No-Fault Case Law

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.

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.

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.

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.