No-Fault Case Law

The court considered the fact that the plaintiff, Sin Medical, P.C., was seeking to recover assigned first-party no-fault benefits from Travelers Insurance Company. The main issues decided included the failure of the plaintiff's assignor to appear for duly scheduled examinations under oath (EUOs), the submission of the claim form, and the timely denial of the claim by the defendant. The court ultimately held that the defendant's cross motion for summary judgment dismissing the complaint was granted. The defendant had established that it had timely mailed the EUO scheduling letters, and that the plaintiff's assignor had failed to appear for the duly scheduled EUOs. The court found that the letters were not offered for a hearsay purpose, and therefore did not need to qualify as business records pursuant to CPLR 4518.

The court considered the denial of claim forms, as well as sworn independent medical examination (IME) reports. The main issue decided was whether the defendant's cross motion for summary judgment dismissing the complaint should be granted. The holding was that defendant's cross motion for summary judgment dismissing the complaint was granted, as the denial of claim form at issue had been timely mailed and fully paid, and the sworn IME report set forth a factual basis and medical rationale for the doctor's conclusion that there was a lack of medical necessity for further treatment. Therefore, the complaint was dismissed.

The relevant facts of this case involved a medical supplies company, Bay LS Medical Supplies, Inc., seeking to recover assigned first-party no-fault benefits from Allstate Insurance Company. Plaintiff moved for summary judgment, which was granted on the first cause of action, denied on the second cause of action, and resulted in a judgment awarding the plaintiff $750. On appeal, defendant argued that plaintiff failed to establish entitlement to summary judgment and that the cross motion for summary judgment dismissing the second cause of action should have been granted. The court held that plaintiff failed to establish their entitlement to summary judgment on the first cause of action, and defendant's proof that the denial of claim form had been timely mailed to plaintiff was unrebutted. As a result, the court reversed the judgment, vacated the branch of plaintiff's motion seeking summary judgment on the first cause of action, and granted the branch of defendant's cross motion seeking summary judgment dismissing the second cause of action.

The court considered a case in which a plaintiff's assignor was injured in a car accident and the plaintiff was seeking no-fault benefits from the defendant. The defendant argued that New Jersey law and the insurance policy required the matter to be submitted to arbitration, but did not move to compel arbitration. The court found that New Jersey law applied to the substantive issues of the case, but New York procedural laws controlled. The court held that while the insurance policy provided for dispute resolution, the existence of an option to arbitrate did not dismiss the complaint in a court action, and the defendant had not moved to compel arbitration. Therefore, the court affirmed the order denying the defendant's cross motion for summary judgment dismissing the complaint.

The relevant facts considered by the court included the commencement of an instant declaratory judgment action by State Farm stating that Tiesha Thompson was insured under an automobile policy issued by them for a 2012 Chevrolet Tahoe. Another individual, Laurentia St. Rose, claimed to have been a pedestrian involved in an accident with the Tahoe and received medical services for personal injuries allegedly arising out of the accident. State Farm sought a declaratory judgment to relieve them from obligations to pay for medical treatment or economic harm stemming from this alleged accident. The main issues decided by the court were if proper service to the healthcare providers was achieved, and if State Farm was entitled to a declaratory judgment on the grounds of the alleged default of the healthcare providers. The court decided that the healthcare providers were properly served with the commencement papers, but State Farm did not establish its right to a declaration on the grounds of the alleged default. The holding of the case was that State Farm's motion for a declaratory judgment against the healthcare providers based on their default in answering the complaint was denied. The court directed State Farm to file a note of issue and present its proof at an inquest. Additionally, the plaintiff conceded that it accepted a late answer and was no longer seeking a default against DME and DHD.

The main issue in this case was whether a medical services provider who failed to commence a no-fault action within 30 days of receipt of an insurer's denial of a claim form should be awarded statutory interest, and if so, when interest should begin to accrue. The court held that statutory prejudgment interest does not begin to accumulate until an action is commenced and that if the provider unreasonably delays the court proceeding, interest should not be awarded. The court found that the plaintiff in this case took no meaningful action to prosecute the case until it served a motion to compel discovery on August 30, 2013, and therefore, interest should be computed from that date rather than from April 30, 2002. The judgment was modified to reflect this decision.

The court considered a small claims action for recovery of first-party no-fault benefits in the amount of $953.77. The plaintiff had performed certain medical testing based on a referral from an orthopedic surgeon without inquiring about the medical necessity of the testing. The defendant's expert witness testified that there was a lack of medical necessity for the services, and the City Court dismissed the action. The main issue was whether the services in question were medically necessary, and the court determined that the defendant had satisfied its burden of demonstrating that the services were not medically necessary. The holding of the court was that the City Court did not err in dismissing the action, and the judgment was affirmed.

The main issue in this case was whether the District Court properly granted the defendant's motion for summary judgment dismissing the complaint on the ground that the action was barred by virtue of the defendant's workers' compensation fee schedule defense. The court considered the fact that the defendant had timely and properly denied the claims at issue on the ground of lack of medical necessity and also argued that a portion of each claim sought to be recovered was in excess of the amount permitted by the workers' compensation fee schedule. Despite the lack of payments made on the claims, the District Court had granted the defendant's motion to dismiss the entire complaint on the basis of the fee schedule defense, without addressing the lack of medical necessity defense. The holding of the case was that the District Court erred in granting the defendant summary judgment dismissing the entire complaint on the basis of the fee schedule defense, and the matter was remitted to the District Court for a new determination of the defendant's motion for summary judgment dismissing the complaint.

The court considered whether a provider was entitled to recover first-party no-fault benefits and whether a motion made by the defendant for summary judgment should be granted. The main issue decided was whether it was impermissible for the doctor to bill using his or her own Social Security number when services were performed by a treating provider in the doctor's employ. The holding of the case was that a billing provider operating as a sole proprietor can use his or her own Social Security number on the claim form if it is the billing provider who rendered the services in question. However, it is impermissible for the doctor to bill using his or her own Social Security number if services were performed by a treating provider in the doctor's employ. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered a case in which a New Jersey surgical center was seeking first-party no-fault benefits from an insurance company for a manipulation under anesthesia (MUA) procedure. The insurance company had issued a timely denial claim based on a lack of medical necessity, supported by the peer review report of a licensed chiropractor. At trial, the chiropractor testified that there was a lack of medical necessity for the MUA procedure. The court ultimately found for the surgical center and awarded the principal sum of $7,590.60, despite stating in the decision that chiropractors cannot perform MUA procedures in New York. The main issue was whether the insurance company had established a lack of medical necessity through its expert witness, and if the surgical center had proven that the services were medically necessary. The court held that the insurance company had satisfied its burden of establishing a lack of medical necessity and, therefore, reversed the judgment in favor of the surgical center, remitting the matter to the Civil Court for the entry of a judgment in favor of the insurance company.