No-Fault Case Law
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.
Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 52398(U))
December 21, 2012
The court considered whether the defendant was entitled to summary judgment dismissing the complaint and whether the plaintiff was entitled to summary judgment. The main issue was whether the defendant established its entitlement to summary judgment by proving the timely mailing of the NF-10 denial of claim forms at issue. The holding was that the defendant failed to establish its entitlement to summary judgment because the affidavit of the defendant's litigation examiner was insufficient to establish the timely mailing of the NF-10 denial of claim forms. As a result, the plaintiff also failed to establish its entitlement to summary judgment with respect to its claims for $1,180, $550.44, $780.98, and $489.28. Therefore, the court denied the branches of the plaintiff's cross motion seeking summary judgment with respect to those claims.
Parsons Med. Supply, Inc. v Utica Mut. Ins. Co. (2012 NY Slip Op 52397(U))
December 21, 2012
The court considered the fact that Parsons Medical Supply, Inc. was seeking to recover first-party no-fault benefits from Utica Mutual Insurance Co. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint. The court held that the defendant was not entitled to summary judgment because they failed to demonstrate that their initial and follow-up requests for examinations under oath of the plaintiff had been timely sent, as required by Insurance Department Regulations. Therefore, the defendant did not establish that it had tolled its time to pay or deny the plaintiff's claims, and was not entitled to summary judgment. The court affirmed the order denying the defendant's motion for summary judgment.
Infinity Health Prods., Ltd. v Liberty Mut. Fire Ins. Co. (2012 NY Slip Op 52396(U))
December 21, 2012
The court considered the fact that the defendant had timely mailed requests and follow-up requests for verification, as well as the affidavit of the defendant's claim specialist which established that the plaintiff had failed to respond to those requests. The main issue decided was whether the 30-day period within which the defendant was required to pay or deny the plaintiff's claims had commenced to run, and whether the plaintiff's action was premature. The holding of the court was that the plaintiff's motion for summary judgment should have been denied and the defendant's cross motion, in effect, for summary judgment should have been granted. Therefore, the judgment was reversed, the order entered on March 5, 2010 was vacated, and the defendant's cross motion for summary judgment was granted.
Lenox Hill Hosp. v Tower Ins. Co. of N.Y. (2012 NY Slip Op 52391(U))
December 20, 2012
The relevant facts considered by the court were that Lenox Hill Hospital was seeking to recover no-fault benefits on behalf of Charles Barclay. The main issue decided was whether Lenox Hill Hospital was entitled to summary judgment in their favor, and the court held that they were not entitled to summary judgment as they had not demonstrated their prima facie entitlement to judgment as a matter of law. The court affirmed the denial of Lenox Hill Hospital's motion for summary judgment, stating that they had not shown sufficient evidence to support their claim.
New York Hosp. Med. Ctr. of Queens v Utica Mut. Ins. Co. (2012 NY Slip Op 52388(U))
December 20, 2012
The court considered the facts that the plaintiff was seeking to recover assigned first-party no-fault benefits under an insurance policy after their assignor was allegedly injured in a motor vehicle incident. The defendant's insured stated that the assignor had jumped on the hood of their parked car and got off without incident, and drove away without further contact. The plaintiff disputed this, submitting a police accident report and the assignor's hospital records which indicated the assignor was injured when the defendant's insured drove their car into the assignor. The main issue decided was whether the injuries arose out of an insured incident. The holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint should have been granted, as the plaintiff failed to raise a triable issue of fact and demonstrated that the injuries in question did not arise out of an insured incident.
NYU-Hospital for Joint Diseases v American Tr. Ins. Co. (2012 NY Slip Op 52387(U))
December 20, 2012
The relevant facts considered in this case were the denial of plaintiff's motion for summary judgment in an action to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff had demonstrated its prima facie entitlement to judgment as a matter of law. The holding of the court was that the District Court properly denied the plaintiff's motion for summary judgment, as they had not shown their entitlement to judgment as a matter of law, citing a similar case as precedent. The order was affirmed without costs by the Appellate Term, Second Department.
NYU Hosp. for Joint Diseases v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 22379)
December 18, 2012
The main issue in this legal case was whether the plaintiff NYU Hospital for Joint Diseases, as assignee of Michael Samilo, had demonstrated its prima facie entitlement to judgment as a matter of law in an action to recover assigned first-party no-fault benefits. The court found that the hospital had not demonstrated such entitlement, as it did not provide proof of the fact and the amount of the loss sustained as required by the Insurance Law § 5106 (a). The court denied the hospital's motion for summary judgment on this ground, finding that the documents submitted did not constitute prima facie proof of the loss sustained, specifically as there was no certification given that the bill was correct, the items were necessary, and the amount charged was reasonable. The court also found that prior cases cited by the plaintiff were not applicable to the case at hand, affirming the lower court's decision. As a result, the order was affirmed by the court, and the motion for summary judgement was denied.