No-Fault Case Law

The court considered the denial of the defendant's motion for summary judgment to dismiss the complaint by Kensington Radiology Group, P.C., seeking first-party no-fault benefits. The main issue decided was whether there was a triable issue of fact regarding the medical necessity of the services at issue. The holding of the case was that the court affirmed the order denying the defendant's motion for summary judgment, as there was a triable issue of fact regarding the medical necessity of the services. Therefore, the order was affirmed, and the plaintiff was allowed to proceed with the case to recover assigned first-party no-fault benefits.

The relevant facts considered by the court were that the plaintiff, Acupuncture Now, P.C., as an assignee of Franco, Nereyda, appealed from an order of the Civil Court of the City of New York, Queens County (Jodi Orlow, J.), denying plaintiff's motion for summary judgment and granting the branches of defendant's cross motion seeking summary judgment. The court found that defendant had established timely denials of the claims underlying that portion of the complaint. The main issue decided was whether defendant's proof established the proper mailing of the denial of claim forms and the application of the workers' compensation fee schedule. The holding of the case was that the order, insofar as appealed from, was affirmed. The court found that defendant had established the timely denials of the claims and that the application of the workers' compensation fee schedule also lacked merit.

The relevant facts of this case involve an action by a provider seeking to recover assigned first-party no-fault benefits. The plaintiff appealed from an order of the Civil Court, which granted the defendant's motion seeking summary judgment dismissing the complaint's claims to recover for services billed under specific CPT codes. The main issue in this case was whether the defendant had established, as a matter of law, its defense that the fees charged for the services exceeded the amounts set forth in the workers' compensation fee schedule. The court held that the defendant had failed to demonstrate that it had used the correct conversion factor in calculating the reimbursement rate. As a result, the branches of the defendant's motion seeking summary judgment dismissing the complaint's claims to recover for those services were denied, and the order was reversed.

The relevant facts the court considered in this case involved an action by a medical care provider to recover assigned first-party no-fault benefits. The main issues decided by the court were whether the defendant was entitled to summary judgment dismissing the third through tenth causes of action, and whether the plaintiff was entitled to summary judgment on these causes of action. The holding of the case was that the defendant was not entitled to summary judgment dismissing the third cause of action and that the plaintiff was not entitled to summary judgment on the fourth through tenth causes of action. The court found that the defendant had failed to establish its defense that the fees charged exceeded the amounts set forth in the workers' compensation fee schedule, and that the initial and follow-up letters scheduling independent medical examinations had not been timely mailed. Therefore, the order was modified to deny the branches of the defendant's cross motion seeking summary judgment dismissing the third through tenth causes of action.

The court considered whether the defendant, Global Liberty Insurance, was entitled to summary judgment dismissing the complaint filed by Faith Acupuncture, P.C. as the assignee of Quinche Mauro, seeking first-party no-fault benefits. The main issues decided were whether the defendant established its defense that the fees charged exceeded the amounts set forth in the workers' compensation fee schedule, and whether the defendant demonstrated that the independent medical examinations (IMEs) had been properly scheduled and that the plaintiff's assignor had failed to appear at duly scheduled IMEs. The holding of the case was that the defendant failed to establish its defenses as a matter of law, and therefore, its motion for summary judgment dismissing the complaint was denied.

The case involved an action by a provider to recover assigned first-party no-fault benefits. The defendant argued that the plaintiff's assignor had been injured during the course of his employment, and therefore workers' compensation benefits might be available. The Civil Court denied the defendant's motion and granted the plaintiff's cross motion for summary judgment. However, the Appellate Term held that there was a sufficient issue as to whether the plaintiff's assignor had been acting in the course of his employment at the time of the accident and therefore the matter should be determined by the Workers' Compensation Board. The Appellate Term reversed the lower court's order and remitted the case back to the Civil Court to be held in abeyance pending a determination by the Workers' Compensation Board of the parties' rights under the Workers' Compensation Law.

The court considered a case in which Precious Acupuncture Care, P.C. was attempting to recover first-party no-fault benefits from GEICO General Insurance Company. Precious Acupuncture Care sought summary judgment, while GEICO cross-moved to dismiss part of the complaint. The issue at hand was whether GEICO had fully paid for the services in accordance with the workers' compensation fee schedule, and if the claims for services rendered on certain dates had been untimely submitted. The court found that GEICO had indeed paid in accordance with the fee schedule and that the claims for services on specific dates had been untimely submitted. Therefore, the court held in favor of GEICO and granted the branches of their cross motion seeking summary judgment dismissing the portion of the complaint related to those claims.

The relevant facts considered by the court in this case were that the defendant, an insurance company, had denied a provider's claim for first-party no-fault benefits based on the provider's alleged failure to provide requested verification. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint. The holding of the court was that the denial of the defendant's motion for summary judgment was affirmed because the plaintiff had submitted an affidavit in opposition to the motion that was sufficient to create a presumption that the requested verification had been mailed to and received by the defendant, thus creating a triable issue of fact as to whether the action was premature. Therefore, the court held that the denial of the defendant's motion for summary judgment was appropriate.

The court considered the defendant's motion for summary judgment dismissing the complaint and the plaintiff's cross-motion for summary judgment. The issue before the court was whether the plaintiff had failed to appear for examinations under oath (EUOs) and whether the EUO scheduling letters and the denial of claim form were timely mailed. The court held that while the plaintiff had failed to appear for scheduled EUOs, the defendant failed to establish that the first EUO scheduling letter had been timely, and did not demonstrate that the claims were timely denied. As a result, the court denied the branches of the defendant's motion seeking summary judgment dismissing the claims for $72.92, $397.30, $208.30, and $540.15, and granted the branches of the plaintiff's cross-motion seeking summary judgment upon those claims.

The Court considered the appeal of an order of the Civil Court grant for summary judgment for the plaintiff in an action by a provider to recover assigned first-party no-fault benefits. The defendant carrier had denied the claim from plaintiff Vital Function Physician Services, P.C. for failing to appear for scheduled examinations under oath (EUOs). At issue was whether the defendant’s denial of claim forms were improper since they did not set forth the dates of the EUOs for which plaintiffs had failed to appear. The Court found that the branch of plaintiffs' motion seeking summary judgment upon so much of the complaint as sought to recover upon the claims submitted by plaintiff Vital Function Physician Services, P.C. is denied and the branch of defendant's cross-motion seeking summary judgment dismissing that portion of the complaint is granted.