No-Fault Case Law
Jamaica Dedicated Medical Care. P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50605(U))
April 16, 2015
The court considered the defendant's motion for summary judgment to dismiss the complaint by the plaintiff, a medical care provider, seeking to recover first-party no-fault benefits. The defendant argued that the insured had fraudulently procured the insurance policy. The main issue was whether the defendant had provided sufficient evidence to establish entitlement to judgment as a matter of law. The court held that the defendant did not submit enough evidence to support its motion, as the insured's testimony at an examination under oath did not eliminate all material issues of fact regarding his actual residence at the time he procured the policy, and the investigative report submitted by the defendant was based on inadmissible hearsay. As a result, the court affirmed the order denying the defendant's motion for summary judgment.
VE Med. Care, P.C. v State Farm Mut. Auto. Ins. Co. (2015 NY Slip Op 50603(U))
April 16, 2015
The main issue in the case was whether the provider had failed to appear for duly scheduled examinations under oath (EUOs) as claimed by the defendant. The court considered the evidence and found that the defendant had failed to establish, as a matter of law, its defense that the plaintiff had failed to appear for properly scheduled EUOs. Therefore, the court held that the defendant's motion for summary judgment dismissing the complaint should have been denied. The court reversed the order and granted the provider's appeal, denying the defendant's motion for summary judgment.
Priority Med. Diagnostics, P.C. v New York Cent. Mut. Fire, Ins. Co. (2015 NY Slip Op 50538(U))
April 16, 2015
The relevant facts the court considered were that defendant-insurer made a prima facie showing that it timely and properly mailed notices for independent medical examinations (IMEs) to plaintiff's assignor, who then failed to appear. The main issue decided was whether the defendant-insurer 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's motion for summary judgment dismissing the complaint was granted, as they had provided competent evidence of the assignor's nonappearance and the mailing of the IME notices, and the plaintiff did not raise a triable issue with respect to these facts.
Healthy Way Acupuncture, P.C. v One Beacon Ins. Co. (2015 NY Slip Op 50537(U))
April 16, 2015
The court considered an appeal from an order denying defendant's motion for summary judgment in a case seeking recovery of first-party no-fault benefits. The main issue decided was whether the defendant-insurer established the proper and timely mailing of the denial of claim forms at issue, which would warrant summary dismissal. The court held that the action was not ripe for summary dismissal because the defendant failed to establish the proper and timely mailing of the denial of claim forms, as the affidavit submitted by the defendant lacked probative value and failed to set forth the basis of the affiant's personal knowledge of the internal mailing practices and procedures of the defendant during the pertinent period. Therefore, the court affirmed the order denying defendant's motion for summary judgment.
Harmonic Physical Therapy, P.C. v Praetorian Ins. Co. (2015 NY Slip Op 50525(U))
April 14, 2015
The relevant facts considered by the court were that the defendant, an insurance company, had denied the plaintiff's claim for first-party no-fault benefits on the ground of lack of medical necessity. The insurance policy's coverage limits had been exhausted through payment of no-fault benefits in satisfaction of arbitration awards rendered in favor of other healthcare providers, in compliance with the priority of payment regulation. The main issue decided by the court was whether the defendant was entitled to summary judgment dismissing the action for first-party no-fault benefits. The holding of the court was that the defendant-insurer made a prima facie showing of entitlement to summary judgment, and the plaintiff failed to raise a triable issue in opposition. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted.
Metro Psychological Servs., P.C. v 21st Century N. Am. Ins. Co. (2015 NY Slip Op 50470(U))
April 7, 2015
The court considered the plaintiff's claim for first-party no-fault benefits, and the defendant's motion for summary judgment dismissing the complaint based on the assignor's failure to appear at scheduled examinations under oath (EUOs). The main issues decided were whether the defendant established its entitlement to judgment as a matter of law and whether an insurer is required to set forth objective standards for requesting an EUO. The court held that the defendant had timely mailed the EUO scheduling letters, that the assignor had failed to appear for the EUOs, and that the denial of the claim form had been timely mailed. The court also held that there is no provision of No-Fault Regulation 68 that requires an insurer to set forth objective standards for requesting an EUO. The holding was that the defendant's motion for summary judgment dismissing the complaint was granted.
Saddle Brook Surgicenter, LLC v All State Ins. Co. (2015 NY Slip Op 25099)
April 7, 2015
Plaintiff, a medical provider, sued defendant, an insurance company, to recover unpaid first-party no-fault benefits for medical services it provided to a car accident injury victim. Defendant rejected part of plaintiff's claim, arguing that the claim exceeded the fee schedule limit under New Jersey law. The main issue is whether the insurance company is obligated to pay the full bill submitted by the medical provider, even if it exceeds the fee schedule. The court found in favor of the defendant, holding that the medical provider was bound by New Jersey's fee schedule because they are located outside of New York; and that the New York Statute intended to reduce the amount paid by insurers for medical services. Therefore, plaintiff was not entitled to recover the full amount of the bill.
21st Century Acupuncture, P.C. v Allstate Ins. Co. (2015 NY Slip Op 50445(U))
April 2, 2015
The court considered the fact that the defendant-insurer had mailed notices for independent medical examinations (IMEs) to plaintiff's assignor, and that the assignor failed to appear. The main issue decided was whether the defendant was entitled to summary judgment dismissing the action for first-party no-fault benefits. The holding of the court was that the defendant-insurer had made a prima facie showing of entitlement to summary judgment by establishing that it had timely and properly mailed the IME notices, and that the assignor failed to appear. The court also found that the plaintiff did not raise a triable issue in opposition to the defendant's evidence, and therefore granted the defendant's motion for summary judgment dismissing the complaint.
Country-Wide Ins. Co. v New Century Acupuncture P.C. (2015 NY Slip Op 50636(U))
April 1, 2015
The main issues in this case involved an arbitration in which respondent New Century Acupuncture P.C. sought reimbursement from petitioner Country-Wide Insurance Company for healthcare services provided to an assignor, William Dew, following a motor vehicle accident. Country-Wide alleged that New Century was fraudulently incorporated and actually owned or controlled by an individual who had pleaded guilty to conspiracy to commit mail fraud and health care fraud. Arbitrator Rosenberger issued an Arbitration Award in favor of New Century, but Country-Wide argued that the award should be vacated based on the arbitrator's failure to disclose a relationship with New Century and its attorneys. The court held that the failure of the arbitrator to disclose his connection to New Century's attorneys mandated vacatur of the Arbitration Award, and granted the petition to vacate the award.
Matter of Motor Veh. Acc. Indem. Corp. v American Country Ins. Co. (2015 NY Slip Op 02714)
March 31, 2015
The court considered the fact that the offending vehicle in a no-fault arbitration was insured by Global Liberty Insurance of New York subsequent to the respondent's coverage. It was determined that the subsequent coverage terminated the respondent's coverage of the same vehicle as of the effective date and hour of Global's coverage, irrespective of whether the respondent had otherwise complied with the cancellation requirements of the Vehicle and Traffic Law. The main issues decided were that the respondent failed to demonstrate that it had properly cancelled its policy, and that the arbitration award was in excess of the arbitrator's authority. The holding of the case was that the arbitration award in favor of the petitioner was vacated, and the respondent's cross petition seeking to vacate the arbitration award was granted.