No-Fault Case Law
Elmont Open MRI & Diagnostic Radiology, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 22242)
August 17, 2012
The relevant facts of the case include Abdelghani Kinane sustaining injuries in a motor vehicle accident and MRI work being performed by Elmont Open MRI & Diagnostic Radiology. New York Central Mutual Fire Insurance Company (NYCMFIC) requested verification from Elmont, who subsequently claimed to have mailed the requested verification, but NYCMFIC denied receiving it. NYCMFIC moved for summary judgment on the grounds that the action was premature since its time to pay or deny the claim had not yet run. The main issue decided was whether Elmont's action to obtain payment of first-party no-fault benefits was premature due to NYCMFIC's time to pay or deny the claim. The court held that Elmont responded to NYCMFIC's verification requests and that NYCMFIC failed to offer any proof that the material was not received, granting summary judgment to the plaintiff. Therefore, the court denied summary judgment to the defendant and entered judgment in favor of the plaintiff.
Willets Point Chiropractic P.C. v Allstate Ins. (2012 NY Slip Op 51614(U))
August 16, 2012
The court considered the fact that two separate plaintiffs, as assignees of Mirna Flores, filed separate actions against Allstate Insurance seeking compensation for professional chiropractic services in the form of "manipulation under anesthesia" (MUA). The defendant denied the applications based on an independent chiropractic examination report that concluded no further treatment was necessary. The court also examined the treatment history of the patient, including injuries and related medical procedures. The main issues were whether chiropractors are permitted to perform MUA and to what extent they can manipulate body parts other than the vertebral column. The holding of the case was that the plaintiffs' causes of action in both cases were dismissed because the chiropractors failed to establish the medical necessity of the MUA and were prohibited from performing MUA in New York. They were also not permitted to collect the full rate for their services.
All Star Wellness Med., P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51630(U))
August 7, 2012
The relevant facts that the court considered in this case were that a provider was seeking to recover assigned first-party no-fault benefits, and the insurance company had timely denied the claims at issue, asserting that the assignor had failed to appear for an independent medical examination (IME) and that certain services billed for were not medically necessary. The main issues decided were whether the insurance company had timely denied the claims and whether the denial was valid based on the assignor's failure to appear for the IME and the lack of medical necessity for the services billed. The holding of the court was that the insurance company's cross motion for summary judgment dismissing the complaint was granted, as they had appropriately denied the claims based on the assignor's failure to satisfy a condition precedent to coverage and the lack of medical necessity, and the provider failed to raise a triable issue of fact with respect to these defenses.
Brownsville Advance Med., P.C. v Kemper Independence Ins. Co. (2012 NY Slip Op 51629(U))
August 7, 2012
The relevant facts the court considered were that an insurance company was denying claims for first-party no-fault benefits on the grounds of lack of medical necessity, and the provider was seeking to recover the assigned benefits. The main issue decided was whether the denial of claim form had been timely mailed and whether the affirmed independent medical examination report provided a sufficient factual basis and medical rationale for the doctor's determination of lack of medical necessity. The holding of the court was that the insurance company had sufficiently established the timely mailing of the denial of claim form and provided a report that shifted the burden to the provider to rebut the insurance company's prima facie showing. Since the provider failed to submit an affidavit or affirmation from a medical professional, the court granted the insurance company's motion for summary judgment dismissing the complaint.
Quality Psychological Servs., P.C. v Interboro Mut. Indem. Ins. Co. (2012 NY Slip Op 51628(U))
August 7, 2012
The court considered whether the defendant's motion for summary judgment dismissing the complaint should be granted. The main issue in the case was whether the examination under oath (EUO) scheduling letters and the denial of claim form had been timely mailed and if the assignor had failed to appear at the scheduled EUOs. The court ultimately held that the order denying defendant's motion for summary judgment should be reversed and that defendant's motion for summary judgment dismissing the complaint should be granted. Despite the dissent, the court found that the affidavits submitted by defendant established that the assignor had failed to appear at the scheduled EUOs, which is a condition precedent to an insurer's liability on a policy. Therefore, the defendant's motion was properly granted.
Essential Acupuncture Servs., P.C. v NY Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51623(U))
August 7, 2012
The main issue in the case was whether the defendant had timely denied the plaintiff's claims for first-party no-fault benefits and whether the fees charged exceeded the amounts set forth in the workers' compensation fee schedule. The court held that the plaintiff failed to establish its entitlement to summary judgment for all claim forms except for one, and that the defendant had timely and properly denied certain claims on the ground of lack of medical necessity. The court found that the defendant had submitted evidence demonstrating lack of medical necessity for the services, and thus the defendant's cross motion seeking summary judgment to dismiss the complaint for these claims was granted. The court also held that the defendant had failed to conclusively establish its stated defenses for the remaining claims, and thus the judgment was reversed, and the plaintiff's motion for summary judgment was denied.
Infinity Health Prods., Ltd. v Unitrin Advantage Ins. Co. (2012 NY Slip Op 51502(U))
August 6, 2012
The main issue in this case was whether a trial court abused its discretion in refusing to allow the defendant to offer the deposition testimony of its doctor into evidence at a nonjury trial to recover assigned first-party no-fault benefits. The trial court directed judgment in favor of the plaintiff after refusing to permit the defendant to offer the deposition testimony. The appellate court held that the trial court abused its discretion in refusing to allow the defendant to offer the deposition testimony of its doctor into evidence. As a result, the judgment was reversed, and the matter was remitted to the Civil Court for a new trial limited to the issue of medical necessity. The main fact considered by the court was the refusal of the trial court to permit the defendant to offer the deposition testimony of its doctor into evidence.
Infinity Health Prods., Ltd. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51497(U))
August 6, 2012
The court considered the fact that the plaintiff, Infinity Health Products, Ltd., was seeking to recover first-party no-fault benefits as the assignee of Alexander Fitzmichael, Jr. The main issue before the court was whether the defendant, New York Central Mutual Fire Insurance Company, had established its "independent medical examination" No Show defense in order to deny the plaintiff's claim. The court reviewed evidence that showed the scheduling letters for the independent medical examinations had been timely mailed, and that the assignor had failed to appear for the scheduled examinations. The holding of the court was that the defendant was entitled to summary judgment dismissing the complaint, as the plaintiff had not challenged the defendant's entitlement to judgment. Therefore, the court reversed the order, and granted the defendant's cross motion for summary judgment.
Chi Point Acupuncture, P.C. v Clarendon Ins. Co. (2012 NY Slip Op 51496(U))
August 6, 2012
The court considered the fact that the plaintiff initiated the action to recover assigned first-party no-fault benefits in May of 2008, and the defendant defaulted. More than two years later, the defendant moved to dismiss the complaint pursuant to CPLR 3215 (c), and the Civil Court denied defendant's unopposed motion. The main issue decided was whether the plaintiff offered a reasonable excuse for the delay in moving for leave to enter a default judgment and demonstrated that the complaint was meritorious. The holding of the case was that, upon review of the facts and plaintiff's failure to submit opposition to defendant's motion, dismissal of the complaint was required pursuant to CPLR 3215 (c). Therefore, the order was reversed, and defendant's motion to dismiss the complaint was granted.
Bright Med. Supply Co. v GMAC Integon Ins. Co. (2012 NY Slip Op 51495(U))
August 6, 2012
The main issue in this case involved whether Bright Medical Supply Co. was barred by a temporary restraining order (TRO) from commencing an action to recover assigned first-party no-fault benefits. The court considered whether Bright Medical Supply Co. had knowledge of the TRO or its terms at the time the action was commenced. The court also examined whether GMAC Integon Ins. Co. had provided proof that Bright Medical Supply Co. was aware of the TRO. The court ultimately held that GMAC Integon Ins. Co. did not establish that Bright Medical Supply Co. had knowledge, actual or imputed, of the TRO's terms, and therefore, did not show that Bright Medical Supply Co. was barred from commencing the instant action. As a result, the judgment was reversed, the order was vacated, and GMAC Integon Ins. Co.'s motion to dismiss the complaint was denied.