No-Fault Case Law
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.
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.