No-Fault Case Law

The court considered the denial of payment of first-party no-fault benefits by an insurance company to an acupuncture provider. The main issues decided were whether the insurance company sufficiently demonstrated that the denial of claim forms had been timely mailed, and whether the provider had failed to demonstrate its entitlement to summary judgment. The holding of the court was that the insurance company did not sufficiently demonstrate that the denial of claim forms had been timely mailed, and therefore was not entitled to summary judgment dismissing the first three causes of action. The court modified the order to deny the branches of the insurance company's cross-motion seeking summary judgment dismissing the first through third causes of action.

The case involved Adelaida M. Laga, P.T., as the assignee of Mustapha, Jimoh, who was suing GEICO Ins. Co. for first-party no-fault benefits. The Civil Court granted the plaintiff's motion for summary judgment and denied GEICO's cross motion for summary judgment dismissing the complaint, awarding the plaintiff $3,344.87. GEICO appealed, arguing that the court improperly granted plaintiff's motion for summary judgment and citing various cases to support their argument. The Appellate Term, Second Department, held that the plaintiff failed to establish prima facie case for summary judgment, as the proof submitted did not demonstrate that the claim at issue had not been timely denied, or that GEICO had issued a timely denial of claim that was conclusory, vague, or without merit as a matter of law. However, the court also held that GEICO's cross motion for summary judgment was properly denied, as the papers submitted did not establish, as a matter of law, that the fees charged exceeded the amounts set forth in the workers' compensation fee schedule, or that plaintiff's assignor had failed to appear for independent medical examinations. Therefore, the judgment was reversed, and the plaintiff's motion for summary judgment was denied.

The court considered the issues of whether the fees charged for the services exceeded the amounts set forth in the workers' compensation fee schedule, and whether the defendant had used the correct conversion factor in calculating the reimbursement rate and appropriately applied Ground Rule 11. The court held that the defendant failed to establish its defense that the fees charged exceeded the amounts set forth in the workers' compensation fee schedule, and also failed to demonstrate that it had used the correct conversion factor in calculating the reimbursement rate or that it had appropriately applied Ground Rule 11. Therefore, the court denied the branches of the defendant's cross motion seeking summary judgment dismissing the first, second and fourth causes of action.

The relevant facts considered by the court in this case were that the plaintiff, a medical equipment provider, was seeking to recover first-party no-fault benefits on behalf of an injured individual. The defendant, an insurance company, moved for summary judgment dismissing the complaint, alleging that the injured individual was eligible for workers' compensation benefits. The Civil Court held the motion in abeyance pending a determination by the Workers' Compensation Board to decide the parties' rights under the Workers' Compensation Law. The main issue decided in this case was whether the court had jurisdiction to hear the appeal, and the holding of the court was that the appeal was dismissed as the order being appealed from did not decide the defendant's motion, but instead held the motion in abeyance pending a determination by the Workers' Compensation Board. Therefore, the court declined to grant leave to appeal.

The court considered the denial of plaintiff's motion for summary judgment and the granting of the defendant's cross motion for summary judgment dismissing the complaint. The main issue was the failure of the plaintiff's assignor to appear for scheduled examinations under oath. The holding of the case was that, while defendant did not demonstrate entitlement to summary judgment dismissing the complaint, plaintiff also failed to establish that the claims at issue had not been timely denied or that the defendant had issued a timely denial of claim. Therefore, defendant's cross motion for summary judgment dismissing the complaint was denied.

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits. The court found that the defendant had adequately demonstrated payment in accordance with the workers' compensation fee schedule for the claims underlying the first, fourth, and fifth causes of action. It was decided that the defendant did not appropriately reduce the claims in accordance with the workers' compensation Ground Rules for the claims underlying the second, third, and sixth through tenth causes of action. The court held that the branches of the defendant's motion seeking summary judgment dismissing the second, third, and sixth through eighth causes of action were denied, and the findings on the ninth and tenth causes of action were vacated.

The court considered the issues in an action to recover assigned no-fault benefits for treatment rendered to plaintiff's assignor for injuries sustained in a motor vehicle accident. The main issues included lack of medical necessity for the treatment, billing in excess of the applicable fee schedule, and lack of authority to do business in the State of New Jersey. The court granted the defendant's motion for summary judgment, reducing the amount in dispute to $9,160.08 based on the uncontested merits of the fee schedule defense. However, the court denied the motion in all other respects, finding material facts in dispute as to the medical necessity of the treatment provided. The court also concluded that the failure to obtain a certificate of authority to transact business in New Jersey did not warrant claim preclusion, and that the insurer could not rely solely on this to delay or withhold payment. The court determined that the plaintiff had established its prima facie case, and that the defendant had established its timely denial of the assigned no-fault benefits, so there were material facts in dispute to be decided at a trial.

The relevant fact that the court considered was that the plaintiffs, who issue automobile insurance policies, wanted to seek judgment in court that they were not obligated to pay any past, pending, or future claims for no-fault benefits submitted to them by the defendants based on fraudulent incorporation on the grounds that defendants were fraudulently incorporated in the names of licensed medical professionals, while they were owned, operated, and controlled by a nonphysician. The main issue that the court considered was whether an insurance carrier may withhold payment for medical services provided by a professional corporation which has been fraudulently incorporated to allow nonphysicians to share in its ownership and control. The holding of the court was that the trial court should reversed the order, as the documented evidence did not show that the defendant exercised dominion and control over the assets of the professional corporation. Thus, the plaintiffs failed to demonstrate their prima facie entitlement to judgment as a matter of law and the motion for summary judgment was denied.

The main issue in this case was whether a provider could recover assigned first-party no-fault benefits when the plaintiff had failed to appear for scheduled examinations under oath. The court considered the motion for summary judgment by the plaintiff, as well as the cross-motion for summary judgment by the defendant. The court ultimately decided to vacate the portion of the order that awarded defense counsel $250 in "fees," and affirmed the rest of the order without costs. The holding was based on the reasoning stated in a related case, and the decision was made by Justices Michelle Weston, Michael L. Pesce, and Martin M. Solomon.

The relevant facts considered by the court were that plaintiff Gentlecare Ambulatory Anesthesia Services sought to recover assigned first-party no-fault benefits from defendant Geico Ins. Co. The main issue decided in the case was whether plaintiff had failed to appear for scheduled examinations under oath, which led to defendant cross-moving for summary judgment to dismiss the complaint. The holding of the case was that the order denying plaintiff's motion for summary judgment, granting defendant's cross motion for summary judgment, and awarding defense counsel $250 in "fees" was modified by vacating the portion awarding defense counsel the "fees." The court also referred to a similar case decided herewith to support its decision.