No-Fault Case Law
Alrof, Inc. v Praetorian Ins. Co. (2012 NY Slip Op 51445(U))
July 18, 2012
In this case, Alrof, Inc. sued Praetorian Ins. Co. to recover assigned first-party no-fault benefits. The main issue was whether the medical supplies provided to the plaintiff's assignor were medically necessary. Both parties established their prima facie cases, and the Civil Court concluded that the only issue for trial was the medical necessity of the supplies. Defendant submitted peer review reports that stated there was a lack of medical necessity for the supplies, and plaintiff's affirmation from a doctor failed to rebut these conclusions. The court reversed the order and granted the branch of defendant's cross motion seeking summary judgment, dismissing the second through fifth causes of action, as it was determined that there was a lack of medical necessity for the supplies provided.
Patchogue Physical Therapy, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51444(U))
July 18, 2012
The court considered the evidence presented by the defendant, which included an affirmed peer review report stating that the services rendered were not medically necessary. The main issue decided was whether the plaintiff had rebutted the defendant's showing that the services were not medically necessary. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted, as the plaintiff had not challenged the finding that the defendant was otherwise entitled to judgment. Therefore, the order denying the defendant's motion for summary judgment was reversed.
Dvs Chiropractic, P.C. v Interboro Ins. Co. (2012 NY Slip Op 51443(U))
July 18, 2012
The relevant facts considered by the court included an appeal from an order of the Civil Court which granted the plaintiff's motion for summary judgment and denied the defendant's cross motion to dismiss the complaint regarding the recovery of assigned first-party no-fault benefits. The main issue decided was whether the defendant had proven that the plaintiff failed to comply with a condition precedent to coverage by not appearing at scheduled examinations under oath (EUOs). The court held that since the initial EUO had been rescheduled by mutual agreement prior to the scheduled dates, it did not constitute a failure to appear. Therefore, the defendant did not prove that the plaintiff had failed to comply with a condition precedent to coverage. The judgment was affirmed without costs.
Chiemi v Redland Ins. Co. (2012 NY Slip Op 51442(U))
July 18, 2012
The relevant facts considered by the court were that in a no-fault benefits case, the plaintiff moved for summary judgment and the motion was adjourned for a year. The defendant served a cross motion for summary judgment four days before the return date, but the plaintiff did not submit opposition to the cross motion. The main issue decided by the court was whether the cross motion by the defendant was timely and properly served. The holding of the case was that the defendant failed to demonstrate that the cross motion was timely and properly served, and therefore, the cross motion was denied. The court also stated that since the plaintiff did not have an adequate opportunity to rebut the allegations contained in the cross motion, the cross motion should not have been considered.
Promed Orthocare Supply, Inc. v Travelers Ins. Co. (2012 NY Slip Op 51441(U))
July 18, 2012
The court considered the fact that Promed Orthocare Supply, Inc. as the assignee of Omar Brown, had brought an action to recover assigned first-party no-fault benefits from Travelers Insurance Company. The main issue decided was whether Promed Orthocare Supply, Inc. was entitled to bring the action as Omar Brown's assignee, since it was not plaintiff who had provided the equipment at issue directly to Brown. The court held that accelerated judgment for either party was inappropriate based on the conflicting evidence presented, and reversed the judgment, vacating the order that granted plaintiff's motion for summary judgment and denying plaintiff's motion for summary judgment. The court concluded that there was not enough evidence to support a summary judgment, and the judgment was reversed.
Midtown Med. Assoc., P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51351(U))
July 13, 2012
The relevant facts that the court considered were that the defendant insurer demonstrated with an affidavit that the denial of claim forms had been timely mailed, that one of the claims had been paid in full, and that the plaintiff had submitted three of the claims more than 45 days after the dates of service. The main issues decided were that the denial of claim forms advised the plaintiff of the late submission of the claims and that defendant's two affirmed independent medical examination reports showed a lack of medical necessity for the remaining services. The holding was that the order denying defendant's motion for summary judgment was reversed, and defendant's motion for summary judgment dismissing the complaint was granted.
Natural Therapy Acupuncture, P.C. v Interboro Ins. Co. (2012 NY Slip Op 51350(U))
July 13, 2012
The relevant facts considered in this case include a provider seeking to recover assigned first-party no-fault benefits and the denial of claim forms by the insurance company. The court considered whether the denial of claim forms had been timely mailed, the deductible in the assignor's insurance policy, and whether the amounts sought by the plaintiff exceeded the amounts permitted by the workers' compensation fee schedule. The main issues decided were whether the denial of claim forms were timely and specific enough to apprise the provider of the grounds for denial, and whether the insurance company had received the claim form from the provider. The holding of the case was that the insurance company's motion for summary judgment dismissing the complaint was granted, as the denial of claim forms had been timely and specific, and there was insufficient evidence that the insurance company had received the claim form from the provider.
J.M. Chiropractic Servs., PLLC v State Farm Mut. Ins. Co. (2012 NY Slip Op 51348(U))
July 13, 2012
The court considered a case in which the plaintiff, a chiropractic services provider, was seeking to recover first-party no-fault benefits from the defendant, State Farm Mutual Insurance Company. The main issue was whether the defendant's motion to dismiss the complaint should be denied based on the plaintiff's failure to appear at scheduled examinations under oath (EUOs). The court held that the defendant failed to establish that the EUO scheduling letters had been timely mailed, and therefore did not demonstrate that the 30-day claim determination period had been tolled. As a result, the defendant's denial of claim form was not timely, and they could not raise as a defense the failure of the plaintiff's owner to appear for an EUO. The order denying the defendant's motion to dismiss the complaint was affirmed.
Beal-Medea Prods., Inc. v NY Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51347(U))
July 13, 2012
The relevant facts of the case involved a provider seeking to recover assigned first-party no-fault benefits, with the defendant insurance company denying the claims. The main issue before the court was whether the defendant's denial of claim forms constituted evidence in admissible form. The court held that the denial of claim forms did not need to qualify as business records as they were not offered for a hearsay purpose, but rather to show that the claims had been denied. The court affirmed the order of the Civil Court granting the defendant's motion for summary judgment dismissing the complaint, stating that the plaintiff's remaining contentions were without merit.
All Boro Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 51346(U))
July 13, 2012
The relevant facts considered by the court were that the plaintiff, All Boro Psychological Services, P.C., was seeking to recover no-fault benefits from the defendant, State Farm Mutual Automobile Insurance Co. The main issue decided was whether the defendant had met the necessary requirements for mailing letters scheduling examinations under oath (EUOs) and denial of claim forms. The court held that the defendant had submitted sufficient proof of mailing of the EUO scheduling letters, and the plaintiff had failed to appear at the scheduled EUOs. The court further held that the appearance of the provider at the requested EUOs was a condition precedent to the insurer's liability, and since the plaintiff did not respond in any way to the EUO requests, their complaints regarding the EUO requests would not be considered. Therefore, the judgment to dismiss the complaint was affirmed.