No-Fault Case Law
Renelique v American Tr. Ins. Co. (2016 NY Slip Op 51526(U))
October 13, 2016
The court considered an action by a provider to recover assigned first-party no-fault benefits. The plaintiff appealed from an order of the Civil Court which denied plaintiff's motion for summary judgment and granted defendant's cross motion for summary judgment dismissing the complaint. The main issues were regarding the fees billed by the plaintiff for certain medical services and whether they exceeded the amounts permitted by the workers' compensation fee schedule. The court held that the defendant had made a prima facie showing that it had used the assigned relative value for the medical codes in question to calculate the sum to which plaintiff was entitled to be reimbursed. The court affirmed the order of the Civil Court, denying the plaintiff's motion and granting defendant's cross motion for summary judgment.
Integrative Pain Medicine, P.C. v Allstate Ins. Co. (2016 NY Slip Op 51525(U))
October 13, 2016
The court considered an action by a provider to recover assigned first-party no-fault benefits, where the defendant had granted a cross motion for summary judgment dismissing the complaint on the condition that the plaintiff's assignor failed to appear for a new examination under oath (EUO). The main issue decided was whether appearance at an EUO is a condition precedent to coverage, which the court found to be the case. The holding of the court was that the Civil Court should not have given the plaintiff's assignor an opportunity to cure its failure to act during claims processing, and should have granted the defendant's cross motion for summary judgment unconditionally. Therefore, the order was reversed, and the conditions imposed by the Civil Court were vacated.
Renelique v National Liab. & Fire Ins. Co. (2016 NY Slip Op 51524(U))
October 13, 2016
The court considered a case in which Pierre Jean Jacques Renelique, as assignee of Rohan Streek, filed a motion for summary judgment to recover assigned first-party no-fault benefits, while the defendant, National Liability & Fire Insurance Company, cross-moved for summary judgment to dismiss the complaint based on the assignor's failure to appear for independent medical examinations (IMEs). The main issue was whether the defendant's submissions were sufficient to give rise to a presumption that the IME scheduling letters and denial of claim form had been properly mailed. The court held that the defendant's submissions were indeed sufficient to establish this presumption, and therefore affirmed the order denying plaintiff's motion for summary judgment and granting the defendant's cross motion.
Prime Diagnostic Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51523(U))
October 13, 2016
The court considered the fact that the plaintiff was seeking to recover first-party no-fault benefits as an assignee, and that the defendant had filed a motion for summary judgment dismissing the complaint on the basis that the plaintiff's assignor had failed to appear for independent medical examinations (IMEs). The main issue decided was whether the proof submitted by the defendant was sufficient to give rise to a presumption that the IME scheduling letters and the denial of claim form had been properly mailed, and if the plaintiff's assignor had failed to appear for the IMEs. The court held that the proof submitted by the defendant was indeed sufficient to establish the presumption, and that the argument raised by the plaintiff regarding the address used on the IME scheduling letters was not considered as it was being raised for the first time on appeal. The court ultimately affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.
Integrative Pain Medicine, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51520(U))
October 13, 2016
The court considered a case in which a provider was seeking to recover assigned first-party no-fault benefits. The defendant had cross-moved for summary judgment to dismiss the complaint on the grounds that the plaintiff's assignor had failed to appear for duly scheduled examinations under oath (EUOs). The main issue decided was whether the EUO scheduling letters had been properly mailed, and the Civil Court denied both motions but limited the issue for trial. The holding of the court was that the proof submitted by the defendant in support of its cross motion failed to establish a practice and procedure sufficient to give rise to a presumption that the EUO scheduling letters had been properly mailed, and therefore, the order was affirmed.
New Way Med. Supply Corp. v American Tr. Ins. Co. (2016 NY Slip Op 51518(U))
October 13, 2016
The court considered the denial of plaintiff's motion for summary judgment and the granting of defendant's cross motion for summary judgment in a case where a provider sought to recover assigned first-party no-fault benefits. The main issue decided was whether the provider was entitled to recover assigned first-party no-fault benefits from the insurance company, and the court ultimately held that the order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment was affirmed. The court's decision was based on the reasoning stated in Metro Health Prods., Inc. as Assignee of Omar Boyce v American Tr. Ins. Co., and the decision was made by Pesce, P.J., Aliotta and Solomon, JJ. on October 13, 2016.
Metro Health Prods., Inc. v American Tr. Ins. Co. (2016 NY Slip Op 51517(U))
October 13, 2016
The court considered the fact that the plaintiff, Metro Health Products, Inc., was seeking to recover assigned first-party no-fault benefits from the defendant, American Transit Insurance Company. The main issue in the case was whether the defendant had provided proof that examination under oath (EUO) scheduling letters had been properly mailed, and whether the plaintiff's assignor had failed to appear for the EUOs. The court ultimately held that the proof submitted by the defendant was sufficient to give rise to a presumption that the EUO scheduling letters had been properly mailed, and that the plaintiff's assignor had indeed failed to appear for the EUOs. As a result, the court affirmed the order that denied the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment dismissing the complaint.
Sal Med., P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51516(U))
October 13, 2016
The court considered a case involving a dispute over first-party no-fault benefits for medical services provided by the plaintiffs. The main issues decided in the case were whether the services rendered on specific dates were medically necessary and whether the defendant insurance company was entitled to summary judgment dismissing the claims for those services. The holding of the court was that the branches of the defendant's cross motion seeking summary judgment dismissing the claims for services rendered on July 23, 2008, and from March 24, 2009, to April 23, 2009 were granted. The court reversed the order of the Civil Court and ruled in favor of the defendant insurance company, granting their motion to dismiss the claims for those specific dates.
Al Acupuncture, P.C. v Praetorian Ins. Co. (2016 NY Slip Op 51515(U))
October 13, 2016
The court considered the fact that the plaintiff, AL Acupuncture, P.C., had moved for summary judgment to recover assigned first-party no-fault benefits, while the defendant, Praetorian Insurance Company, cross-moved for summary judgment to dismiss the complaint based on lack of medical necessity. The specific issue at hand was the medical necessity of the claims for services rendered from October 27, 2008 to April 23, 2009. The court ultimately held that the defendant's cross motion seeking summary judgment to dismiss those claims was granted. The court noted that the defendant had submitted a sworn report of an independent medical examination, which demonstrated a lack of medical necessity for the services in question, and the plaintiff had failed to oppose this evidence. As a result, the court found in favor of the defendant and reversed the previous order, granting the branch of the defendant's cross motion seeking summary judgment dismissing the claims in question.
Matter of Unitrin Advantage Ins. Co. Kemper A. Unitrin Bus. v Professional Health Radiology (2016 NY Slip Op 06767)
October 13, 2016
In the case of Matter of Unitrin Advantage Insurance Company v Professional Health Radiology, the court considered Unitrin's petition to vacate a no-fault master arbitration award. The main issue was whether Unitrin failed to establish that it was entitled to deny Professional Health's claims on the ground that the assignors, Nestor and Anggi Camacho did not appear for independent medical examinations. The court held that Unitrin failed to meet the mandatory notice requirements governing insurer requests for independent medical examinations, and that it should pay the attorney's fees in connection with securing payment of the overdue claim.
In other words, the court's decision was to deny Unitrin's petition to vacate the no-fault master arbitration award, and to confirm the award in favor of Professional Health Radiology. They also granted the counterclaim for attorney's fees and remanded the matter to the trial court for further proceedings to determine those fees.