No-Fault Case Law

The main issue considered in this case was whether paragraph 11 of the Official New York Workers' Compensation Medical Fee Schedule, Physical Medicine (2010) limits claims reimbursement to 8.0 units (codes) per day for each provider individually or for all provider claims cumulatively. The plaintiff medical service provider submitted claims for assorted code procedures constituting 10 units and sought to recover $1,876.76 of "no-fault" claim benefits after the defendant insurance company denied the claim, asserting that the fees were in excess of the workers' compensation fee schedule. The court determined that the doctrine of claim benefit exhaustion as described in regulation 11 NYCRR 65-3.15 was inapplicable to the excessive fee limitations imposed by paragraph 11 of the Official New York Workers' Compensation Medical Fee Schedule. The court held that the language of the regulation itself indicated that it regulated benefits for "all" claims on any given day and ruled in favor of the plaintiff, allowing reimbursement for 8 of its claims' 10 billing units, in the sum of $1,876.76 plus appropriate statutory interest, attorneys fees and costs.

The court considered the fact that Garden State Anesthesia Associates provided anesthesia services to Angela Gowan-Walker and had requested payment from Progressive Casualty Insurance Company. Progressive had received the claims for these services but had not paid or denied them, despite sending letters requesting verification and additional documentation. Progressive moved for summary judgment to dismiss the action to obtain payment of the first-party no-fault benefits. The main issue before the court was whether Progressive was entitled to delay payment of the claims due to outstanding verification requests. The court held that actions brought before an insurer receives all timely requested verification are premature and subject to dismissal. The court also found that Progressive's requests for verification were not related or relevant to their evaluation of the specific provider's claim, denying the motion for summary judgment.

The court considered a dispute between Flushing Traditional Acupuncture and Geico Ins. Co. regarding the amount of first-party no-fault benefits owed to the provider for acupuncture services. The main issue decided was whether the defendant insurer had properly used the workers' compensation fee schedule to determine the amount owed for certain services. The court held that the insurer had properly used the fee schedule for some of the services billed, but it had not addressed an "initial evaluation" billed under a different code, so summary judgment dismissing that claim was denied. Overall, the court modified the order to deny the insurer's motion to dismiss the claim for the initial evaluation, but affirmed the order in all other respects.

The main issues in this case revolve around the death of the sole owner of a PC, which has led to delays in the progress of the case. The court considered the fact that the defendant, State Farm Mutual Automobile Insurance Co., has been unable to obtain a final resolution of the claim due to the death of the plaintiff's sole shareholder and the lack of present authority to pursue the pending claim. The court decided that the defendant can seek dismissal of the complaint if the representatives of the deceased doctor's estate fail to obtain de facto authority to pursue the PC's claims within a reasonable time after the doctor's death, and that it can request an order retroactively denying plaintiff's right to obtain statutory interest upon the claim based on proof of unreasonable delay. The holding of the court was that the motion to dismiss under CPLR 1021 was denied without prejudice to renewal upon further proof of unreasonable delay. The Court also decided to stay all proceedings in the action until a representative of the deceased doctor's estate is appointed, and the judgment in favor of the plaintiff shall carry post-commencement no-fault interest only from a date, going forward, when the requisite Surrogate's approval is obtained.

The main issue in this case was whether the defendant, Redland Insurance Company, had timely and properly denied the plaintiff's claims for first-party no-fault benefits based on a lack of medical necessity. The court considered a sworn peer review report submitted by the defendant, which provided a factual basis and medical rationale for the determination that there was a lack of medical necessity for the services at issue. The plaintiff, Intuitive Chiropractic, P.C. as Assignee of Ruth Santamaria, failed to rebut the defendant's prima facie showing. As a result, the court held that the defendant's cross motion for summary judgment dismissing the complaint should be granted. Therefore, the holding of the case was that the defendant was entitled to summary judgment dismissing the complaint, and the order of the Civil Court denying the defendant's cross motion was reversed.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, denying the plaintiff's motion for summary judgment in a case involving the recovery of assigned first-party no-fault benefits. The main issue decided was whether the denial of the plaintiff's motion for summary judgment was appropriate, and the court ultimately reversed the order and granted the plaintiff's motion for summary judgment. The holding of the case was that the matter was remitted to the Civil Court for a calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106 and the regulations promulgated thereunder. The Appellate Term, Second Department, made the decision on August 26, 2013.

The relevant facts the court considered in this case were that a provider was seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the provider had established the fact and amount of the loss sustained, and whether there were triable issues of fact as to the medical necessity of the service provided. The holding of the case was that the court affirmed the order, finding that the plaintiff had indeed established the fact and amount of the loss sustained, and that there were triable issues of fact as to the medical necessity of the service provided. The order directed that a trial be held on the issue of medical necessity.

The relevant facts considered by the court were that the plaintiff, Canarsie Chiropractic, P.C., was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. The main issue decided was whether the plaintiff had failed to comply with a condition precedent to coverage by not appearing for scheduled examinations under oath (EUOs). The court affirmed the order of the Civil Court, granting State Farm's motion for summary judgment dismissing the complaint, as the affidavits submitted by State Farm established that the EUO scheduling letters and denial of claim forms had been timely mailed. The holding of the case was that since the plaintiff did not respond in any way to the EUO requests, their objections regarding the EUO requests would not be heard, and therefore discovery relevant to the reasonableness of the EUO requests was not necessary to oppose the motion.

The main facts of the case are that Queens Integrated Medical Care P.C. brought a lawsuit against New York Central Mutual Fire Insurance Company, in relation to a no-fault claim for physical therapy and related services. The main issue considered by the court was whether there was a triable issue as to the medical necessity of the physical therapy and related services, due to conflicting medical expert opinions. The holding of the court 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 services, and therefore the motion for summary judgment dismissing the complaint was denied in part.

The relevant facts in the case include that the plaintiff, Eagle Surgical Supply, Inc., sought to recover first-party no-fault benefits. The defendant, AIG Insurance Co., denied the benefits on the basis that the plaintiff and its assignor had not appeared for examinations under oath. The Civil Court granted summary judgment in favor of the plaintiff, but the defendant obtained a declaratory judgment in a Supreme Court action stating that the defendant had no duty to defend or indemnify the plaintiff and its assignor due to their failure to appear for an examination under oath. The main issue was whether the plaintiff was seeking to relitigate the same claims or causes of action that were decided in the prior litigation, and if the doctrine of res judicata should apply. The holding was that since the declaratory judgment did not apply to the incident date of the plaintiff's claim, the plaintiff was not seeking to relitigate the same transaction or series of transactions, and thus the order denying the defendant’s motion to vacate the judgment was affirmed.