessment of attorney's fees thereon and for all further proceedings on the remaining claim;  as so modified, affirmed without costs.

In this action to recover first-party no-fault benefits, plaintiff A.B. Medical Services PLLC (A.B. Medical) established a prima facie entitlement to partial summary judgment in the sum of $3,971.20, by proof that it submitted claims, setting forth the fact and the amounts of the losses sustained, and that payment of no-fault benefits was overdue (see Insurance Law § 5106 [a];  Mary Immaculate Hosp. v. Allstate Ins. Co., 5 A.D.3d 742, 774 N.Y.S.2d 564 [2004];  Amaze Med. Supply v. Eagle Ins. Co., 2 Misc.3d 128(A), 2003 N.Y. Slip Op. 51701[U], 2003 WL 23310886 [App. Term, 2d & 11th Jud. Dists.] ).   While the court below awarded plaintiff summary judgment in the sum of $4,061.96, in his affirmation in support of plaintiff's motion, David Safir, plaintiff's “practice and medical billing manager,” specifically requested summary judgment in the sum of $3,971.20.   Plaintiff has failed to make out a prima facie entitlement to a claim for the additional sum of $90.76.

 It is uncontroverted on the record that defendant timely denied A.B. Medical's claims in the respective sums of $1,972.08, and $1,999.12.   However, a timely denial alone does not avoid preclusion where said denial is factually insufficient, conclusory or vague (Amaze Med. Supply v. Allstate Ins. Co., 3 Misc.3d 43, 779 N.Y.S.2d 715 [App. Term, 2d & 11th Jud. Dists. 2004];  see also Nyack Hosp. v. Metropolitan Prop. & Cas. Ins. Co., 16 A.D.3d 564, 791 N.Y.S.2d 658 [2005];  Nyack Hosp. v. State Farm Mut. Auto. Ins. Co., 11 A.D.3d 664, 784 N.Y.S.2d 136 [2004] ).   The claims were essentially denied for failure to establish medical necessity.   Although defendant was not required to attach to its denial of claim forms the peer reviews upon which the denials were purportedly based (see 11 NYCRR 65-3.8[b][4];  A.B. Med. Servs. PLLC v. Nationwide Mut. Ins. Co., 7 Misc.3d 132(A), 2005 N.Y. Slip Op. 50605 [U], 2005 WL 948879 [App. Term, 2d & 11th Jud. Dists.] ), defendant's denial of claim forms fail to set forth with sufficient particularity the factual basis and medical rationale for its denial based on lack of medical necessity, and it is therefore precluded from asserting said defense (see Amaze Med. Supply v. Allstate Ins. Co., 3 Misc.3d 43, 779 N.Y.S.2d 715, supra ).   Moreover, the peer reviews submitted by defendant in opposition to plaintiff's motion were unsworn, and therefore in inadmissible form (see A.B. Med. Servs. PLLC v. Motor Veh. Acc. Indem. Corp., 6 Misc.3d 131(A), 2005 N.Y. Slip Op. 50088[U], 2005 WL 263757 [App. Term, 2d & 11th Jud. Dists.];  A.B. Medical Servs. PLLC v. Lumbermens Mut. Cas. Co., 4 Misc.3d 86, 781 N.Y.S.2d 818 [App. Term, 2d & 11th Jud. Dists. 2004] ).   In any event, even assuming said reports' admissibility and that they set forth a sufficient factual basis and medical rationale for denial of the claims, they cannot remedy the factual insufficiency of defendant's denials (see Nyack Hosp. v. State Farm Mut. Auto. Ins. Co., 11 A.D.3d 664, 784 N.Y.S.2d 136, supra ).

As set forth in the majority opinion, it is “uncontroverted on the record that defendant timely denied A.B. Medical's claims in the respective sums of $1,972.08 and $1,999.12”. The majority also acknowledges that the regulations do not require defendants to attach a copy of the peer review report to an NF-10 denial of claim form.   Nevertheless, my colleagues assert that the denial of claim form failed to state, with the requisite specificity, the reasons the claims were being denied.

What they fail to recognize is that the specific reason for the denial was the “negative” peer review report (see 11 NYCRR 65-3.8[b][4] ).   That is all the specificity that is required under that regulation which states:  “If the specific reason for a denial of a no-fault claim ․ is a ․ peer review report ․” (emphasis added).

To follow the reasoning of the majority would be to require a non-physician claims examiner to interpret a physician's peer review report, and then list, with specificity, the medical reasons for the claim's denial.   It seems a tad incongruous for the regulations to permit the NF-10 denial of claim form to be sent without attaching the doctor's peer review report and then to require a “lay” person to interpret that report and state with “specificity” the doctor's reasons for finding the treatment medically unnecessary.

In the case at bar, the claimant submits an affidavit stating that it requested a copy of that report but never received same.   The defendant submits an affidavit by a person in charge of the file stating that no such request is present in the file.   For the purpose of the issues before this Court, it doesn't matter if the request was sent, if the mail was lost, or if the defendant's affidavit is inaccurate, inasmuch as the regulations do not provide for any draconian remedy for defendant's failure to provide the report in a timely manner.   The claim denials were mailed on the 20th and 27th of January 2003, and the request for the peer review was not mailed until July 18, 2003.   The underlying action was “commenced” two months later, on September 17, 2003.   Apparently, the claimant waited six months to request the reports but waited less than two months to decide to bring this action.

Finally, a question arises as to whether the failure of the defendant to submit a “sworn” copy of the peer review report, in opposition to a claimant's motion for summary judgment, mandates that the motion be granted.   I do not find such a failure to be fatal when opposing a motion for summary judgment, for the reasons stated in my dissent in Ocean Diagnostic Imaging, P.C. v. Lancer Ins. Co., 6 Misc.3d 62, 791 N.Y.S.2d 267 [App. Term, 2d & 11th Jud. Dists.].

PESCE, P.J., and RIOS, J., concur. GOLIA, J., dissents in a separate memorandum.