No-Fault Case Law

The court considered whether a provider was entitled to recover assigned first-party no-fault benefits, and whether the insurance company had reimbursed the provider properly and in a timely manner. The main issues were whether the insurance company had properly reimbursed the provider for some services according to the workers' compensation fee schedule and whether the denial of reimbursement for other services was justified due to a lack of medical necessity. The court held that there was a triable issue of fact regarding the medical necessity of the denied claims and that the insurance company failed to establish their defense that they had properly paid according to the workers' compensation fee schedule. As a result, the court affirmed the denial of the insurance company's cross motion for summary judgment dismissing the complaint.

In this case, Pro-Align Chiropractic, as assignee of Fatoumata Kouyate, sought reimbursement of assigned first-party no-fault benefits for medical services provided to its assignor after an automobile accident. The defendant, Travelers Property Casualty Insurance Company, sought summary judgment for dismissal of the complaint, arguing that plaintiff's assignor failed to fully comply with defendant's written verification requests. The court denied defendant's motion for summary judgment and granted plaintiff's cross-motion for summary judgment for the relief demanded in the complaint. The court reached this decision based on no-fault regulations and Insurance Law § 5106 (a), stating the insurer must request and receive necessary information to process and verify the applicant's claim, but the scope of the requested materials is not unlimited and must have "good reasons" to demand verification. Additionally, insurers must follow the basic principles of providing prompt and fair payment and must assist an applicant in the processing of a claim, and may not treat the applicant as an adversary.

The court considered the fact that the defendant-insurer failed to establish its entitlement to summary judgment dismissing the underlying first-party no-fault action based upon plaintiff's alleged failure to provide proof of claim. The defendant's claim specialist asserted that they had "no record of receiving" the claim, which was allegedly improperly mailed to a Florida post office box where the defendant "never accepted mail." However, the court found these assertions to be vague and conclusory, and that the defendant failed to make a prima facie showing that the claim was not properly and timely submitted. The main issue decided was whether the defendant had met its burden in proving that the claim was not properly submitted, and the court determined that they had not. The holding of the case was that the defendant's motion for summary judgment was denied, and the complaint was reinstated.

The court considered a case about a medical provider seeking payment under a first-party no-fault benefits assignment. The defendant denied the claim in part because the plaintiff did not bill the services in accordance with the applicable fee schedule. Both parties moved for summary judgment. The main issue decided was whether the "report" in a "By Report" claim is an additional form of documentation or an integral part of the bill or claim form. The court held that the report is a necessary component of the bill for a "By Report" claim, and its absence renders the claim form incomplete, failing to satisfy the prima facie requirements laid out in Viviane Etienne, and therefore failing to trigger the insurer's obligation to timely pay or deny the claim. Therefore, plaintiff's motion to renew and reargue was denied.

The main issues in this case were whether the defendant had a reasonable excuse for its delay in serving an answer and whether the defendant had a meritorious defense to the action. The court found that the defendant had established a reasonable excuse for its failure to serve an answer and had made a prima facie showing of a viable defense based on a lack of medical necessity. As a result, the court reversed the order, denying the plaintiff's motion to enter a default judgment and granting the defendant's cross motion to open its default in answering and to compel the plaintiff to accept a late answer. Therefore, the holding of the case was in favor of the defendant, and the plaintiff's motion was denied while the defendant's cross motion was granted.

The court considered the fact that the defendant had moved for summary judgement to dismiss a complaint by a provider seeking to recover assigned first-party no-fault benefits, on the basis that the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs). The Civil Court had denied the defendant's motion, but made findings that the denial of claim form had been timely and proper, and that the sole issue for trial was whether the plaintiff's assignor had failed to appear for the scheduled IMEs. The main issue decided was whether the plaintiff's assignor had failed to appear for the scheduled IMEs, and the holding of the appellate term was that the defendant's motion for summary judgment was granted, reversing the order of the Civil Court. The court found that the affirmation submitted by the doctor who was to perform the IMEs was sufficient to establish that the plaintiff's assignor had failed to appear for the scheduled IMEs, and as the plaintiff had not challenged the finding that the defendant was otherwise entitled to judgement, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the appeal from an order of the Civil Court of the City of New York, Queens County, which granted the defendant's motion for summary judgment dismissing the second through seventh causes of action in a case where a provider sought to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff's assignor had failed to appear for duly scheduled examinations under oath. The court affirmed the order, holding that the plaintiff's assignor had indeed failed to appear for the scheduled examinations under oath, and therefore, the defendant's motion for summary judgment was granted. The decision was consistent with a previous case, Greenway Med. Supply Corp., as Assignee of Tellechea Maria v Travelers Ins. Co., which was decided at the same time and provided similar grounds for affirming the lower court's decision.

The case involves Radiology Today, P.C. suing Geico Ins. Co. to recover assigned first-party no-fault benefits for services provided to its assignor. The main issue was whether the peer review report could be admitted into evidence at trial to prove the insurer's defense of lack of medical necessity. The court held that an insurer cannot use a peer review report at trial for its "truth" to prove the defense and that this would be impermissible bolstering of the expert's testimony. The court directed a verdict in favor of plaintiff, but the Appellate Term reversed and remitted the matter for a new trial on the first cause of action, indicating that a new trial is required to determine whether the services at issue were medically necessary.

The relevant facts considered by the court were that Greenway Medical Supply Corp. was seeking to recover first-party no-fault benefits as an assignee of Castillo Teofilo from Travelers Insurance Company. The issue decided was whether the lower court had erred in granting the defendant's motion for summary judgment dismissing the complaint on the grounds that the plaintiff had failed to appear for scheduled examinations under oath. The holding of the case was that the lower court's decision to grant the defendant's motion for summary judgment was affirmed, and the plaintiff's complaint was dismissed. The court based its decision on a similar case involving the same plaintiff and defendant, wherein it reached the same conclusion.

The court considered whether the provider had failed to appear for scheduled examinations under oath (EUOs) and whether the denial of claim form had been timely mailed. The main issue was whether the provider had failed to appear for the EUOs as required, and whether the denial of claim form had been timely mailed. The court held that the provider had failed to appear for the EUOs, as evidenced by the affirmation submitted by the defendant's attorney. The court also held that the denial of claim form had been timely mailed, as established by the affidavits submitted by the defendant. As a result, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.