No-Fault Case Law
Urban Well Acupuncture, P.C. v Erie Ins. Co. of N.Y. (2016 NY Slip Op 51300(U))
September 19, 2016
The insurer established its fee schedule defense for CPT codes 97813 and 97814, but a factual issue remained on code 99202. Its affidavits and documentary evidence established timely denials of the acupuncture claims under codes 97813 and 97814 because the charges exceeded the applicable workers' compensation fee schedule. The provider raised no triable issue concerning mailing or fee calculations for those claims. A triable issue remained as to whether the insurer properly denied the initial-evaluation claim billed under code 99202. The Appellate Term, First Department, modified the order to grant the insurer partial summary judgment dismissing the claims under codes 97813 and 97814, and otherwise affirmed the denial of summary judgment on the code 99202 claim.
Alleviation Med. Servs., P.C. v Elrac, Inc. (2016 NY Slip Op 51351(U))
September 19, 2016
The defendant's summary judgment motion based on the assignor's IME nonappearance was granted and affirmed on appeal. The Appellate Term, Second Department, found the supporting affidavit sufficient to establish timely mailing of the denial under St. Vincent's Hosp. of Richmond v Government Empls. Ins. Co. It rejected the provider's remaining contention without explanation.
Compas Med., P.C. v MVAIC (2016 NY Slip Op 51355(U))
September 19, 2016
MVAIC's own submissions raised a factual issue about whether the assignor had other no-fault coverage that had to be exhausted. Its claim representative reported that a search using the assignor's address identified another resident who owned an insured vehicle. But MVAIC also submitted the assignor's household affidavit stating that the assignor lived alone when the accident occurred. Those conflicting submissions left unresolved whether benefits were available from the vehicle's insurer, which the provider and assignor would have to exhaust before seeking recovery from MVAIC. The Appellate Term, Second Department, reversed the order granting MVAIC summary judgment and denied its motion to dismiss the provider's assigned-benefits action.
GL Acupuncture, P.C. v Allstate Ins. Co. (2016 NY Slip Op 51328(U))
September 15, 2016
The insurer's fee schedule defense did not support summary judgment because its affidavits failed to establish timely mailing of denials. The insurer moved to dismiss the provider's assigned no-fault claims, asserting that it had fully paid for the services under the workers' compensation fee schedule. The Civil Court, Queens County, granted the motion. On appeal, the Appellate Term, Second Department, found that the affidavits did not sufficiently describe a standard office practice or procedure ensuring timely mailing of the denial forms. It reversed the order and denied the insurer's motion for summary judgment.
TAM Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51327(U))
September 15, 2016
The insurer's motion for summary judgment dismissing the provider's assigned no-fault claims was granted and affirmed on appeal. The Appellate Term, Second Department, affirmed the Civil Court, Queens County, order for the reasons stated in Metro Health Prods., Inc. v State Farm Mut. Auto. Ins. Co., without giving independent reasoning or identifying the underlying defense.
Restoration Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2016 NY Slip Op 51325(U))
September 15, 2016
The insurer established proper mailing of IME scheduling letters and denial forms, as well as the assignor's nonappearance. The insurer sought summary judgment dismissing the provider's assigned no-fault claims based on timely denials for failure to attend duly scheduled IMEs. On appeal, the provider challenged both the mailing proof and the evidence of nonappearance. The Appellate Term, Second Department, found the insurer's submissions sufficient to raise a presumption of proper mailing and to establish that the assignor had failed to attend the IMEs. It affirmed the order granting the insurer's motion and rejected the provider's remaining contention without further discussion.
Dr. Ronda M. Bachenheimer/Meadowbrook Chiropractic v Allstate Ins. Co. (2016 NY Slip Op 51324(U))
September 15, 2016
The provider's summary judgment motion was denied because the record presented a triable issue of medical necessity. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, agreeing with the Civil Court, Queens County, determination and citing Zuckerman v City of New York without describing the evidence or giving further reasoning.
Daily Med. Equip. Distrib. Ctr., Inc. v National Liab. & Fire Ins. Co. (2016 NY Slip Op 51323(U))
September 15, 2016
The insurer's affidavits established timely and proper mailing of IME scheduling letters and denial forms. The provider moved for summary judgment in its action for assigned no-fault benefits, and the insurer cross-moved to dismiss the complaint based on the assignor's failure to attend duly scheduled IMEs. The Civil Court, Queens County, denied the provider's motion and granted the insurer's cross motion. Rejecting the provider's challenge to the mailing proof, the Appellate Term, Second Department, found no basis to disturb that order and affirmed the dismissal in the insurer's favor.
DAC Medical, P.C./Timothy Mosomillo, D.O. v Allstate Ins. Co. (2016 NY Slip Op 51322(U))
September 15, 2016
The provider's summary judgment motion was denied because the record presented a triable issue of medical necessity. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, agreeing with the Civil Court, Queens County, determination and citing Zuckerman v City of New York without describing the evidence or giving further reasoning.
New Way Med. Supply Corp. v State Farm Mut. Auto. Ins. Co. (2016 NY Slip Op 51321(U))
September 15, 2016
The insurer's motion for summary judgment dismissing the provider's assigned no-fault claims was granted and affirmed on appeal. The Appellate Term, Second Department, affirmed the Civil Court, Queens County, order for the reasons stated in Metro Health Prods., Inc. v State Farm Mut. Auto. Ins. Co., without giving independent reasoning or identifying the underlying defense.