No-Fault Case Law
Hunt City Chiropractic, LLP v Chubb Indem. Ins. Co. (2013 NY Slip Op 51679(U))
October 15, 2013
The court considered the conflicting medical expert opinions presented by both parties regarding the medical necessity of the chiropractic services underlying the plaintiff's first-party no-fault claim. The main issue decided was whether the conflicting expert opinions raised a triable issue, and the court held that they did, thereby denying the defendant's motion for summary judgment dismissing the complaint. The holding of the case was that the conflicting medical expert opinions presented by the parties were sufficient to raise a triable issue as to the medical necessity of the chiropractic services, and therefore the defendant's motion for summary judgment was denied.
Gl Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 51748(U))
October 8, 2013
The court considered the appeal of an order by the Civil Court that granted the defendant's motion for summary judgment dismissing the complaint by a provider seeking to recover first-party no-fault benefits. The main issue decided was whether the defendant properly used the workers' compensation fee schedule to determine the amount the plaintiff was entitled to receive for acupuncture services performed by chiropractors. The court held that the defendant's affidavits sufficiently established the timely mailing of denial of claim forms, and that the defendant had properly used the workers' compensation fee schedule to determine payment for the services at issue. The judgment of the Civil Court granting the defendant's motion for summary judgment was affirmed.
Elite Med. NY, P.C. v American Tr. Ins. Co. (2013 NY Slip Op 51738(U))
October 8, 2013
The court considered the plaintiff's motion for summary judgment on the grounds that the defendant failed to comply with a discovery stipulation and the defendant's cross-motion for summary judgment dismissing the complaint based on lack of medical necessity and outstanding verifications. The court found that the defendant had a reasonable excuse for the delay in compliance with the discovery order and had demonstrated meritorious defenses to the action. The court also found that the defendant had submitted peer review reports and evidence establishing timely verification requests, while the plaintiff failed to submit any medical evidence to rebut the reports or respond to the verification requests. As a result, the court granted the defendant's cross-motion for summary judgment dismissing the complaint.
Great Health Care Chiropractic, P.C. v Interboro Ins. Co. (2013 NY Slip Op 51737(U))
October 8, 2013
The court considered the request by the defendant to compel the plaintiff to produce its treating chiropractor for a deposition in a case where a provider was seeking first-party no-fault benefits. The main issue decided was whether the defendant was entitled to reasonable discovery of any facts bearing on the controversy to assist in the preparation for trial. The court held that under CPLR 3101 (a), parties are entitled to full disclosure of all material and necessary matters in the prosecution or defense of an action, and that the defendant, in defending the action on the ground that the services rendered lacked medical necessity, was entitled to compel the plaintiff to produce its treating chiropractor for a deposition. The holding was that the order denying the defendant's motion to compel the plaintiff to produce its treating chiropractor for a deposition was reversed, and the branch of the defendant's motion was granted.
Shara Acupuncture, P.C. v Allstate Ins. Co. (2013 NY Slip Op 51731(U))
October 8, 2013
The court considered the timely denial of claim forms issued by the defendant, as well as the payment of the subject claims at the highest rate available for acupuncture services. The main issue decided in this case was whether the defendant had paid the subject claims at the highest rate available for acupuncture services, as set forth in the chiropractic fee schedule. The holding of the case was that the defendant had established that it had paid the subject claims at the highest rate available for acupuncture services as set forth in the chiropractic fee schedule. Additionally, the court found that the denial of the claim forms had been timely mailed in accordance with the defendant's standard office practices and procedures. Therefore, the order was modified by deleting the award of summary judgment to the defendant for the initial evaluation which had been billed under code 99203.
Ranbow Supply of N.Y., Inc. v Progressive Northeastern Ins. Co. (2013 NY Slip Op 51729(U))
October 8, 2013
The main issue in this case was whether a provider could recover first-party no-fault benefits when the assignor failed to appear for scheduled independent medical examinations (IMEs). The court considered the fact that the defendant had mailed the IME scheduling letters to the correct address provided by its insured, and copies of the letters were also received by the assignor's attorney. The court held that the defendant had sufficiently demonstrated that it had addressed the letters to the correct address, and therefore the assignor's failure to appear for the IMEs was a valid reason for denying the plaintiff's motion for summary judgment. The order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment dismissing the complaint was affirmed.
American Tr. Ins. Co. v Curry (2013 NY Slip Op 23470)
October 8, 2013
The court considered the facts that the plaintiff filed for a default judgment against several defendants for not appearing for an examination under oath, as required under the insurance policy. The plaintiff also sought a summary judgment against Stand-Up MRI regarding payment for expenses incurred from a collision involving defendant Curry and a motor vehicle. The main issue decided by the court was whether the plaintiff's requests for the examination under oath were reasonable and justified. The court found that the plaintiff failed to provide specific objective justification for the examination, and there was no evidence that the defendant actually failed to appear for the examination. Therefore, the court denied the plaintiff's motion for a default declaratory judgment and for a summary declaratory judgment. As a result, the plaintiff's relief was denied.
New York Diagnostic Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 23360)
October 8, 2013
The relevant facts the court considered were that a provider had moved for summary judgment to recover assigned first-party no-fault benefits, plaintiff proved submission of claim forms by annexing denials, and the court made a finding to further limit the trial to the issue of medical necessity only. The main issue was whether plaintiff had established the submission to defendant of the claim forms and the fact and the amount of the loss sustained and the holding of the court was that the order was reversed and the branch of plaintiff's motion seeking a finding, pursuant to CPLR 3212 (g), that plaintiff had established, for all purposes in the action, the submission to defendant of the claim forms and the fact and the amount of the loss sustained is granted.
AP Diagnostic Med., PC v Chubb Indem. Ins. Co. (2013 NY Slip Op 51647(U))
October 7, 2013
The relevant facts considered by the court were that AP Diagnostic Medical, acting on behalf of Ivan Aybar, sought to recover first-party no-fault benefits from Chubb Indemnity Insurance Company, who had denied the claim for MRI testing as not medically necessary. The main issue decided by the court was whether the defendant-insurer was entitled to summary judgment dismissing the complaint. The holding of the court was that the action was not ripe for summary dismissal, as the plaintiff's opposing submission raised a triable issue of fact regarding the medical necessity of the MRI testing. The court found that the medical affidavit submitted by the plaintiff, detailing the assignor's complaints of pain and restricted range of motion in his cervical spine, was sufficient to raise a triable issue as to the medical necessity of the MRI. Therefore, the order of the Civil Court denying the defendant's motion for summary judgment was affirmed.
American Tr. Ins. Co. v Rodriguez (2013 NY Slip Op 51630(U))
October 7, 2013
The court considered an action for declaratory judgment arising out of a motor vehicle accident, in which defendant Jazmine L. Rodriguez was allegedly injured. She sought medical treatment from several defendants and allegedly assigned her No-Fault rights to them. Plaintiff American Transit Insurance Company moved for a default judgment against some of the defendants, which was granted as they had failed to appear in the action. However, plaintiff's motion for summary judgment was denied as they failed to establish prima facie entitlement to summary judgment as a matter of law. Therefore, the court ordered that the portion of plaintiff's motion seeking a default judgment be granted, while the portion for summary judgment was denied without prejudice to move for summary judgment after the completion of disclosure. Additionally, documentary discovery and depositions of the parties were ordered to be completed within specific timeframes, and a compliance conference was scheduled.