No-Fault Case Law

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.

The case involved an appeal from a judgment in an action by a New Jersey facility to recover assigned first-party no-fault benefits from an insurance company. The insurance company had issued a timely denial of the claim based on a lack of medical necessity, which was determined after an independent medical examination (IME) by a licensed chiropractor. The Civil Court initially found for the plaintiff, awarding them the principal sum of $7,790.60. However, the Appellate Court reversed the judgment, determining that the chiropractor's testimony at the IME demonstrated a lack of medical necessity for the procedure. As the plaintiff did not present any evidence to rebut this, the court held that the complaint should have been dismissed. The Appellate Court did not address the issue of whether chiropractors are allowed to perform the specific procedure in New York and remitted the matter back to the Civil Court for the entry of a judgment in favor of the defendant.

The relevant facts the court considered in this case are that DJS Medical Supplies, Inc. was seeking to recover first-party no-fault benefits for medical supplies that it had provided to its assignor. The trial was based on defendant's defense of lack of medical necessity, with plaintiff failing to call any witness to rebut defendant's doctor's testimony. The Civil Court directed the entry of a judgment in favor of plaintiff in the principal sum of $181.50 for a massager, and also found that defendant had demonstrated that the remaining supplies in question were not medically necessary. The main issue decided was whether the judgment dismissing the complaint, except for $181.50, should be reversed. The holding of the case was that the judgment was reversed and the matter was remitted to the Civil Court for the entry of a judgment in favor of plaintiff in the principal sum of $181.50, together with costs, plus statutory interest and attorney's fees due pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

The relevant facts the court considered were that the plaintiff sought to recover first-party no-fault benefits for medical supplies provided to its assignor after a motor vehicle accident. The defendant had commenced a declaratory judgment action seeking a declaration that it was not obligated to pay the plaintiff's claims due to the plaintiff's failure to comply with a condition precedent. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint based on the preclusive effect of the judgment in the declaratory judgment action. The holding of the case was that the Civil Court properly granted the defendant's motion for summary judgment under the doctrine of res judicata, as any judgment in favor of the plaintiff in this action would destroy or impair rights or interests established by the judgment in the declaratory judgment action. The order granting the defendant's motion for summary judgment was affirmed.

The court considered the fact that Island Life Chiropractic, P.C. had commenced an action to recover first-party no-fault benefits for services provided to its assignor as a result of injuries sustained in a motor vehicle accident which had occurred on April 6, 2012. The insurer identified itself as Kemper Independence Insurance Company and argued that Island Life's action was barred by collateral estoppel and res judicata. Before Island Life commenced its action, a declaratory judgment action had been commenced in the Supreme Court by Kemper claiming that the assignor had breached the terms of an insurance policy. The Supreme Court declared that Island Life was "not entitled to no-fault reimbursements or benefits for the motor vehicle accident that occurred on April 6, 2012 under policy FZ717084." As a result, the Civil Court granted the insurer's motion for summary judgment, dismissing the complaint. The main issue decided in the case was whether the action brought by Island Life Chiropractic, P.C. was barred by res judicata due to the declaratory judgment action that had been determined in favor of the insurer. The court ultimately held that the action was indeed barred by res judicata and affirmed the order of the Civil Court granting the insurer's motion for summary judgment.

The relevant facts considered by the court were that Atlantic Chiropractic, P.C. was trying to recover assigned first-party no-fault benefits from Liberty Mutual Fire Insurance Co., but Liberty Mutual claimed the action was barred by res judicata. This was based on a previous declaratory judgment in the Supreme Court, Bronx County, which declared that Liberty Mutual was not obligated to pay the benefits due to the assignor's failure to appear for scheduled examinations under oath. The main issue was whether the default declaratory judgment in the Supreme Court action was valid, as the Civil Court had denied Liberty Mutual's motion for summary judgment on the grounds that the judgment had not been entered and served. The holding of the court was that the default declaratory judgment was valid based on res judicata and defendant's motion for summary judgment was granted, while plaintiff's cross motion for summary judgment was denied.

The relevant facts in this case included a lawsuit by a medical provider to recover first-party no-fault benefits, and a declaratory judgment in Supreme Court, Bronx County declaring that the defendant had no obligation to pay the claims due to the failure of the plaintiff's assignor to attend examinations under oath. The main issue decided was whether the defendant's action was barred by res judicata, and whether the defendant's failure to include res judicata as an affirmative defense in its answer was sufficient reason to grant summary judgment. The holding of the case was that the defendant's answer was deemed amended to include the affirmative defense of res judicata, and the defendant's motion for summary judgment dismissing the complaint was granted, while the plaintiff's cross motion for summary judgment was denied.

The relevant facts under consideration include an action, pursuant to Insurance Law § 5106 (c), for a de novo determination of a no-fault insurance dispute between plaintiff AutoOne Insurance Company and defendant Eastern Island Medical Care, P.C. The main issue decided by the court concerns the erroneous denial of the plaintiff's motion for summary judgment on the complaint, cross motion to confirm the master arbitrator's award, and other motions seeking to dismiss different affirmative defenses. The holding of the case is in favor of AutoOne Insurance Company, the no-fault insurance carrier, finding that it was entitled to commence the action to compel de novo adjudication, as the master arbitrator’s award exceeded the statutory threshold amount of $5,000. The court determined that the plaintiff timely invoked its right to a de novo review, rendering the defendant’s claim that the plaintiff failed to exhaust its administrative remedies or satisfy a condition precedent without merit. The court reversed the judgment, granted the plaintiff's motion to dismiss the affirmative defenses, and remitted the matter for a determination on the remaining branches of the plaintiff's motion.