No-Fault Case Law
Walden-Bailey Chiropractic v Erie Ins. Co. (2015 NY Slip Op25353)
October 19, 2015
The case involved a dispute between a chiropractic provider and an insurance company over assigned first-party no-fault benefits. The provider requested a discontinuance without prejudice in the Civil Court, which was granted. The insurance company subsequently moved to vacate or modify the order of discontinuance and sought attorney's fees and sanctions. The Civil Court denied the motion to vacate or modify the discontinuance, but also implicitly denied the insurance company's request for attorney's fees and sanctions. The Appellate Term modified the order to grant the insurance company's motion for attorney's fees, stating that the provider did not indirectly seek to change venue by requesting discontinuance and filing elsewhere, and that the insurance company was entitled to recover the reasonable attorney's fees incurred in its defense of the action. The matter was remitted to the Civil Court for a determination of the reasonable amount of attorney's fees incurred by the insurance company up to the date of discontinuance.
Cliffside Park Imaging & Diagnostic v Travelers Ins. Co. (2015 NY Slip Op 51489(U))
October 8, 2015
The court considered the defendant's motion for partial summary judgment in a case involving a dispute over the reimbursement of health services rendered in New Jersey. The main issue decided was whether the defendant could rely on the New Jersey fee schedule to establish the "prevailing fee" for the purposes of the plaintiff's no-fault claim. The court held that the defendant could properly rely on the New Jersey fee schedule, and therefore sustained the grant of defendant's motion for partial summary judgment. The court also noted that the plaintiff's objections to the sufficiency of the defendant's proof pertaining to the calculation of the fees under the New Jersey fee schedule were premature, as the Civil Court had not made a determination on the amount reimbursable under that fee schedule. The decision was affirmed, with costs.
Surgicare Surgical Assoc. v National Interstate Ins. Co. (2015 NY Slip Op25338)
October 8, 2015
The legal case is about a first-party no-fault action arising from health services rendered at a New Jersey location. The insurer only paid a portion of the amount billed by the health service provider according to the New Jersey fee schedule, which plaintiff argues was not permissible. Plaintiff seeks the difference between the amount charged and payment made by the defendant pursuant to the New Jersey fee schedule. The court decided that insurers may properly rely on such fee schedule to establish the prevailing fee and demonstrate compliance therewith by payment within that fee schedule. The Superintendent of Insurance had issued an opinion letter stating that the reimbursement amount is determined by the permissible cost in the out-of-state location. The ruling is affirmed to apply the permissible rate authorized in New Jersey for the services rendered by plaintiff at a rate significantly higher than the permissible charges in the New Jersey fee schedule, which would undermine the purpose of Insurance Law §5108.
Metro Health Prods., Inc. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 51451(U))
September 30, 2015
The court considered the facts that the plaintiff, an assignee of Michael Headley, appealed an order from the Civil Court of New York City which granted the defendant's motion for summary judgment to dismiss the complaint. The defendant claimed that the plaintiff failed to appear at scheduled examinations under oath (EUOs) and sought summary judgment based on this alleged nonappearance. The court held that the defendant's notice to admit, which sought plaintiff's written admission of the nonappearance, was improper and the plaintiff's failure to timely respond to the notice did not constitute an admission of the matters stated therein. The court also held that the branches of the defendant's motion seeking summary judgment dismissing certain causes of action should have been deemed an application to mark those causes of action as discontinued with prejudice, and granted. Therefore, the order was modified by denying the motion for summary judgment on certain causes of action and deeming the motion as an application to discontinue other causes of action with prejudice.
SAL Med., P.C. v Clarendon Natl. Ins. Co. (2015 NY Slip Op 51449(U))
September 30, 2015
The court considered that the defendant had timely mailed denial of claim forms that denied the plaintiff's claims on the grounds of lack of medical necessity. The defendant also submitted the properly affirmed report of an independent medical examination (IME) and two affirmed peer review reports that set forth a factual basis and medical rationale for the determination of defendant's doctors that there was no medical necessity for the services rendered to plaintiff's assignor. The court decided that the defendant's prima facie showing that the services rendered by plaintiff were not medically necessary was unrebutted by the plaintiff, and therefore, the defendant was entitled to summary judgment dismissing the complaint. The holding of the court was that the order is reversed, defendant's motion for summary judgment dismissing the complaint is granted, and plaintiff's cross motion for summary judgment is denied.
Premier Health Choice v Praetorian Ins. Co. (2015 NY Slip Op 51383(U))
September 29, 2015
The court considered the motion for summary judgment dismissing the complaint made by the defendant, Praetorian Insurance Company, in a case brought by Premier Health Choice, a/a/o Jessica Calderon, regarding no-fault claims for physical therapy treatment. The defendant submitted independent medical examination (IME) reports from an orthopedic doctor and neurologist, which concluded that the injuries were resolved and further physical therapy was not needed. The plaintiff submitted an unsworn doctor's report with their attorney's affirmation, which the court deemed to be without probative value and insufficient to raise a triable issue. Ultimately, the court reversed the lower court's decision and granted the defendant's motion for summary judgment, dismissing the complaint. The holding of the case was in favor of the defendant, Praetorian Insurance Company, based on the insufficient evidence provided by the plaintiff to support their claim for continued physical therapy treatment.
MRJA Radiology, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51381(U))
September 29, 2015
The relevant facts the court considered were that the defendant-insurer mailed notices for independent medical examinations (IMEs) to the plaintiff's assignor and his attorney, and the assignor failed to appear for the IMEs. The main issue decided was whether the defendant was entitled to summary judgment dismissing the plaintiff-provider's claim for first-party no-fault benefits. The holding of the case was that the defendant-insurer made a prima facie showing of entitlement to summary judgment and that the plaintiff did not raise a triable issue with respect to the assignor's nonappearance or the mailing and reasonableness of the underlying notices. Therefore, the motion for summary judgment was granted and the complaint was dismissed.
Compas Med., P.C. v Fiduciary Ins. Co. of Am. (2015 NY Slip Op 51472(U))
September 17, 2015
The relevant facts considered by the court were that Compas Medical, P.C. was seeking to recover first-party no-fault benefits as an assignee of Clarence Dupiton. The main issue decided was whether the defendant had failed to deny the claim within the requisite 30-day period or issued a timely denial of claim that was conclusory, vague, or without merit as a matter of law. The holding of the case was that plaintiff failed to establish either that the defendant had failed to deny the claim within the requisite 30-day period or that the defendant had issued a timely denial of claim that was conclusory, vague or without merit as a matter of law, and therefore plaintiff failed to demonstrate its prima facie entitlement to summary judgment. The order denying plaintiff's motion for summary judgment was affirmed by the court.
Compas Med., P.C. v Praetorian Ins. Co. (2015 NY Slip Op 51467(U))
September 17, 2015
The court considered the fact that the plaintiff, Compas Medical, P.C., was seeking to recover assigned first-party no-fault benefits, but the defendant, Praetorian Ins. Co., had denied the claims due to lack of verification and failure of the plaintiff's assignor to comply with independent medical examinations (IMEs) and examinations under oath (EUOs). The main issue decided was whether the defendant had timely requested verification and scheduled IMEs and EUOs, and whether the plaintiff's assignor had complied with these requests. The holding of the court was that the defendant had demonstrated that it had timely requested verification and scheduled IMEs and EUOs, and that the plaintiff's assignor had failed to comply with these requests. Therefore, the court affirmed the order denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint.
Healing Art Acupuncture, P.C. v Country Wide Ins. Co. (2015 NY Slip Op 51465(U))
September 17, 2015
The main issues decided in this case were whether the defendant had timely and properly denied the plaintiff's claims based on the failure of the plaintiff's assignor to appear for scheduled independent medical examinations (IMEs). The court considered the evidence submitted by the defendant, which demonstrated that the denial of claim forms and the IME scheduling letters had been timely mailed, and that the assignor had failed to appear for the scheduled IMEs. The court found that the assignor's appearance at a duly scheduled IME is a condition precedent to the insurer's liability on the policy, and therefore granted the defendant's motion for summary judgment dismissing the second through seventh causes of action. However, the court also found that the defendant had failed to establish, as a matter of law, that it had timely denied the claim, so the branch of the defendant's motion seeking summary judgment dismissing the first cause of action was denied. Therefore, the holding of the court was that the order was modified to deny the branch of the defendant's motion seeking summary judgment dismissing the first cause of action.