No-Fault Case Law
Laga v Lancer Ins. Co. (2017 NY Slip Op 51243(U))
September 22, 2017
The insurer's summary judgment dismissing the provider's claims for failure to appear for EUOs was affirmed. The Appellate Term, Second Department, relied on the reasons stated in the companion appeal decided the same day, No. 2014-1811 Q C.
T & S Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2017 NY Slip Op 51240(U))
September 22, 2017
The insurer's summary judgment based on the assignor's EUO nonappearance was affirmed after its scheduling letters were found to toll the deadline. The Appellate Term, Second Department, rejected the provider's sole appellate argument, finding that the initial and follow-up EUO letters properly tolled the time to pay or deny under 11 NYCRR 65-3.5 (b) and 11 NYCRR 65-3.6 (b).
Compas Med., P.C. v American Tr. Ins. Co. (2017 NY Slip Op 51239(U))
September 22, 2017
The provider's mailing affidavit raised a factual issue over receipt of verification, and the insurer failed to prove fee-schedule payment. In this assigned no-fault action, the Appellate Term, Second Department, modified the order, insofar as appealed from, to deny the insurer's cross motion on the third through seventh causes of action, while affirming denial of the provider's motion on the second through seventh causes. The provider's affidavit supported a presumption that verification for the third through fifth causes was mailed and received, raising an issue of prematurity. For the sixth and seventh causes, the insurer failed to establish full fee-schedule payment, while the provider failed to show untimely or legally insufficient denials. Factual issues also remained on the second cause.
TAM Med. Supply Corp. v 21st Century Ins. Co. (2017 NY Slip Op 51238(U))
September 22, 2017
The insurer's summary judgment dismissal of the second cause was affirmed after the provider's denial-mailing challenge was rejected. The Appellate Term, Second Department, also sustained the CPLR 3212 (g) finding of proper denial mailing for the first cause, for which summary judgment had been denied. The provider's sole appellate contention concerned mailing, and the decision found the insurer's proof sufficient.
GBI Acupuncture, P.C. v GEICO Ins. Co. (2017 NY Slip Op 51237(U))
September 22, 2017
The insurer's summary judgment dismissal of fee-schedule claims was affirmed after the provider's mailing and fee-schedule challenges were rejected. The Appellate Term, Second Department, also affirmed denial of the provider's motion and the CPLR 3212 (g) finding of timely denials for the remaining claims, whose dismissal was denied. It rejected the fee-schedule argument under Great Wall Acupuncture, P.C. v Geico Ins. Co.
Royal Med. Supply, Inc. v Nationwide Gen. Ins. Co. (2017 NY Slip Op 51235(U))
September 22, 2017
The insurer's summary judgment dismissal for EUO nonappearance was affirmed after the provider's proof challenges were rejected. The Appellate Term, Second Department, found the assignor's nonappearance sufficiently established under Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co. It also rejected the provider's challenges to proof of mailing of the EUO scheduling letters and denial forms.
Citywide Acupuncture Servs., P.L.L.C. v Clarendon Natl. Ins. Co. (2017 NY Slip Op 51233(U))
September 22, 2017
The insurer's cross motion for summary judgment based on untimely claim submission was denied because a factual issue remained. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, in the provider's favor, finding a triable issue on timely submission under St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co.
Vladenn Med. Supply Corp. v American Tr. Ins. Co. (2017 NY Slip Op 51230(U))
September 22, 2017
The insurer established untimely accident notice and claim submission, together with a timely denial on both grounds. The provider sought summary judgment on its assigned no-fault claims, and the insurer cross-moved for dismissal. As to the claim at issue on appeal, the record established noncompliance with the notice and submission requirements of 11 NYCRR 65-1.1. The Appellate Term, Second Department, also sustained the insurer's proof of timely denial under St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co. It affirmed the order, insofar as appealed from, denying the provider summary judgment and granting the insurer summary judgment dismissing that claim.
LMS Acupuncture, P.C. v Titan Ins. Co. (2017 NY Slip Op 51229(U))
September 22, 2017
EUO requests sent more than 30 days after receipt of claims are nullities as to those claims. The insurer obtained summary judgment dismissing six causes of action based on the assignor's failure to appear for duly scheduled EUOs. The Appellate Term, Second Department, modified the order to deny dismissal of the first through third causes because the EUO requests were sent beyond that interval. It affirmed dismissal of the fourth through sixth causes, finding that the insurer established timely mailing of the initial and follow-up EUO scheduling letters and the denials for those claims, citing 11 NYCRR 65-3.8 (l). The result preserved three causes for the provider and dismissed three in the insurer's favor.
Compas Med., P.C. v 21st Century Ins. Co. (2017 NY Slip Op 51228(U))
September 22, 2017
The insurer failed to establish a timely denial of the fourth claim but proved full fee-schedule payment of the first and fifth claims. The Appellate Term, Second Department, modified the order, insofar as appealed from, to deny the insurer summary judgment on the fourth cause, citing 11 NYCRR 65-3.8 (a) (1). The provider also failed to establish entitlement to summary judgment on that claim because its proof did not show an untimely or legally insufficient denial. Dismissal of the first and fifth causes was affirmed because the insurer established full payment for services billed under code 64550 and the provider failed to rebut that showing. Denial of the provider's motion on the remaining causes was affirmed because receipt of those claims remained disputed.