No-Fault Case Law
Dugo v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 52375(U))
December 26, 2012
The court considered the first-party no-fault benefits sought by two separate chiropractors on behalf of a patient who had undergone manipulation under anesthesia (MUA) following a motor vehicle accident. The main issues were whether chiropractors in New York could perform MUA, the validity of the peer review conducted by a chiropractor, and whether the defendant had the obligation to join other claims for MUA-related services in the litigation. The holding was that the claims brought by the plaintiffs were dismissed, as MUA is classified as surgery and chiropractors are not permitted to perform surgery in New York. Additionally, the peer review conducted by the defendant was found to lack the necessary information to form an informed opinion, and the defendant was obligated to consolidate all claims arising from a particular MUA for a joint trial. If MUA were authorized in the future, the plaintiffs would be entitled to reduced amounts based on the failure of the defendant to prove its case.
Seacoast Med., P.C. v Praetorian Ins. Co. (2012 NY Slip Op 52354(U))
December 24, 2012
The relevant facts considered by the court were that the defendant-insurer had timely and properly mailed notices for independent medical examinations (IMEs) and examinations under oath (EUOs) to the plaintiff's assignor, and the assignor failed to appear. The main issue decided was whether the defendant-insurer was entitled to summary judgment dismissing the action for first-party no-fault benefits based on the assignor's failure to appear for the IMEs and EUOs. The holding of the court was that the defendant-insurer made a prima facie showing of entitlement to summary judgment, and the plaintiff did not raise a triable issue with respect to the assignor's nonappearance or the mailing and reasonableness of the underlying notices. Therefore, the motion for summary judgment was granted and the complaint was dismissed.
Devonshire Surgical Facility, LLC v Allstate Ins. Co. (2012 NY Slip Op 52351(U))
December 24, 2012
The court considered the action brought by Devonshire Surgical Facility, LLC seeking recovery of assigned first-party no-fault benefits. The main issues considered were whether the amounts of the timely denied claims properly reflected plaintiff's status as a surgical facility or were in excess of the rates set forth in the governing fee schedule, as well as the admissibility of the affidavit of defendant's adjuster. The court held that the action was not ripe for summary disposition, as there were several triable issues raised in the record. The court also noted that the new arguments raised in plaintiff's reply papers failed to eliminate all triable issues of fact, and therefore denied the cross motion for summary judgment on the complaint.
Lenox Hill Hosp. v Allstate Ins. Co. (2012 NY Slip Op 52411(U))
December 21, 2012
The relevant facts in the case Lenox Hill Hosp. v Allstate Ins. Co. include the denial of the plaintiffs' motion for summary judgment in an action to recover assigned first-party no-fault benefits. The main issue decided by the court was whether the plaintiffs had demonstrated their entitlement to judgment as a matter of law, and the court held that they had not. In affirming the denial of the motion for summary judgment, the court found that the plaintiffs had not met their burden of proof to show their prima facie entitlement to judgment. As a result, the order denying the motion for summary judgment was upheld by the court.
New York Diagnostic Med. Care, P.C. v GEICO Cas. Ins. Co. (2012 NY Slip Op 52409(U))
December 21, 2012
The relevant facts considered by the court were that New York Diagnostic Medical Care, P.C. was seeking to recover assigned first-party no-fault benefits from GEICO Casualty Insurance Co. The main issue decided was whether the plaintiff's motion for summary judgment should be granted. The court held that the plaintiff's moving papers did not establish a prima facie entitlement to judgment as a matter of law because the affidavit submitted by the plaintiff's billing manager was insufficient to prove that the defendant had failed to pay or deny the claims within the required 30-day period, or that the defendant had issued timely denial of claims that were conclusory, vague, or without merit as a matter of law. Therefore, the court affirmed the order denying plaintiff's motion for summary judgment.
T & M Rehab PT, P.C. v Unitrin Auto & Home Ins. Co. (2012 NY Slip Op 52407(U))
December 21, 2012
The main issue in this case was whether the holding in Excel Imaging, P.C. v MVAIC constituted a change in the law that required an insurer to issue denial of claim forms in duplicate. T & M Rehab PT, P.C. had previously been denied their motion for summary judgement by the Civil Court, and subsequently filed a motion for leave to renew their prior motion based on this new law. The court considered the relevant facts of the case, including the timing of the motion for leave to renew and the holding in Excel Imaging, P.C.
The holding of the court was that the Civil Court properly denied T & M Rehab PT, P.C.'s motion for leave to renew, as the holding in Excel Imaging, P.C. did not constitute a change in the law. Therefore, the order denying the motion for leave to renew was affirmed.
Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52406(U))
December 21, 2012
The relevant facts considered by the court in this case included the timely mailing of independent medical examination (IME) scheduling letters by the defendant's assigned entity, as well as the failure of the plaintiff's assignor to appear for the scheduled IMEs. The main issue decided by the court was whether the denials of claim forms by the defendant were nullities because they had not been issued in duplicate, as required by the Insurance Department Regulations. The holding of the court was that the denial of claim forms, issued by the defendant to notify the applicant, were valid and complied with the requirement, and that the defendant had established its prima facie entitlement to the judgment as a matter of law. As a result, the judgment was reversed and the order denying summary judgment to the defendant was vacated, with the defendant's motion for summary judgment dismissing the complaint being granted and the plaintiff's cross-motion for summary judgment being denied.
Alfa Med. Supplies v GEICO Gen. Ins. Co. (2012 NY Slip Op 52405(U))
December 21, 2012
The court considered the case of Alfa Medical Supplies as Assignee of JULIO C. DIAZ v GEICO General Ins. Co., in which the provider appealed for first-party no-fault benefits being denied. The main issue decided was whether the denial of the claim was valid based on lack of medical necessity, and if the peer review report submitted by the defendant provided the necessary medical rationale to support the denial. The court held that the branch of the plaintiff's motion seeking summary judgment to recover a $70 claim for a thermophore was granted, but the branch of the defendant's cross motion seeking summary judgment to dismiss the remainder of the complaint was denied. The court found that the defendant's peer review report established the lack of medical necessity, except for the thermophore, and that the plaintiff failed to raise a triable issue of fact to rebut the peer review report. Therefore, the order was affirmed with modifications.
Essential Acupuncture Servs., P.C. v Ameriprise Auto & Home Ins. (2012 NY Slip Op 52404(U))
December 21, 2012
The court considered an appeal from a judgment entered after the Civil Court granted plaintiff's motion for summary judgment and denied defendant's cross motion for summary judgment dismissing the complaint. The main issue decided was whether the defendant had raised a triable issue of fact based on the failure of the plaintiff's owner to appear at scheduled examinations under oath (EUOs). The court held that the defendant had failed to establish that the EUO scheduling letters had been timely mailed, and therefore failed to demonstrate that the 30-day claim determination period had been tolled. As a result, the defendant also failed to establish that its denial of claim forms were timely, and therefore was not precluded from raising as a defense the failure of plaintiff's owner to appear for the EUOs. Therefore, the judgment was affirmed.
W & Z Acupuncture, P.C. v Unitrin Auto & Home Ins. Co. (2012 NY Slip Op 52400(U))
December 21, 2012
The court considered the motion by the defendant to compel the plaintiff to appear for an examination before trial in a case involving the plaintiff's assignment to recover first-party no-fault benefits. The main issue decided was whether the plaintiff should be compelled to appear for an examination before trial, limited to the issue of the relationship between the plaintiff and the treating acupuncturists. The holding of the court was that the branch of the defendant's motion seeking to compel the plaintiff to appear for an examination before trial was denied. The court found that because the defendant's denial of claim forms did not deny the plaintiff's claims on the ground that the treatment at issue had been rendered by independent contractors, the defendant was precluded from asserting that ground for denial of coverage as a defense in the litigation. Therefore, the demand for the plaintiff to appear for an examination before trial in support of this defense was deemed palpably improper and was denied.