No-Fault Case Law
Jian Kang, Inc. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50851(U))
May 14, 2013
The court considered a case in which a provider sought to recover assigned first-party no-fault benefits from an insurance company. The insurance company denied the provider's claims, alleging that there was a "material misrepresentation" because the provider had billed for a heating pad that had not been provided to the assignor. The main issue decided was whether the provider was barred from receiving benefits not only for the heating pad but also for the remaining supplies for which they sought to recover. The holding of the court was that the insurance company failed to establish that the claim forms sought payment for medical supplies that were not actually provided, and that billing for a heating pad that was not delivered did not void the insurance policy. Therefore, the court affirmed the denial of the insurance company's motion to dismiss the claims for the remaining supplies.
Urban Radiology, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50850(U))
May 14, 2013
The court considered the fact that after the plaintiff presented its case in a trial to recover first-party no-fault benefits, the defendant offered no defense but relied on the record. Despite the claim forms not containing language about an assignment of benefits, the defendant did not object to the completeness of the forms or seek verification of the existence of a valid assignment. The main issue decided was whether the plaintiff had established a prima facie case and whether the defendant waived any defense based on the absence of an assignment of benefits. The court held that the defendant waived any defense based on the absence of an assignment of benefits and that it was the defendant's burden to show a meritorious defense, therefore it reversed the previous judgment and remitted the matter to the Civil Court for the entry of a judgment in favor of the plaintiff in the principal sum of $2,063.10, plus statutory interest and attorney's fees.
Radiology Today, P.C. v Travelers Ins. Co. (2013 NY Slip Op 50849(U))
May 14, 2013
The court considered the case of Radiology Today, P.C. as Assignee of BRIANT JOSEPH v. Travelers Insurance Company, where the plaintiff sought to recover first-party no-fault benefits. The main issue was whether the defendant had established a lack of medical necessity for the radiology services at issue. The court held that the defendant's expert witness testimony did not provide a factual basis or medical rationale for her opinion, therefore, it was insufficient to establish the lack of medical necessity for the services rendered. Additionally, the court ruled that a peer review report, unlike a witness, is not admissible to prove lack of medical necessity and is not subject to cross-examination. The Civil Court's determination that the defendant had not established that the services at issue were not medically necessary was upheld, and the judgment in favor of the plaintiff was affirmed.
LK Health Care Prods. Inc v GEICO Gen. Ins. Co. (2013 NY Slip Op 50810(U))
May 9, 2013
The court considered the fact that the plaintiff, LK Health Products, Inc., objected to an Examination Under Oath (EUO) request made by defendant GEICO General Insurance Company, citing the New York No-Fault Regulations. The main issue decided was whether the defendant insurance company was required to respond to the plaintiff's objection to the EUO request as being unreasonable. The court held that the plaintiff timely objected to the EUO request, but the defendant provided evidence justifying the need for the EUO, based on an investigation into the plaintiff for improper billing practices. Therefore, the defendant was justified in requesting the EUO, and the plaintiff's failure to show up for the EUO constituted a violation of a condition precedent to coverage, voiding the contract ab initio. As a result, the defendant was not obligated to pay the claim, and the case was dismissed with prejudice.
Art of Healing Medicine, P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50766(U))
May 6, 2013
The relevant facts that the court considered in this case were that Art of Healing Medicine, P.C. was seeking to recover first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint insofar as it sought to recover upon a claim in the amount of $2,619.20. The holding of the court was that defendant did not establish its entitlement to summary judgment with respect to the $2,619.20 claim, as it did not deny the claim on the ground that the plaintiff's assignor had failed to appear for scheduled independent medical examinations. Additionally, the court found that plaintiff failed to establish its prima facie case with respect to the $2,619.20 claim as it did not prove the fact and the amount of the loss sustained. Therefore, the court modified the order and held that plaintiff had not established its prima facie case with respect to the claim.
Sky Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50764(U))
May 6, 2013
The court considered an action by a provider to recover assigned first-party no-fault benefits. Plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The main issue was whether the supply at issue was medically necessary. The court found that defendant had established a timely and proper denial of the claim at issue on the ground of lack of medical necessity and that the sole remaining issue for trial was medical necessity. The court held that defendant's cross motion for summary judgment dismissing the complaint was granted, as plaintiff did not challenge the Civil Court's finding that defendant was entitled to judgment.
Flatlands Med., P.C. v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 50763(U))
May 6, 2013
The relevant facts in this case included a medical provider's attempt to recover no-fault benefits from an insurance company. The insurance company had denied the claim based on the medical provider's failure to appear for scheduled examinations under oath (EUOs). The main issue decided was whether the insurance company had proven that it had mailed the EUO scheduling letters and denial of claim forms on time, and whether the medical provider had failed to comply with the condition precedent to coverage. The holding of the case was that the insurance company had indeed timely mailed the EUO scheduling letters and denial of claim forms, and the medical provider's failure to respond to the EUO request meant that their objections regarding the request could not be heard. As a result, the order to grant the insurance company's motion for summary judgment dismissing the complaint was affirmed.
Compas Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50762(U))
May 6, 2013
The court considered the denial of defendant's motion for summary judgment dismissing the complaint and the granting of plaintiff's cross motion for summary judgment in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff proved prima facie entitlement to summary judgment and whether the defendant established that it was not precluded from raising defenses. The court held that the plaintiff satisfied the requirements for its prima facie case, including proving that the claims had been mailed to the defendant and laying a foundation for its claim forms. Additionally, the court found that the defendant failed to establish that it was not precluded from raising defenses, including the defense that the plaintiff's assignor had failed to comply with a condition precedent to coverage. Therefore, the judgment of the Civil Court of the City of New York, Kings County was affirmed.
Park Slope Med. v Praetorian Ins. Co. (2013 NY Slip Op 50761(U))
May 6, 2013
The court considered the denial of both the plaintiff's motion for summary judgment and the defendant's cross motion for summary judgment, with the sole issue for trial being medical necessity. The main issue decided was whether the defendant was entitled to summary judgment in a case by a provider to recover assigned first-party no-fault benefits. The court held that the defendant's cross motion for summary judgment dismissing the complaint should have been granted as the sworn peer review report provided a factual basis and medical rationale for the lack of medical necessity for the medical supplies at issue, and the plaintiff's opposition failed to meaningfully rebut the conclusions set forth in the peer review report. Therefore, the court reversed the prior determination and granted the defendant's cross motion for summary judgment dismissing the complaint.
Jamaica Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50760(U))
May 6, 2013
The court considered the case of Jamaica Medical Supply, Inc. as Assignee of Clayton Williams v GEICO General Insurance Co. The main issue decided was whether the provider was entitled to recover assigned first-party no-fault benefits. The court held that the provider was not entitled to recover the benefits, reversing the order of the Civil Court and granting the defendant's cross motion for summary judgment dismissing the complaint. This decision was based on the fact that the defendant had timely mailed the denial of the claim form, citing lack of medical necessity, and had submitted a properly affirmed peer review report. The court found that the plaintiff's submission of an affirmation by a doctor failed to rebut the conclusions set forth in the peer review report. Therefore, the defendant's cross motion should have been granted, and the plaintiff's motion for summary judgment was denied.