No-Fault Case Law
Diagnostic Radiographic Imaging v GEICO Gen. Ins. Co. (2014 NY Slip Op 50869(U))
May 22, 2014
The court considered the fact that the provider was seeking to recover assigned first-party no-fault benefits from the insurance company. The insurance company had denied the claims based on a lack of medical necessity and submitted affirmed peer review reports to support their determination. The main issue decided was whether the denial of the claims by the insurance company was justified based on the lack of medical necessity. The court held that the insurance company's showing that the services were not medically necessary was not rebutted by the plaintiff, and therefore, the insurance company's cross motion for summary judgment dismissing the complaint should have been granted. The court reversed the lower court's order and granted the insurance company's cross motion for summary judgment dismissing the complaint.
Sky Med. Supply, Inc. v GEICO Gen. Ins. Co. (2014 NY Slip Op 50868(U))
May 22, 2014
The court considered the motion for summary judgment by the plaintiff to recover assigned first-party no-fault benefits and the cross motion by the defendant for summary judgment dismissing the complaint based on a lack of medical necessity. The court made findings in favor of the plaintiff and denied the defendant's cross motion, holding that the only remaining issue for trial was medical necessity. The defendant submitted a peer review report showing a lack of medical necessity for the supply at issue, and the plaintiff's opposition failed to rebut the conclusions in the peer review report. Ultimately, the court reversed the findings in favor of the plaintiff, vacated the findings as academic, and granted the defendant's cross motion for summary judgment dismissing the complaint.
Queens-Roosevelt Med. Rehab, P.C. v Alea Care of Gab Robins Ins. Co. (2014 NY Slip Op 50867(U))
May 22, 2014
The relevant facts considered in this case were that the Civil Court had previously granted, on default, a motion by Alea North America Insurance Company seeking summary judgment dismissing part of the complaint against them and to recover a specific amount. Queens-Roosevelt Medical Rehab, P.C. subsequently filed a motion to vacate part of that order, claiming law office failure as the reason for the default. The issue at hand was whether the claim of law office failure provided a reasonable excuse for the default. The holding of the case was that the claim of law office failure was not considered a reasonable excuse for the default, as the attorney's explanation did not adequately detail and substantiate the alleged law office failure. Therefore, the order in question was affirmed.
Healing Health Prods., Inc. v New York Cent. Mut. Fire Ins. Co. (2014 NY Slip Op 24145)
May 22, 2014
The court considered whether an action to recover payment was premature when the provider had failed to respond to a request for verification, as well as whether a request for written verification from the insurer communicated by mail was complete upon its delivery to the United States Postal Service. The main issue decided was that the operative question in the case was not whether the requests were received by the provider, but whether the insurer had mailed them. The holding of the case was that the provider raised a triable issue of fact as to whether the verification requests had been properly mailed to them in the first place. The Civil Court's order was affirmed.
Uptown Healthcare Mgt. Inc. v Allstate Ins. Co. (2014 NY Slip Op 03594)
May 15, 2014
The court considered the motion of the defendants Allstate Insurance Company, Robert P. Macchia, and Mehmet F. Gokce to dismiss the complaint. The main issue in the case was whether the amended complaint was sufficient to state a cause of action upon which relief could be granted. The court held that the amended complaint, like the original complaint, was insufficient to state a cause of action. Plaintiffs had asserted that Allstate had no right to investigate whether they were fraudulently licensed under Public Health Law article 28 and therefore ineligible to receive no-fault reimbursements, but the court found that Allstate plainly has that right. Additionally, the court found that no cause of action lies against Allstate's counsel for undertaking a legitimate investigation at Allstate's behest. Therefore, the court affirmed the order to grant the motions of the defendants to dismiss the complaint and denied plaintiffs' cross motion for summary judgment.
Utica Natl. Ins. Co. of Tex. v Clennan (2014 NY Slip Op 50806(U))
May 7, 2014
The relevant facts the court considered were that the plaintiff's insured's vehicle was struck and damaged by a bicycle allegedly operated by the defendant, which was legally parked on the street in front of her residence. The main issue decided was whether the evidence established defendant's liability for the collision. The holding of the court was that the plaintiff had established its prima facie entitlement to summary judgment on the issue of liability by submitting evidence demonstrating that defendant's bicycle struck plaintiff's subrogor's legally parked vehicle, and the defendant failed to submit competent evidence to rebut the inference of negligence. Therefore, the order granting plaintiff summary judgment on the issue of liability was affirmed.
EMC Health Prods., Inc. v Geico Ins. Co. (2014 NY Slip Op 50786(U))
April 30, 2014
The main issue in this case was whether the provider was entitled to recover assigned first-party no-fault benefits, specifically focusing on the medical necessity of the services provided. The court denied the plaintiff's motion for summary judgment and made findings in plaintiff's favor, limiting the issues for trial to medical necessity. The defendant failed to provide a sufficient basis to dispute the findings made in plaintiff's favor. Additionally, the court's order did not intend to find that the defendant had issued denials that were untimely or without merit as a matter of law. Ultimately, the court affirmed the order, and the case was directed to go to trial to determine the medical necessity of the services provided by the provider.
Mount Sinai Hosp. of Queens v Country Wide Ins. Co. (2014 NY Slip Op 50780(U))
April 30, 2014
The court considered the timing of the denial of the claim form and the submission of the claim by the plaintiff. The main issue decided was whether the defendant's denial of claim form had been timely mailed and whether the plaintiff submitted the claim more than 45 days after the date the services had been rendered. The holding of the court was that the defendant's denial of claim form was timely mailed and the plaintiff had submitted its claim more than 45 days after the services had been rendered. As a result, the court affirmed the order granting the defendant's cross motion for summary judgment dismissing the complaint.
New Way Med. Supply Corp. v Geico Ins. Co. (2014 NY Slip Op 50776(U))
April 30, 2014
The relevant facts the court considered in this case were that New Way Medical Supply Corp., as the assignee of JESULA ST. VICTOR, was seeking to recover assigned first-party no-fault benefits from Geico Ins. Co. Plaintiff moved for summary judgment, and defendant cross-moved for summary judgment on the basis that the claim was denied due to a lack of medical necessity. The Civil Court denied plaintiff's motion and made findings in plaintiff's favor, denying defendant's cross motion and holding that the only remaining issue for trial was medical necessity. The main issue decided in the case was whether there was a triable issue of fact regarding the medical necessity of the services at issue. The holding of the case was that the order, insofar as appealed from, was affirmed, with the court finding that there was a triable issue of fact regarding the medical necessity of the services at issue.
High Quality Med. Supplies, Inc. v Praetorian Ins. Co. (2014 NY Slip Op 50775(U))
April 30, 2014
The relevant facts considered in this case were that the plaintiff, High Quality Medical Supplies, Inc., was seeking to recover first-party no-fault benefits from the defendant, Praetorian Ins. Co. The plaintiff moved for summary judgment, while the defendant cross-moved for summary judgment on the grounds that it had properly denied the claims based on lack of medical necessity. The Civil Court denied the plaintiff's motion and made findings in the plaintiff's favor, as well as denying the defendant's cross motion. On appeal, the defendant failed to provide a sufficient basis to strike the Civil Court's findings in the plaintiff's favor and there was a triable issue of fact regarding the medical necessity of the supplies at issue. As a result, the defendant was not entitled to summary judgment dismissing the complaint. Therefore, the Appellate Term affirmed the order in favor of the plaintiff.