No-Fault Case Law
New York Diagnostic Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50419(U))
March 15, 2013
The main issue in this case was whether the provider had established its prima facie case to recover assigned first-party no-fault benefits. The court considered the fact that the defendant had not paid the claim, but the plaintiff failed to show that the basis for the denial of the claim lacked merit as a matter of law. The Civil Court determined that the plaintiff had failed to establish its prima facie case. However, in opposition to the defendant's cross motion for summary judgment dismissing the complaint on the ground of lack of medical necessity, the plaintiff submitted an affidavit by its doctor which sufficiently demonstrated the existence of a question of fact as to medical necessity. Therefore, the court modified the order by denying the defendant's cross motion for summary judgment dismissing the complaint.
Apple Tree Acupuncture, P.C. v Allstate Ins. Co. (2013 NY Slip Op 50413(U))
March 15, 2013
The court considered whether an insurer may use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount a licensed acupuncturist is entitled to receive, and whether the insurer had properly denied the remaining portion of each of the claims at issue. The main issue decided was whether the defendant had established, as a matter of law, that the amount it had paid the plaintiff was the maximum amount permitted by the workers' compensation fee schedule for acupuncture services rendered by a chiropractor. The holding of the case was that the defendant failed to demonstrate its prima facie entitlement to summary judgment, and therefore the judgment was reversed, with the order of summary judgment dismissing the complaint vacated and the defendant's cross motion for summary judgment dismissed.
American Ind. Ins. Co. v Art of Healing Medicine, P.C. (2013 NY Slip Op 01546)
March 13, 2013
The main facts of the case are that American Independent Insurance Company began a proceeding to permanently stay arbitration of Art of Healing Medicine, P.C.'s claims for no-fault benefits, arguing that they were not subject to personal jurisdiction in New York. Central to the decision is the rule that personal jurisdiction must first be obtained over a party before judgment may be entered upon an arbitration award. However, public policy favors arbitration courts interfere as little as possible with the freedom of parties to submit their disputes to arbitration. The courts held that the Supreme Court erred in granting the petition to permanently stay arbitration on the ground that there was no personal jurisdiction over AIIC and the counterclaims from the appellants were properly dismissed. Therefore, the order is modified, denying the petition to stay arbitration, but affirming the dismissal of the counterclaims.
Innovative MR Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50359(U))
March 12, 2013
The court considered the motion to dismiss the complaint pursuant to CPLR 3211, filed by the defendant, New York Central Mutual Fire Insurance Company. The main issue was whether the complaint, supported by the affidavit in opposition of plaintiff's billing manager, was sufficient to state a cause of action for recovery of first-party no-fault benefits. The court held that the complaint, combined with the affidavit, was indeed sufficient to state a cause of action for recovery of first-party no-fault benefits. The court also found that the affidavit of the defendant's no-fault litigation examiner was not "essentially undeniable" enough to conclusively refute any claim that the plaintiff might have. Therefore, the court affirmed the order of the Civil Court, denying the defendant's motion to dismiss the complaint.
Ideal Med. Supply v Mercury Cas. Ins. Co. (2013 NY Slip Op 23068)
March 12, 2013
The main issue in this case was whether or not the plaintiff, Ideal Medical Supply, as assignee of Lee Cuffie, was bound by a previous declaratory judgment action which denied all no-fault claims related to injuries sustained by Cuffie in a motor vehicle accident. The defendant insurer argued that the plaintiff was bound by the judgment, but the court ultimately disagreed. The court ruled that as Ideal Medical Supply was not a party in the previous declaratory judgment action, it was not bound by the outcome. Additionally, the court held that the plaintiff and their assignor were not in "privity", which meant that plaintiff could not be bound by the result of the previous judgment. The court also considered earlier case law, such as in Gramatan Home Invs. Corp. v Lopez, and the unique nature of assignments of claims in first-party no-fault cases, in reaching their decision. Ultimately, the court ruled in favor of the plaintiff, affirming the original order denying summary judgement to the defendant insurer.
Matter of Infinity Ins. Co. v Daily Med. Equip. Distrib. Ctr., Inc. (2013 NY Slip Op 23066)
March 11, 2013
The relevant facts the court considered in this case were that Infinity Insurance Company sought to stay an arbitration demanded by Daily Medical Equipment Distribution Center, Inc. after Infinity rescinded an automobile insurance policy issued to Derrick St. Louis due to a misrepresentation made by St. Louis in the procurement of the policy. Daily Medical, as St. Louis' assignee, filed a request with the American Arbitration Association seeking reimbursement for no-fault benefits. The main issue decided by the court was whether Infinity's petition for a permanent stay of the arbitration should be granted and the court held that the application for the permanent stay must be denied. The court found that Infinity's participation in the arbitration, by sending documents to AAA in response to Daily Medical's arbitration request, effectively barred its application for a stay of arbitration. Therefore, the court denied Infinity's motion for a permanent stay of the arbitration and dismissed the special proceeding.
Dayna Physical Therapy, P.C. v Travelers Ins. Co. (2013 NY Slip Op 50322(U))
March 5, 2013
The main issue in this case was whether the provider of assigned first-party no-fault benefits was precluded from litigating its claims for reimbursement. The court considered the fact that the assignor had assigned the benefits to the provider prior to commencement of his arbitration. The main issue decided was that the provider was not precluded from litigating the claims at issue in the action because the assignment of benefits predated the assignor's election to arbitrate. The holding of the case was that the Civil Court properly denied the defendant's motion to dismiss the complaint, but should have denied plaintiff's cross motion for summary judgment. Therefore, the judgment was reversed and plaintiff's cross motion for summary judgment was denied.
RDB Med. Care, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50301(U))
March 1, 2013
The court considered the fact that the defendant-insurer had timely and properly mailed notices for independent medical examinations (IMEs) to the plaintiff's assignor, and that the assignor failed to appear. The main issue decided was whether the defendant was entitled to summary judgment dismissing the first through sixth, and ninth through twelfth causes of action. The holding of the case was that the defendant-insurer made a prima facie showing of entitlement to summary judgment, and that the notices for IMEs were timely and properly mailed to the plaintiff's assignor. The court affirmed the order, with the modification of dismissing the first through sixth, and ninth through twelfth causes of action.
Forest Rehabilitation Medicine PC v Geico Ins. Co. (2013 NY Slip Op 50340(U))
February 27, 2013
The relevant facts the court considered in this case were the services provided by Forest Rehabilitation Medicine PC to John Russo, the denial of payment by GEICO Insurance Company based on "lack of medical necessity," and the expert testimony regarding the use of high frequency pulsed electromagnetic stimulation treatments. The main issue decided by the court was whether the TMR treatments provided by Forest Rehabilitation Medicine PC were medically necessary and whether they were accepted in the medical community. The holding of the court was a judgment for the defendant, GEICO Insurance Company, as the plaintiff, Forest Rehabilitation Medicine PC failed to rebut the defendant's defense. The court dismissed the plaintiff's cause of action, determining that the TMR treatments were not widely accepted in the medical community for the treatment of soft tissue injuries and therefore were not reimbursable.
Medalliance Med. Health Servs. v Allstate Ins. Co. (2013 NY Slip Op 23156)
February 25, 2013
In Medalliance Medical Health Services v. Allstate Insurance Company, the plaintiff brought the action to recover statutory interest and attorney fees on no-fault insurance claims that were overdue when they were paid by the defendant. The plaintiff submitted proof that the claims were mailed to the defendant and subsequently paid more than 30 days after they were mailed and received. The court considered the provisions of Insurance Law § 5106(a), 11 NYCRR 65-3.5, 11 NYCRR 65-3.9(a), and 11 NYCRR 65-3.10(a) in ruling on the matter. The court held that overdue payments earn monthly interest at a rate of two percent and entitle a claimant to reasonable attorneys' fees incurred in securing payment of a valid claim, and that the plaintiff is entitled to recover overdue interest and attorney fees as alleged in the complaint. Therefore, the plaintiff's motion for summary judgment was granted and the plaintiff was awarded judgment for the overdue interest and attorney fees, while the defendant's cross motion to dismiss the action was denied.