No-Fault Case Law

The relevant facts considered in this case were that Xvv, Inc. was seeking to recover assigned first-party no-fault benefits as the assignee of Jerome Barrow from New York Central Mutual Fire Insurance Company. The main issue decided was whether there was a lack of medical necessity for the supplies provided, which was the ground for the defendant's motion seeking summary judgment to dismiss the complaint. The holding of the case was that there was a triable issue of fact as to whether there was a lack of medical necessity for the supplies provided, and as a result, the defendant's motion was properly denied. The order was affirmed, and the decision was made on May 18, 2015.

The relevant facts the court considered were that Bay LS Medical Supplies, Inc. was seeking to recover assigned first-party no-fault benefits from Chubb Indemnity Insurance Company. Plaintiff moved for summary judgment, while the defendant cross-moved for summary judgment, arguing that the assignor had failed to appear for properly scheduled independent medical examinations (IMEs). The main issue decided was whether the assignor was properly notified of the IMEs, as the scheduling letters were addressed to someone with a slightly different name than the assignor. The holding of the case was that the IME scheduling letters did not provide sufficient notice that the assignor was to appear for the IMEs, so the court affirmed the order denying the defendant's cross motion for summary judgment dismissing the complaint.

The relevant facts of the case were that Compas Medical, P.C. was seeking to recover assigned first-party no-fault benefits from Hartford Insurance Company. The court considered the denial of claim forms and the timely mailing of those forms. The main issues decided were whether defendant's denial of claim forms were timely mailed and whether plaintiff was entitled to summary judgment on certain causes of action. The holding of the case was that the court modified the order by providing that plaintiff's motion for summary judgment on the 4th, 5th, and 10th causes of action were granted, and defendant's cross motion for summary judgment dismissing the 5th and 10th causes of action were denied.

The court considered the case of New Way Medical Supply Corp. as Assignee of Junie Sully Moliere v National Liability & Fire Insurance Company, where the plaintiff sought to recover assigned first-party no-fault benefits. The main issue was whether the plaintiff had responded to the defendant's requests for verification, as a claim need not be paid or denied until all demanded verification is provided. The court held that since there was a triable issue of fact as to whether the plaintiff responded to the verification requests, neither party was entitled to summary judgment. Therefore, the court modified the order by denying the defendant's cross motion for summary judgment dismissing the complaint. The remaining contention of the plaintiff was found to lack merit.

The court considered the issue of whether the plaintiff, Great Health Care Chiropractic, P.C., was entitled to recover first-party no-fault benefits from Unitrin Advantage Insurance Company. The main issue was whether the defendant had established that the letters scheduling examinations under oath (EUOs) had been timely mailed to the plaintiff's assignor, as required for the defendant to be entitled to summary judgment dismissing the complaint. The court held that the defendant had failed to establish the timely mailing of the EUO scheduling letters and therefore was not entitled to summary judgment. Additionally, the court found that the plaintiff's motion for summary judgment was properly denied, as the plaintiff's moving papers failed to demonstrate entitlement to judgment as a matter of law. Therefore, the court modified the order to provide that the defendant's cross motion for summary judgment dismissing the complaint is denied.

The relevant facts the court considered were the failure of the plaintiff's assignor to appear for scheduled chiropractic independent medical examinations (IMEs) and the timely denial of the claim by the defendant insurance company. The main issues decided were whether the scheduling letters for the IMEs had been timely mailed and whether the plaintiff's assignor had failed to comply with a condition precedent to coverage. The holding of the court was that the defendant insurance company had established that the IME scheduling letters had been timely mailed and that the plaintiff's assignor had failed to appear for the scheduled IMEs, entitling the defendant to summary judgment dismissing the complaint. The court also declined to consider the plaintiff's remaining contentions and affirmed the order.

The relevant facts considered by the court were that a medical service provider was seeking first-party no-fault benefits from an automobile insurance company. The insurance company had reduced the amount billed for a specific code of medical services pursuant to the workers' compensation fee schedule. The main issue decided was whether the insurance company had properly applied the fee schedule and whether this defense was properly set forth in the denial of the claim form. The holding of the case was that the insurance company's affidavit was sufficient to demonstrate that the fee schedule was properly applied, and the denial of benefits referenced an attached "Explanation of Review," which supported the insurance company's defense. Therefore, the court affirmed the order granting the insurance company's motion for summary judgment and denying the medical service provider's cross motion for summary judgment.

The court considered the facts of a nonjury trial in which a provider was attempting to recover assigned first-party no-fault benefits. The sole witness at the trial was the plaintiff's third-party biller. The main issue decided was whether the witness was capable of establishing a business record foundation for the plaintiff's claim forms, which had been admitted into evidence. The court held that, pursuant to the holding in Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., the testimony of the plaintiff's witness was sufficient to establish the plaintiff's prima facie case. As the defendant failed to proffer a defense, the judgment in favor of the plaintiff was affirmed.

The main issue in this case was whether the provider, Health Needles Acupuncture, P.C., was entitled to recover assigned first-party no-fault benefits from the defendant, Allstate Insurance Company. The court considered the claim forms that had been mailed to and received by the defendant, and whether the defendant had failed to pay or deny the claim within the prescribed 30-day period. The court found that the plaintiff had established its entitlement to judgment as a matter of law based on the untimeliness of the denials. However, the defendant's affidavits described its standard mailing practices and procedures, establishing the timely mailing of the denial of claim forms and raising a triable issue of fact. As a result, the court affirmed the order denying plaintiff's motion for summary judgment.

The main issue in this case was whether the insurance company was entitled to summary judgment dismissing the portion of a claim for first-party no-fault benefits that was billed under code 97810, based on the provider's failure to respond to the insurer's verification requests. The court considered the fact that the single claim form involved two types of services, each billed under a separate code, and found that the insurer had established its defense as to one code, but not as to code 97810. The court held that a claim need not be paid or denied until all demanded verification is provided, and that a timely verification request tolls an insurer's time to pay or deny the entire claim. The insurer demonstrated that it had timely mailed initial and follow-up requests for verification and had not received the requested verification, so the court reversed the lower court's decision and granted the insurer's motion for summary judgment dismissing the claim billed under code 97810.