No-Fault Case Law

The court considered the denial of a healthcare provider's motion for summary judgment and the granting of the insurance company's cross motion for summary judgment in a case to recover first-party no-fault benefits. The main issue was whether the insurance company adequately demonstrated that it had fully paid the provider for services in accordance with the workers' compensation fee schedule and whether there was a triable issue of fact as to the medical necessity of the services rendered. The holding was that the insurance company demonstrated it had fully paid the provider in accordance with the fee schedule, but there was a triable issue of fact regarding the medical necessity of the services, and therefore the insurance company was not entitled to summary judgment dismissing that claim. The court modified the order to deny the insurance company's cross motion seeking summary judgment dismissing the claim based on a lack of medical necessity.

The relevant facts considered by the court in the case of Eagle Surgical Supply, Inc. v Allstate Insurance Company included the plaintiff's failure to appear for scheduled examinations under oath (EUOs) as part of the process to recover assigned first-party no-fault benefits. Defendant moved for summary judgment to dismiss the complaint on this ground. The main issue decided was whether the EUO scheduling letters were defective and whether the plaintiff's objections regarding the EUO requests should be heard. The court held that the EUO scheduling letters advised the plaintiff that the EUO would concern plaintiff's eligibility to be reimbursed for assigned no-fault benefits, and the plaintiff's objections were not grounds for dismissal since the plaintiff did not respond in any way to the EUO requests. The court also held that the plaintiff's remaining contentions were improperly raised for the first time on appeal and therefore not properly before the court. The judgment granting defendant's motion for summary judgment was affirmed.

The court considered the facts that the timely mailing of examination under oath (EUO) scheduling letters had tolled the defendant's time to pay or deny the plaintiff's claim, and that the plaintiff's assignor had failed to appear for the properly scheduled EUOs. The main issue decided was whether the insurer's time to pay or deny the claim had been properly tolled, and if the claim had been timely and properly denied on that ground. The holding of the court was that the judgment was reversed, the order entered was vacated, and plaintiff's motion for summary judgment was denied, while the defendant's cross motion for summary judgment dismissing the complaint was granted. The court also determined that an assignor's appearance at an EUO is a condition precedent to the insurer's liability on the policy.

The relevant facts the court considered were that Island Chiropractic Testing, P.C. was seeking to recover first-party no-fault benefits from Praetorian Ins. Co. as the assignee of Shawn Killingbeck. Praetorian Ins. Co. argued that the action was premature because Island Chiropractic Testing, P.C. had not provided verification as requested, while Island Chiropractic Testing, P.C. argued the opposite. The main issue decided was whether the action to recover payment for first-party no-fault benefits was premature when the provider had failed to respond to a request for verification. The holding of the case was that there was a triable issue of fact as to whether Island Chiropractic Testing, P.C. adequately responded to the verification requests, and therefore the court denied the motion for summary judgment in favor of Island Chiropractic Testing, P.C. and modified the order accordingly.

The relevant facts the court considered in the case were that the plaintiff, Right Solution Medical Supply, Inc., sued Praetorian Ins. Company to recover assigned first-party no-fault benefits. Plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The main issue decided was whether defendant's cross motion for summary judgment dismissing the complaint should have been granted and whether the branch of plaintiff's motion seeking summary judgment on the fourth cause of action should have been denied. The holding of the case was that the judgment awarding plaintiff the principal sum of $2,357.95 was reversed and the branch of plaintiff's motion seeking summary judgment on the fourth cause of action was denied. The order denying defendant's cross motion and granting plaintiff's motion on the fourth cause of action was affirmed.

The main issue in this case was whether the insurance company had properly scheduled examinations under oath (EUOs) and provided timely denial of claim forms in order to deny the provider's claim for first-party no-fault benefits. The court considered the evidence presented by the defendant that they had timely mailed the EUO scheduling letters and denial of claim forms, and also submitted certified transcripts of the scheduled EUOs that showed the plaintiff's assignor had failed to appear. The court held that the defendant had established its entitlement to judgment as a matter of law, and that the plaintiff had failed to raise a triable issue of fact in opposition. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint was granted, and the plaintiff's cross motion for summary judgment was denied.

The court considered the defendant's motion for summary judgment dismissing the plaintiff's no-fault claim for $355 stemming from acupuncture services rendered. Defendant failed to demonstrate prima facie that its denials were properly mailed. The affidavit submitted by the defendant's claims administrator failed to adequately describe their mailing procedures and did not remedy these deficiencies in their reply papers. Additionally, the report of defendant's peer review acupuncturist did not set forth sufficient facts or medical rationale for the conclusion that further acupuncture treatment was not medically necessary. The main issue decided was whether the defendant's motion for summary judgment should have been denied, and the court held that the plaintiff's claim for first-party no-fault benefits in the amount of $355 should be reinstated. Therefore, the defendant's motion for summary judgment was reversed, and the plaintiff's claim was reinstated.

The main issue in the case was whether the defendant insurer had established, prima facie, that it did not timely receive the plaintiff provider's no-fault claim. The court considered the affidavit of a claims representative who stated there was no record of the claim in their office's files, but had no personal knowledge of the procedures for handling claims sent to the insurer's Oklahoma City office. The plaintiff, in opposition, produced a stamped mailing certificate to support the assertion that it timely mailed the claim to the designated Oklahoma City address. The court held that the action seeking recovery of first-party no-fault benefits was not ripe for summary dismissal and reversed the lower court's decision, denying the defendant's motion for summary judgment and reinstating the complaint.

The case involved a dispute over whether State Farm was obligated to pay claim by Avanguard Medical Group for providing health services to Patria Martell, for injuries sustained in a car accident, which was denied on the basis of improper fee schedule billing. Avanguard is an office-based surgical facility not licensed under Article 28 of the New York State Public Health Law and State Farm's policy included payment of No-Fault benefits. Avanguard billed State Farm $2,550.00 for services provided to Martell, but State Farm denied the claim and argued that Avanguard improperly billed pursuant to a fee schedule reserved exclusively for facilities licensed under Article 28. The court held that State Farm's denial of the claim was proper because Avanguard, as an office-based surgical facility, is not authorized to bill pursuant to the fee schedule reserved for facilities licensed under Article 28, and therefore, the complaint was dismissed. The court reasoned that there was no fee schedule for office-based surgical facilities and thus, Avanguard was not entitled to recover a facility fee.

The court considered the fact that the plaintiff had failed to appear for scheduled examinations under oath (EUOs), as required by the insurance company in order to recover assigned first-party no-fault benefits. The main issue decided was whether the insurance company was justified in denying the claim based on the plaintiff's failure to appear for the scheduled EUOs. The holding of the case was that the insurance company's affidavits established that the EUO scheduling letters had been timely mailed, and the plaintiff had failed to appear at the scheduled EUOs, therefore the denial of the claim was justified. The judgment of the Civil Court granting the insurance company's motion for summary judgment and dismissing the complaint was affirmed.