No-Fault Case Law

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits. The provider appealed from an order of the Civil Court that granted the defendant's motion seeking summary judgment dismissing part of the complaint related to claims for services billed using specific CPT codes. The defendant had paid the claims in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The court affirmed the order, ruling in favor of the defendant. The court held that the claims were properly paid under the workers' compensation fee schedule, and therefore, the provider was not entitled to recover on those claims.

The relevant facts considered by the court in this case were that the plaintiff, John A. Nasrinpay, was seeking to recover assigned first-party no-fault benefits from the defendant, Travelers Insurance Company. The defendant had filed a motion for summary judgment dismissing the complaint, which was granted by the Civil Court, and the plaintiff's cross motion for summary judgment was denied. The main issue decided was whether the defendant's lack of coverage defense was established, prima facie, and whether the plaintiff had demonstrated the existence of a triable issue of fact. The holding of the court was that as the defendant had submitted an affidavit and documentary evidence establishing its lack of coverage defense, and the plaintiff had failed to demonstrate the existence of a triable issue of fact, the Civil Court properly granted the defendant's motion for summary judgment and denied the plaintiff's cross motion for summary judgment. Therefore, the order was affirmed.

The court considered the provider's appeal to recover assigned first-party no-fault benefits, which included claims for services billed using specific CPT codes and services performed on or after August 10, 2016. The main issue decided was whether the defendant's motion for summary judgment to dismiss the claims was valid, as well as the plaintiff's cross motion for summary judgment. The court held that the affidavit submitted by the plaintiff failed to raise a triable issue of fact regarding the lack of medical necessity for the services performed after August 10, 2016. Additionally, the court affirmed the dismissal of the claims for acupuncture services billed using CPT codes 97810 and 97811, based on a previous case with similar circumstances.

The court considered a case where UGP Acupuncture, P.C. sought to recover first-party no-fault benefits from GEICO Ins. Co. The main issue decided was whether GEICO Ins. Co. had properly paid claims using specific CPT codes in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The court ultimately held that the order from the Civil Court, which denied UGP Acupuncture, P.C.'s motion for summary judgment and granted GEICO Ins. Co.'s cross motion seeking summary judgment dismissing the claims billed using those specific CPT codes, was affirmed. The decision was based on the reasoning and decision in a similar case, Mind & Body Acupuncture, P.C., as Assignee of Wilson, Bernadette v State Farm Mut. Auto. Ins. Co. The holding of the case was ultimately in favor of GEICO Ins. Co.'s decision to dismiss the claims billed using the specific CPT codes.

The court considered whether the plaintiff, New York Wellness PT, P.C., as assignee of Sang, Kashana, was entitled to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Ins. Co. The main issue was whether defendant's motion for summary judgment dismissing the complaint should be granted on the ground that plaintiff's assignor failed to appear for duly scheduled examinations under oath (EUOs) and whether plaintiff's cross motion for summary judgment should be denied. The holding was that defendant's motion for summary judgment was denied, as the court found that defendant failed to establish its entitlement to summary judgment dismissing the complaint on the ground that plaintiff's assignor had failed to appear for EUOs. Additionally, plaintiff failed to demonstrate prima facie entitlement to judgment as a matter of law, so defendant's motion for summary judgment was denied.

The relevant facts considered by the court were that the plaintiff, Hand By Hand PT, P.C., was seeking to recover assigned first-party no-fault benefits from the defendant, Nationwide Property and Casualty Insurance Company. The defendant had scheduled examinations under oath (EUOs) for the plaintiff, but the plaintiff failed to appear on either date. The defendant then timely denied the claims on the ground of plaintiff's failure to appear for the EUOs. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should have been granted, and whether the plaintiff's opposition papers were sufficient to rebut the defendant's prima facie showing. The holding of the court was that the order of the Civil Court denying the defendant's motion for summary judgment was reversed, and the defendant's motion for summary judgment dismissing the complaint was granted. The court determined that the proof submitted by the defendant demonstrated that the plaintiff had failed to appear for the scheduled EUOs, and that the claims were timely denied on that ground. Therefore, the defendant was entitled to summary judgment dismissing the complaint.

The court considered a case in which a provider was seeking to recover assigned first-party no-fault benefits. The defendant had sought summary judgment dismissing the complaint on the basis that the plaintiff's assignor had failed to appear for duly scheduled independent medical examinations (IMEs). In support of its motion, the defendant submitted an affidavit demonstrating that the IME scheduling letters had been timely mailed to the plaintiff's assignor and that the assignor failed to appear for the scheduled IMEs. The defendant also demonstrated that the plaintiff failed to comply with a condition precedent to coverage and timely denied the claim on that ground. The court held that the defendant was not required to comply with the obligations of 11 NYCRR 65-3.6 (b) as the IMEs were scheduled before defendant received the claim at issue, and therefore, the branch of the defendant's motion seeking summary judgment dismissing the complaint was granted.

The relevant facts the court considered are that the plaintiff, New Millennium Medical Imaging, P.C., was seeking to recover first-party no-fault benefits from the defendant, 21st Century Insurance Company. The plaintiff failed to submit its claim form to the defendant within the required 45 days after the services were rendered and the defendant timely denied the claim. The plaintiff argued that it initially sent the claim form to a different insurance company and only sent it to the defendant after realizing the mistake. The main issue decided was whether the plaintiff provided a reasonable justification for its untimely submission of the claim form to the defendant, as required by the regulations. The court ultimately held that the plaintiff did not establish a reasonable justification for initially submitting the claim form to the wrong insurance company, as the form bore the defendant's name and address. Therefore, the court granted the defendant's motion for summary judgment dismissing the complaint and denied the plaintiff's cross motion for summary judgment.

The relevant facts considered by the court were that Regal Acupuncture, P.C. was seeking to recover first-party no-fault benefits from Allstate Insurance Company. The main issue decided was whether Allstate had properly mailed examination under oath (EUO) scheduling letters in a timely manner. The court held that Allstate had demonstrated prima facie evidence that the EUO scheduling letters had been timely and properly mailed. The court also ruled that an appearance at an EUO is required, regardless of whether the insurance company demands the EUO before or after the claim form is submitted. Additionally, the court declined to consider certain arguments raised by Regal Acupuncture, P.C. for the first time on appeal, or deemed them moot. Therefore, the court affirmed the order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment dismissing the complaint.

The main issue in this case was an appeal from an order of the Civil Court that denied the defendant's motion for summary judgment dismissing the complaint. The court considered the fact that the defendant had fully paid the plaintiff for the acupuncture services at issue in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The plaintiff's claims sought the difference between the amount charged for the services rendered and the payments made. In the end, the court held that the defendant made a prima facie showing of its entitlement to summary judgment by demonstrating that it had fully paid the plaintiff in accordance with the fee schedule, and the plaintiff had failed to demonstrate the existence of a triable issue of fact. Therefore, the court reversed the order and granted the defendant's motion for summary judgment dismissing the complaint.