Universal Acupuncture Pain Services, P.C. v. Lumbermens Mutual Casualty Co.

195 Misc. 2d 352, 758 N.Y.S.2d 795, 2003 N.Y. Misc. LEXIS 261
CourtCivil Court of the City of New York
DecidedMarch 28, 2003
StatusPublished
Cited by5 cases

This text of 195 Misc. 2d 352 (Universal Acupuncture Pain Services, P.C. v. Lumbermens Mutual Casualty Co.) is published on Counsel Stack Legal Research, covering Civil Court of the City of New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Universal Acupuncture Pain Services, P.C. v. Lumbermens Mutual Casualty Co., 195 Misc. 2d 352, 758 N.Y.S.2d 795, 2003 N.Y. Misc. LEXIS 261 (N.Y. Super. Ct. 2003).

Opinion

OPINION OF THE COURT

Charles J. Markey, J.

In a recent article, two practitioner commentators opined: “In an attempt to reduce the strain on the court system, No-Fault has actually increased it” (Michael D. Jaffe & Joseph Chiu, Esqs., Using Independent Medical Examiners in No-Fault, NYLJ, May 10, 2001, at 1, col 1). The lower courts of New York are now teeming with cases of first impression destined to burgeon the dockets of appellate courts trying to fill [353]*353in gaps in the law not covered by either the Legislature or State of New York Insurance Department regulations. Rather than create an exclusive, special arbitration forum in which such complex, particularized issues and claims can be heard, the Legislature’s current no-fault system threatens to engulf the state judiciary into a swamp of unresolved and tangled questions.

The current motion for reargument, headed for an appellate court, raises a unique issue of first impression under New York law. Although not precisely identified as such, the issue in the present case is whether, consistent with the Court of Appeals holding in General Ace. Ins. Group v Cirucci (46 NY2d 862 [1979] [per curiam]), an expert witness may testify at the trial of an action where his conclusion was made as a peer review following the timely denial of a no-fault claim.

Plaintiff Universal Acupuncture Pain Services, P.C. (Universal) moves for reargument of a decision of this court dated December 6, 2002, granting partial summary judgment to the plaintiff on one out of five no-fault claims, in an amount of $220 together with statutory interest and attorneys’ fees. The court ordered that the remaining four claims be adjudicated at trial upon completion of discovery.

At the oral argument of the motion for reargument, both sides stated that the issues posed by the motion raise an issue of first impression and further stated that the side that lost would surely seek appellate review. This court’s own research confirms that the legal issue posed herein is indeed novel.

It is undisputed, in the present case, that four out of five denial of claim forms issued by defendant Lumbermens Mutual Casualty Company (LMCC) were made within 30 days of receipt of plaintiffs bill. With respect to the one denial issued beyond the 30-day period, the court granted (partial) summary judgment.

Plaintiff Universal, however, believes that it was entitled to summary judgment on all five claims. Specifically, plaintiff seeks to preclude LMCC’s expert, Mike Berkley, L.Ac., nationally board certified in acupuncture and a doctor in acupuncture from offering testimony because Dr. Berkley’s peer review was performed more than 30 days after LMCC received the bills.

Each of the five claims was denied on the basis that “Concurrent care involves overlapping/excessive and/or common services, therefore this treatment is denied.” Specifically, while the assignor received acupuncture treatments, he also contemporaneously received either chiropractic or physical therapy [354]*354treatments. In this regard, LMCC states that medical necessity is not the basis for the denial (affirmation of Rhonda H. Barry, Esq., dated Jan. 2, 2003, 12, at 3). The determination to deny treatment was made in accordance with the Workers’ Compensation No-Fault Manual of 1996 and a comparison of the bills submitted for payment indicating treatment of the same body parts for the same claimed condition at the same time. Once payment is made for one form of treatment, it is denied for any other form as treatment exceeded the maximum relative units allowable for any given day.

Having denied timely four out of the five claims, LMCC then requested that Dr. Berkley perform his peer review. Dr. Berkley presented a six-page, detailed report dated January 17, 2002. Significantly, Dr. Berkley, in pertinent part, stated:

“Treating a patient with chiropractic, acupuncture and physical therapy may be of great benefit to the patient. Different medical modalities seek the same result of increased range of motion and alleviation of pain, but attempt to reach this goal through entirely different protocols. The doctors involved are all licensed professionals with professional degrees enabling them to practice their unique type of medicine. Thus, I do not find that multiple modalities given to a patient on the same day is excessive or overlapping.”

Dr. Berkley thus recognizes that chiropractic, acupuncture, and physical therapy are distinct modalities. For example, an acupuncturist may be able to alleviate the patient’s pain, so that he or she may go forward with the work required in physical therapy to rehabilitate the affected muscle, joints, or bones.

Dr. Berkley’s report, however, continues to reject the services made by plaintiff as outright “gouging” characterized by “[t]he extreme frequency and excessiveness of treatment and the exorbitant fee charged.” He further assails the lack of medical necessity, the “inadequate examination” of the patient, and “[t]he unethical nature” of the medical interpretation offered.

Plaintiff Universal does not cite Cirucci (46 NY2d 862 [1979], supra) either in its initial papers or in its motion for reargument. Plaintiff’s argument, however, is, in fact, a “Ciriicci-type” argument. In Cirucci, the Court of Appeals held:

“Although an insurer may disclaim coverage for a valid reason (Insurance Law, § 167, subd 8) the notice of disclaimer must promptly apprise the claimant with a high degree of specificity of the [355]*355ground or grounds on which the disclaimer is predicated. Absent such specific notice, a claimant might have difficulty assessing whether the insurer will be able to disclaim successfully. This uncertainty could prejudice the claimant’s ability to ultimately obtain recovery. In addition, the insurer’s responsibility to furnish notice of the specific ground on which the disclaimer is based is not unduly burdensome, the insurer being highly experienced and sophisticated in such matters.” (46 NY2d at 864 [emphasis added]; accord, Mount Vernon Fire Ins. Co. v Harris, 193 F Supp 2d 674 [ED NY 2002]; State Farm Mut. Auto. Ins. Co. v Cooper, — AD2d —, 2003 WL 734182 [2d Dept, Mar. 3, 2003]; Abreu v Chiung Huang, 300 AD2d 420 [2d Dept 2002]; Paul M. Maintenance, Inc. v Transcontinental Ins. Co., 300 AD2d 209 [1st Dept 2002]).

The plaintiff, in the current case, protests that any consideration of Dr. Berkley’s report undermines the requirement that an insurer generally has 30 days to approve or deny a claim. Plaintiffs position is unfounded. First, in support of its position, plaintiff cites Atlantis Med. v Liberty Mut. Ins. Co. (2002 NY Slip Op 40043 [U] [Nassau Dist Ct 2002]). Atlantis Med. is inapposite. In that case, plaintiff, as an assignee, sought recovery of no-fault benefits. The defendant insurer’s denial of claim form had been issued more than 30 days after plaintiff submitted the required no-fault verification forms. The insurer’s “delay” letters explained that the assignor’s accident and injuries were being investigated and sought a delay for completion of peer review. The insurer did not request additional verification. The court in Atlantis Med. simply held that an insurer’s submission of a claim for “peer review” does not constitute a proper request for verification and cannot extend the 30 days to act on a claim provided by Insurance Law § 5106.

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Bluebook (online)
195 Misc. 2d 352, 758 N.Y.S.2d 795, 2003 N.Y. Misc. LEXIS 261, Counsel Stack Legal Research, https://law.counselstack.com/opinion/universal-acupuncture-pain-services-pc-v-lumbermens-mutual-casualty-co-nycivct-2003.