No-Fault Case Law

The court considered whether the defendant had properly paid the plaintiff for services in accordance with the workers' compensation fee schedule. The main issue was whether the plaintiff's motion for summary judgment should have been granted and the defendant's cross motion for summary judgment should have been denied. The court held that the defendant had fully paid the plaintiff for the services according to the workers' compensation fee schedule. However, the court also held that the plaintiff's motion for summary judgment on its first cause of action should have been granted, as the defendant did not demonstrate that it had timely denied the claim. Therefore, the court modified the order to grant the plaintiff's motion for summary judgment on its first cause of action and deny the defendant's cross motion seeking to dismiss that cause of action.

The Civil Court of the City of New York, Kings County granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment dismissing the complaint. The case involved a provider seeking to recover assigned first-party no-fault benefits. The defendant timely denied the claim based on a lack of medical necessity, but the court found a triable issue of fact regarding the medical necessity of the services at issue. As a result, the court modified the order to provide that the plaintiff's motion for summary judgment is denied. The decision was made on December 17, 2014.

The relevant facts considered by the court in this case were that Dr. Allen Cherkin was seeking to recover assigned first-party no-fault benefits from Praetorian Insurance Company. The insurance company had denied the claim, and argued that the denial was timely mailed. However, the court found that there was a triable issue of fact regarding the medical necessity of the services at issue, and therefore denied the insurance company's motion for summary judgment dismissing the complaint. The main issue decided was whether there was a triable issue of fact regarding the medical necessity of the services, and the holding of the court was that the denial of the claim forms were sufficiently established, but that there was indeed a triable issue of fact regarding the medical necessity. The court ultimately affirmed the order denying the insurance company's motion for summary judgment.

The court considered a dispute between Rainbow Supply of NY, Inc. and Geico General Insurance Co. concerning the recovery of first-party no-fault benefits for medical supplies. Rainbow Supply moved for summary judgment, while Geico cross-moved for summary judgment dismissing the complaint based on a lack of medical necessity. The Civil Court denied Rainbow Supply's motion, made findings in their favor, denied Geico's cross-motion, and held that the only remaining issue for trial was medical necessity. The Appellate Term affirmed the Civil Court's decision, finding that there was a triable issue of fact regarding the medical necessity of the supplies at issue. Therefore, the order was affirmed with costs.

The court considered a provider's motion to recover assigned first-party no-fault benefits, as well as the defendant insurance company's cross motion for summary judgment dismissing the complaint. The main issue was whether the defendant had timely and properly denied the claims at issue, based on the plaintiff's failure to appear for independent medical examinations and the claims exceeding the amount permitted by the workers' compensation fee schedule. The holding was that the defendant had demonstrated appropriate mailing practices and procedures of the denials and IME scheduling letters, and had not established its fee schedule defense as a matter of law. The court modified the order by denying the branches of the defendant's cross motion seeking summary judgment dismissing the plaintiff's first and sixth causes of action.

The main issues considered in this case were whether a provider's action to recover payment of first-party no-fault benefits was premature when the provider had failed to respond to a timely request for verification, and whether the provider had adequately responded to the verification requests. The court considered the fact that the defendant had mailed initial and follow-up requests for verification in support of its motion, and that both sets of requests were timely mailed. The Civil Court had denied the defendant's motion for summary judgment and granted the plaintiff's cross motion, finding that the defendant's initial verification request was untimely. The holding of the case was that while the requests for verification were timely mailed, there was a triable issue of fact as to whether the plaintiff adequately responded to those verification requests, and therefore the plaintiff's cross motion for summary judgment was denied.

The court considered in this case an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was that while the plaintiff had established a prima facie case for their motion for summary judgment, the defendant had sufficiently described its procedures for the receipt of mail and stated that it had no record of receiving the specific claim, thus raising a triable issue of fact. The court held that neither party was entitled to summary judgment as to this cause of action. The court also decided that the defendant had timely mailed independent medical examination (IME) and examination under oath (EUO) scheduling letters, and the denial of claim forms, and that the plaintiff's assignor had failed to comply with conditions precedent to coverage. As a result, the court affirmed the dismissal of those causes of action and denied the branch of defendant's motion seeking summary judgment dismissing plaintiff's fourth cause of action.

The case involved an action by a medical provider to recover assigned first-party no-fault benefits. The main issues considered were the plaintiff's motion for summary judgment and the defendant's cross-motion for summary judgment, as well as the defendant's defenses regarding the plaintiff's assignor's failure to appear for independent medical examinations (IMEs) and payment in accordance with the workers' compensation fee schedule. The court held that the defendant's cross motion seeking summary judgment to dismiss the third cause of action and part of the first and second causes of action due to the assignor's failure to appear for IMEs should be granted. However, the defendant's cross motion seeking summary judgment to dismiss the first and second causes of action based on the workers' compensation fee schedule was denied. Ultimately, the court modified the lower court's decision to grant the defendant's cross motion on the IME issue but denied it on the workers' compensation fee schedule issue. Therefore, the branch of the defendant's cross motion seeking summary judgment to dismiss the third cause of action and part of the first and second causes of action was granted, while the branch seeking summary judgment based on the workers' compensation fee schedule was denied.

The relevant facts considered by the court in this case were that a provider was seeking to recover assigned first-party no-fault benefits. The main issues decided were whether the provider had failed to respond to the insurance company's verification requests and whether the assignor had failed to appear for scheduled independent medical examinations (IMEs). The court held that the insurance company had established the timely and proper mailing of the verification requests and the denial of claim forms, and that the assignor had indeed failed to appear for the scheduled IMEs. As a result, the court affirmed the denial of the provider's motion for summary judgment and granted the insurance company's cross motion for summary judgment, dismissing the complaint.

The main issue in this case was whether the denial of claim forms for first-party no-fault benefits had been timely mailed and whether the plaintiff had failed to comply with a condition precedent to coverage, in this case, appearing for scheduled independent medical examinations (IMEs). The court considered evidence that the denial of claim forms had been timely mailed and that the plaintiff had failed to appear for scheduled IMEs. The court held that with regards to claims for $837.63 and $1,193.50, the denial of claim forms had been timely mailed and the plaintiff had failed to comply with the condition precedent of appearing for scheduled IMEs, so summary judgment in favor of the defendant should have been granted in these instances. However, with respect to claims for $515 and $199.35, the defendant failed to establish as a matter of law that these claims had been timely denied, and therefore the summary judgment motion was denied in these instances.