No-Fault Case Law
Innovative MR Imaging, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50264(U))
February 21, 2013
The court considered the defendant-insurer's denial of the plaintiff's first-party no-fault claim based on a sworn peer review report by a chiropractor, which stated that the MRI tests lacked medical necessity. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint, which the court ultimately granted. The holding of the case was that the defendant-insurer had made a prima facie showing of entitlement to judgment as a matter of law by timely denying the claim based on the peer review report, and that the plaintiff had failed to raise a triable issue in opposition. The court also found that the unsworn letter report submitted by the plaintiff's chiropractor was without probative value, and even if considered, the findings were insufficient to withstand summary judgment.
All Boro Psychological Servs., P.C. v Allstate Ins. Co. (2013 NY Slip Op 50307(U))
February 20, 2013
The relevant facts considered in the case included a provider's attempt to recover first-party no-fault benefits and the denial of the claim by the insurance company. The main issue decided by the court was whether the provider was entitled to summary judgment, and if the insurance company's cross motion for summary judgment dismissing the complaint should have been denied. The holding of the case was that the judgment was reversed and the insurance company's motion for summary judgment dismissing the complaint was denied. The court found that the provider had failed to demonstrate its entitlement to summary judgment, but the insurance company's motion papers also failed to establish that its time to pay or deny the claim had been tolled. Therefore, the judgment dismissing the complaint was reversed and vacated, and the insurance company's cross motion was denied.
Sky Med. Supply, Inc. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50260(U))
February 19, 2013
The relevant facts considered by the court were that the plaintiff, a medical supply provider, was seeking to recover first-party no-fault benefits in an assigned claim. The plaintiff moved for summary judgment, while the defendant cross-moved for summary judgment to dismiss the complaint. The main issue decided was whether the defendant had demonstrated that it had timely and properly denied the plaintiff's claim, and the sole issue for trial was the medical necessity of the supplies provided to the plaintiff's assignor. The holding of the case was that the defendant's cross motion for summary judgment was granted, as the defendant had made a prima facie showing that the supplies were not medically necessary and this showing was unrebutted by the plaintiff. The court found that the defendant was entitled to judgment, and therefore granted the defendant's cross motion for summary judgment dismissing the complaint.
Jamaica Dedicated Med. Care, P.C. v Praetorian Ins. Co. (2013 NY Slip Op 50259(U))
February 19, 2013
The relevant facts considered by the court in this case were that a medical provider was seeking to recover assigned first-party no-fault benefits, and the insurance company had denied these benefits based on lack of medical necessity. The main issue decided by the court was whether the insurance company's cross motion for summary judgment dismissing the complaint should be granted. The holding of the court was that the insurance company's cross motion for summary judgment dismissing the complaint was granted, as the medical provider had not meaningfully challenged the conclusions set forth in the independent medical examination report submitted by the insurance company. Therefore, the court reversed the lower court's decision and granted the insurance company's cross motion for summary judgment.
Alev Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50258(U))
February 19, 2013
The relevant facts considered by the court were related to a lawsuit between a medical supplier and an insurance company over the failure of the medical supplier's assignor to appear for independent medical examinations (IMEs) as requested by the insurance company. The issues decided were whether the insurance company's denials of the medical supplier's claims were timely, and whether the insurance company had properly mailed initial and follow-up IME scheduling letters. The holding of the case was that the insurance company had demonstrated that it had timely and properly mailed initial and follow-up IME scheduling letters, thus tolling its time to pay or deny the claims. Therefore, the judgment was reversed, and the branches of the insurance company's motion were granted, while those of the medical supplier's cross motion were denied.
Triangle R, Inc. v Tri-State Consumer Ins. Co. (2013 NY Slip Op 50256(U))
February 19, 2013
The court considered the fact that the defendant had timely mailed its initial and follow-up requests for verification to the plaintiff, in accordance with insurance department regulations. The plaintiff's office manager denied receiving the verification requests, but this did not overcome the presumption that the proper mailing had occurred. Since the plaintiff did not serve responses to the verification requests prior to the commencement of the action, the defendant's motion for summary judgment dismissing the complaint should have been granted. The main issue decided was whether the defendant had followed proper procedures in mailing the verification requests and whether the plaintiff's denial of receipt was enough to overcome the presumption of proper mailing. The holding of the court was that the order denying the defendant's motion for summary judgment was reversed, and the defendant's motion for summary judgment dismissing the complaint was granted.
Shara Acupuncture, P.C. v New York Cent. Mut. Fire Ins. Co. (2013 NY Slip Op 50255(U))
February 19, 2013
The court considered the denial of claim forms by the defendant and whether they were sufficient to preserve the defendant's fee schedule defense. The main issue was whether the defendant had fully paid the plaintiff for the services at issue in accordance with the workers' compensation fee schedule. The court held that while the denial of claim forms were sufficient to preserve the defendant's fee schedule defense, there were triable issues of fact as to whether the defendant had fully paid the plaintiff for the services in accordance with the fee schedule. Therefore, the court denied the defendant's motion for summary judgment and modified the order accordingly.
Compas Med., P.C. v Farm Family Cas. Ins. Co. (2013 NY Slip Op 50254(U))
February 19, 2013
The court considered an appeal and cross-appeal from an order of the Civil Court of the City of New York related to an action by a provider to recover assigned first-party no-fault benefits. The court denied the plaintiff's motion for summary judgment and also denied the defendant's cross motion for summary judgment on various causes of action. The main issues decided were whether the denial of certain claims based on the plaintiff's assignor's failure to appear for scheduled examinations under oath was untimely and whether the defendant's denial of receipt of certain claims was sufficient to rebut the presumption of receipt established by the plaintiff's proof of mailing. The holding was that the plaintiff's motion for summary judgment was granted, and the matter was remitted to the Civil Court for a calculation of statutory interest and an assessment of attorney's fees.
Infinity Health Prods., Ltd. v Travelers Ins. Co. (2013 NY Slip Op 50253(U))
February 19, 2013
The main issues considered in this case were whether an insurance company was justified in denying first-party no-fault benefits due to the failure of the provider to appear for scheduled examinations under oath (EUOs). The court ultimately decided that the insurance company was justified in denying the benefits, as it had demonstrated that the provider had failed to comply with a condition precedent to coverage. The court reversed the judgment, vacated part of the order, and granted the insurance company's motion to dismiss the portion of the complaint seeking to recover $501.50, as the provider had failed to comply with the scheduled EUOs and there was no need for the insurance company to issue new scheduling letters for this particular bill.
All Boro Psychological Servs., P.C. v Progressive Northeastern Ins. Co. (2013 NY Slip Op 50252(U))
February 19, 2013
The court considered the appeal of a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided was whether the services rendered by the provider were medically necessary. The court held that the provider did not raise a triable issue of fact as to the medical necessity of the psychological testing at issue. The provider's submission of a letter of medical necessity and prior trial testimony of a doctor did not meaningfully refer to, let alone rebut, the conclusions of the insurance company's psychologist. As a result, the judgment granting the insurance company's motion for summary judgment and dismissing the complaint was affirmed.