No-Fault Case Law
Careful Complete Med., P.C. v Delos Ins. Co. (2017 NY Slip Op 51867(U))
December 22, 2017
The court considered the fact that a provider was seeking to recover assigned first-party no-fault benefits, and that the complaint had been dismissed by the lower court following a motion for summary judgment by the defendant. The main issue decided was whether the defendant was entitled to summary judgment based on the plaintiff's failure to appear for examinations under oath (EUOs). The court held that the defendant failed to demonstrate that it was entitled to summary judgment, as the initial EUO request had been sent more than 30 days after the defendant had received the claims at issue, making the requests nullities as to those claims. Therefore, the judgment was reversed, the order was vacated, and the defendant's motion for summary judgment dismissing the complaint was denied.
Healthy Way Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51865(U))
December 22, 2017
The relevant facts of the case involved Healthy Way Acupuncture, P.C. seeking to recover no-fault benefits assigned to them from State Farm Mutual Automobile Insurance Co. The main issue decided in the case was whether State Farm's motion for summary judgment dismissing the complaint based on Healthy Way Acupuncture's failure to appear for scheduled examinations under oath was valid. The court held that State Farm had sufficiently established Healthy Way Acupuncture's failure to appear for scheduled examinations under oath, and therefore affirmed the order granting State Farm's motion for summary judgment dismissing the complaint.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51864(U))
December 22, 2017
The court considered a dispute between Z.M.S. & Y Acupuncture, P.C. and GEICO General Insurance Company regarding the reimbursement for medical services provided. Z.M.S. & Y Acupuncture, P.C. sought to recover first-party no-fault benefits, and GEICO General Insurance Company argued that they had fully paid for the services in accordance with the workers' compensation fee schedule. Specifically, the court focused on the claims for services billed under CPT codes 97810, 97811, 97813, and 97814. The main issues decided were whether the fee schedule was properly applied and whether GEICO General Insurance Company was required to reimburse Z.M.S. & Y Acupuncture, P.C. for the services. The holding of the case was that GEICO General Insurance Company's cross-motion for summary judgment to dismiss the claims for services billed under CPT codes 97811, 97813, and 97814 was granted. The decision was affirmed with modification.
Oleg’s Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51863(U))
December 22, 2017
The main issue in the case was whether the defendant had fully paid the plaintiff for acupuncture services billed under specific CPT codes in accordance with the workers' compensation fee schedule. The court considered the proof submitted by the defendant to show that the denial of claim forms had been timely mailed and that the plaintiff had been fully paid for the services in question. The court held that the defendant had demonstrated that they had fully paid the plaintiff for the services in accordance with the fee schedule, and the plaintiff had failed to raise a triable issue of fact in opposition. As a result, the court reversed the order and granted the branches of the defendant's cross motion seeking summary judgment dismissing the claims for services billed under the specific CPT codes.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51862(U))
December 22, 2017
The court considered a case in which a provider was seeking to recover first-party no-fault benefits and the defendant insurance company argued that it had already fully paid the provider in accordance with the workers' compensation fee schedule. The main issue decided was whether the defendant's cross motion for summary judgment dismissing the complaint on the grounds that it had already paid the provider in accordance with the fee schedule should be granted. The holding of the court was that the branches of the defendant's cross motion seeking summary judgment dismissing the claims for services billed under certain CPT codes were granted, affirming the order entered by the Civil Court with modifications.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51861(U))
December 22, 2017
The main issues in this case revolved around whether or not defendant's cross motion for summary judgment should be granted, seeking to dismiss the claims for services billed under specific CPT codes. The court considered whether the defendant had fully paid the plaintiff for the services at issue in accordance with the workers' compensation fee schedule. The Court found that the branches of defendant's cross motion seeking summary judgment dismissing so much of the complaint as sought to recover upon claims for services billed under CPT codes 97811, 97813 and 97814 are granted. Therefore, the order was affirmed, without costs. The main holding of the court was that the defendant's cross motion was granted in part, and denied in part, due to the proper application of the fee schedule.
Z.M.S. & Y Acupuncture, P.C. v GEICO Gen. Ins. Co. (2017 NY Slip Op 51860(U))
December 22, 2017
The case involved a dispute over the payment for acupuncture services billed under certain CPT codes by Z.M.S. & Y Acupuncture, P.C. Defendant, GEICO General Insurance Company, cross-moved for summary judgment, arguing that it had fully paid the plaintiff in accordance with the workers' compensation fee schedule. The Civil Court had limited the issues for trial to the proper application of the fee schedule and the defendant appealed the denial of summary judgment dismissing the claims for services billed under certain CPT codes. The defendant was able to demonstrate that it had fully paid the plaintiff for some of the services in accordance with the fee schedule, but failed to establish, as a matter of law, that it had properly paid for services billed under a certain CPT code. The Appellate Term held that defendant's cross motion for summary judgment should have been granted as to some services, but not for others. Therefore, the order denying summary judgment was modified to grant the cross motion in part.
Careful Complete Med., P.C. v Hartford Ins. Co. (2017 NY Slip Op 51858(U))
December 22, 2017
The court considered the fact that the plaintiff had failed to appear for scheduled examinations under oath (EUOs), which led to a motion for summary judgment by the defendant to dismiss the complaint. The main issue decided was whether the defendant's attorney's affirmation was sufficient to establish the plaintiff's failure to appear for the EUOs, and if the proof submitted by the defendant was enough to give rise to a presumption that EUO scheduling letters and the denial of claim forms had been properly mailed. The holding of the case was that the order granting the defendant's motion for summary judgment was affirmed, as the proof submitted was sufficient to establish the plaintiff's failure to appear for the EUOs and give rise to a presumption of proper mailing.
Right Aid Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51857(U))
December 22, 2017
The relevant facts considered by the court in this case were that Right Aid Medical Supply Corp. was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. State Farm moved for summary judgment, arguing that the action was premature because Right Aid had failed to provide requested verification. The main issue decided was whether the action was premature due to the failure to provide verification. The holding of the case was that there was a triable issue of fact as to whether the action was premature, as Right Aid submitted an affidavit from an employee that was sufficient to give rise to a presumption that the requested verification had been mailed to and received by State Farm. Therefore, the court reversed the order and denied State Farm's motion for summary judgment dismissing the complaint.
W.H.O. Acupuncture, P.C. v Country-Wide Ins. Co. (2017 NY Slip Op 51856(U))
December 22, 2017
The main legal issues in this case revolved around a provider's attempt to recover first-party no-fault benefits from an insurance company. The court considered the provider's motion for summary judgment and the insurance company's cross motion for summary judgment dismissing the complaint. The court ultimately denied the provider's motion and granted the insurance company's cross motion, affirming the order. The holding of the case was that the provider was not entitled to recover the assigned first-party no-fault benefits from the insurance company. This decision was based on reasoning similar to that in a related case, MT Servs. P.T., P.C., as Assignee of Richardson Steven v Country-Wide Ins. Co. The order of the Civil Court of the City of New York, Queens County was affirmed, and the costs were set at $25.