No-Fault Case Law

The relevant facts the court considered in this case were that Kamara Supplies, Inc. was seeking to recover assigned first-party no-fault benefits, and the defendant, Clarendon Insurance Company, submitted an affirmed peer review report in support of its cross motion for summary judgment dismissing the complaint on the ground of lack of medical necessity. The main issue decided by the court was whether the defendant's peer review report clearly established a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity for the supplies at issue. The court held that the defendant's cross motion for summary judgment was properly denied because the affirmed peer review report failed to establish a lack of medical necessity for the supplies at issue. Therefore, the court affirmed the order, without costs.

In this case, the plaintiff, Right Aid Medical Supply Corp., was seeking to recover first-party no-fault benefits from the defendant, Geico Ins. Co., as the assignee of Andre Kyles. The plaintiff had filed a motion for summary judgment, which was granted by the Civil Court, resulting in a judgment awarding the plaintiff $1,768.76. The defendant appealed this decision. The main issue was whether the denial of claim form provided by the defendant was sufficient to establish a prima facie entitlement to judgment as a matter of law. The Appellate Term, Second Department, reversed the judgment, vacated the order granting the plaintiff's motion for summary judgment, and denied the plaintiff's motion, on the grounds that the denial of claim form provided by the defendant was timely and not conclusory, vague, or without merit as a matter of law. Therefore, the plaintiff did not establish its prima facie entitlement to judgment as a matter of law.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, where the order granted the branches of defendant's motion seeking summary judgment dismissing the complaint insofar as it sought to recover for services rendered from February 23, 2005 to May 4, 2005. The main issue decided was whether the defendant had timely denied those claims based upon the workers' compensation fee schedule. The court found that the defendant had indeed timely denied those claims based on the fee schedule. The holding of the case was that the court affirmed the order, insofar as appealed from, without costs.

The court considered whether there was a triable issue of fact as to whether verification was outstanding in the case of Compas Medical, P.C. as Assignee of TRINA GREEN v. Delos Insurance Company. The main issue decided was whether the Civil Court properly denied the defendant's cross motion for summary judgment dismissing the complaint. The court held that there was a triable issue of fact as to whether verification is outstanding, and therefore affirmed the order without costs. The decision was made by Pesce, P.J., Rios and Aliotta, JJ. on August 31, 2012.

The court considered the affidavit and independent medical examination report submitted by the defendant in support of its motion for summary judgment. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint on the ground of lack of medical necessity for the services at issue. The holding of the case was that since the defendant's prima facie showing of lack of medical necessity was not rebutted by the plaintiff, the defendant was entitled to summary judgment dismissing the complaint. As a result, the order of the Civil Court denying defendant's motion for summary judgment was reversed, and the defendant's motion for summary judgment dismissing the complaint was granted.

The relevant facts considered by the court in this case were that a physical therapy provider was seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company had scheduled independent medical examinations (IMEs) for the plaintiff's assignor, but the assignor failed to appear for the IMEs. The insurance company timely mailed the IME scheduling letters and denial of claim forms. The main issue decided by the court was whether the insurance company had met the condition precedent to its liability on the policy by scheduling the IMEs and mailing the denial of claim forms in a timely manner. The holding of the court was that the insurance company had raised a triable issue of fact by demonstrating that it had timely mailed the IME scheduling letters and denial of claim forms, and that the plaintiff's assignor had failed to appear for the IMEs. Therefore, the branches of the plaintiff's motion seeking summary judgment on the causes of action based on the assignor's nonappearance at the IMEs should have been denied. The judgment in favor of the plaintiff was reversed, and the branches of the plaintiff's motion seeking summary judgment on the causes of action were denied.

The court considered the denial of claim forms and explanation of benefit forms, which were deemed sufficient to inform the plaintiff that the defendant was partially paying and denying the plaintiff's bills based on the workers' compensation fee schedule. The main issue was whether the defendant's partial payments and denials were justified and in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The holding was that the defendant was entitled to use the workers' compensation fee schedule to determine the amount the plaintiff was entitled to receive for acupuncture services, and as such, the defendant was granted summary judgment dismissing the portion of the complaint seeking to recover upon the claims that had been reimbursed at that rate. The remaining claims had been paid based on the workers' compensation fee schedule for acupuncture services performed by a medical doctor, and the court found no reason to disturb the portion of the order that granted the defendant summary judgment dismissing those claims. Therefore, the judgment was affirmed.

The court considered that the plaintiff was seeking to recover no-fault benefits that had been assigned to them. The defendant had denied the claims based on the assignor's failure to appear for independent medical examinations. The main issue was whether the IME scheduling letters had been mailed in accordance with the entity's standard office practices and procedures. The court held that the defendant was not entitled to summary judgment dismissing the plaintiff's claims for dates of service within a certain time period, as the first IME had not been scheduled to be held within 30 days of defendant's receipt of those claims, as required by Insurance Department Regulations. Therefore, the judgment was reversed and the branches of defendant's motion seeking summary judgment were vacated.

The main issues in this case were whether the denial of a claim form had been timely mailed, and whether there was lack of medical necessity for certain services billed by the plaintiff as a provider of first-party no-fault benefits. The court considered the submission of an affidavit by the defendant insurer, which established the timely mailing of the denial of claim form. Regarding the claim for a diagnostic interview, the court found that there was an issue of fact and that the branch of the defendant's cross motion to dismiss this claim should have been denied. However, for the remaining services at issue, the defendant had submitted a sworn peer review report which provided factual basis and a medical rationale for the psychologist's determination that there was a lack of medical necessity. The court concluded that the defendant was entitled to summary judgment dismissing the claims for these services, as the plaintiff's contentions on appeal lacked merit. The holding of the court was that the judgment was reversed, and so much of the order granting the defendant's cross motion seeking summary judgment dismissing the complaint insofar as it sought to recover upon the claim for a diagnostic interview was vacated. The branch of the defendant's cross motion seeking summary judgment dismissing the plaintiff's claim for the diagnostic interview was denied. The remaining order granting summary judgment dismissing the complaint insofar as it sought to recover for the remaining services was left undisturbed, and the judgment was reversed accordingly.

The court considered a denial of a claim form submitted by the defendant on the grounds of lack of medical necessity, as well as a sworn peer review report by a psychologist outlining the reasons for the determination of lack of medical necessity for the services in question. The main issue decided was whether the defendant's submission of the denial of claim form and peer review report constituted a prima facie showing for summary judgment. The holding of the case was that the defendant's prima facie showing was not rebutted by the plaintiff, and therefore the defendant was entitled to summary judgment dismissing the complaint. The judgment of the lower court was affirmed.