No-Fault Case Law
LMS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51655(U))
November 16, 2018
An insurer need not state objective reasons for requesting EUOs to establish prima facie entitlement to summary judgment for nonappearance. The provider challenged both the proof of its EUO nonappearances and the absence of objective reasons for the requests. The Appellate Term, Second Department, found the nonappearance proof sufficient. Under Interboro Ins. Co. v Clennon, the insurer need only establish two duly demanded EUOs, two failures to appear, and a timely denial of the claims. The appellate court affirmed the Civil Court, Kings County, order granting the insurer summary judgment dismissing the provider's assigned no-fault benefits complaint.
Pavlova v Allstate Ins. Co. (2018 NY Slip Op 51654(U))
November 16, 2018
An insurer must request missing documentation for a "By Report" claim before denying payment for insufficient documentation. The provider billed services under CPT code 20999 without the additional documentation needed to determine reimbursement. Under 11 NYCRR 65-3.5 (b), an insurer unwilling to pay the claim as submitted must request necessary verification within 15 business days of receiving it. The insurer did not demonstrate such a request. The Appellate Term, Second Department, modified the Civil Court, Kings County, order, insofar as appealed from, to deny the insurer's cross motion concerning those services. It upheld denial of the provider's motion because the provider failed to show an untimely denial or a timely denial that was conclusory, vague, or legally meritless.
Gentlecare Ambulatory Anesthesia Services; Lyonel F. Paul, M.D. v GEICO Ins. Co. (2018 NY Slip Op 51653(U))
November 16, 2018
The insurer's proof established presumptively timely mailing of EUO notices and the denial, as well as the provider's nonappearances. The provider appealed the denial of its summary judgment motion and the grant of the insurer's cross motion dismissing the assigned no-fault benefits complaint. The Appellate Term, Second Department, rejected challenges to mailing and nonappearance proof and held that the insurer need not supply objective reasons for requesting EUOs to establish prima facie entitlement to summary judgment. It declined to consider another argument concerning the cross motion because the provider raised it for the first time on appeal. The Civil Court, Queens County, order was affirmed in the insurer's favor.
Parisien v 21st Century Ins. Co. (2018 NY Slip Op 51652(U))
November 16, 2018
The insurer established timely mailing of the denial forms asserting lack of medical necessity, defeating the provider's appellate challenge. The provider sought assigned first-party no-fault benefits and appealed an order denying its summary judgment motion and granting the insurer's cross motion dismissing the complaint on medical necessity grounds. The Appellate Term, Second Department, rejected the provider's mailing argument and affirmed the Civil Court, Kings County, order in the insurer's favor.
All Healthy Style Med., P.C. v Ameriprise Ins. Co. (2018 NY Slip Op 51651(U))
November 16, 2018
The insurer's summary judgment motion based on an alleged material misrepresentation of the assignor's residence was denied on appeal. The Appellate Term, Second Department, reversed the Civil Court, Kings County, order dismissing the provider's assigned no-fault benefits complaint, relying on the reasons stated in Liliya Veksler, LCSW, P.C. v Ameriprise Ins. Co.
All Healthy Style Med., P.C. v Ameriprise Ins. Co. (2018 NY Slip Op 51650(U))
November 16, 2018
The insurer's summary judgment motion based on an alleged material misrepresentation of the assignor's residence was denied on appeal. The Appellate Term, Second Department, reversed the Civil Court, Kings County, order dismissing the provider's assigned no-fault benefits complaint, relying on the reasons stated in Liliya Veksler, LCSW, P.C. v Ameriprise Ins. Co.
PR Med., P.C. v Travelers Home & Mar. Ins. Co. (2018 NY Slip Op 51649(U))
November 16, 2018
The insurer established timely EUO notices and denials and the assignor's two nonappearances; the provider raised no triable issue. The insurer moved for summary judgment dismissing the provider's assigned no-fault benefits complaint on EUO nonappearance grounds. Its proof showed timely mailing of the initial and follow-up scheduling letters, nonappearance on both scheduled dates, and timely denials based on those failures. The Appellate Term, Second Department, reversed the Civil Court, Kings County, order denying the motion and granted summary judgment dismissing the complaint in the insurer's favor.
Solution Bridge, Inc. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51648(U))
November 16, 2018
The provider's affidavit raised a triable issue whether it supplied verification requested under the 120-day rule. The insurer sought summary judgment dismissing the assigned no-fault benefits complaint under 11 NYCRR 65-3.5 (o). Its proof established prima facie timely mailing of initial and follow-up requests, nonreceipt of the requested verification, and timely denial on that ground. The provider's opposing affidavit, however, created a presumption that the verification had been mailed to and received by the insurer. The Appellate Term, Second Department, reversed the Civil Court, Kings County, order and denied the insurer's motion, allowing the provider's action to proceed.
Acupuncture Now, P.C. v GEICO Ins. Co. (2018 NY Slip Op 51647(U))
November 16, 2018
The insurer's cross motion for summary judgment on the fee-schedule defense to claims billed under CPT codes 97810 and 97811 was granted on appeal. The Appellate Term, Second Department, reversed the Civil Court, Kings County, order, insofar as appealed from, and dismissed those claims for the reasons stated in the companion appeal decided the same day, No. 2016-1377 K C.
Maiga Prods. Corp. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51646(U))
November 16, 2018
The insurer established timely EUO notices and denials and the provider's two nonappearances, with no triable issue raised in opposition. The insurer sought summary judgment dismissing the provider's assigned no-fault benefits complaint. Its proof showed timely mailing of initial and follow-up EUO scheduling letters, the provider's failure to appear on either date, and timely denial of the claims on that ground. The Appellate Term, Second Department, reversed the Civil Court, Kings County, order denying the insurer's motion and granted summary judgment dismissing the complaint.