No-Fault Case Law
Brooklyn Hgts. Physical Therapy, P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51337(U))
July 12, 2012
The court considered a dispute between Brooklyn Heights Physical Therapy, P.C., as assignee of Stephanie Bundrick, and New York Central Mutual Fire Insurance Company regarding the payment of first-party no-fault benefits. The main issue decided was whether the defendant had submitted sufficient evidence to establish mailing of timely and proper denial of claim forms. The court held that the defendant failed to submit sufficient evidence to establish mailing of timely and proper denial of claim forms, resulting in untimely denial of the claims and precluding the defendant from offering its defense that the policy provision had been breached due to the assignor's failure to appear for IMEs, as well as its defense that the fees sought were improper. Therefore, the judgment denying the defendant's motion for summary judgment and granting the plaintiff's cross motion for summary judgment was affirmed.
Five Boro Psychological Servs., P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51336(U))
July 12, 2012
The main issue in this case was whether the defendant's motion for summary judgment to dismiss the complaint should be granted. The court considered the fact that the defendant had denied the plaintiff's claim based on the failure of the plaintiff's assignor to appear for two scheduled independent medical examinations. However, the president of the independent medical review service retained by the defendant stated that there was a mutual agreement to reschedule the initial examination. The court held that the defendant failed to establish that the assignor had failed to appear for the examinations, and therefore, the motion for summary judgment was properly denied. The order, insofar as appealed from, was affirmed by the court.
W.H.O. Acupuncture, P.C. v Progressive Preferred Ins. Co. (2012 NY Slip Op 51335(U))
July 12, 2012
The court considered a case involving a provider seeking first-party no-fault benefits from an insurance company. The provider sought summary judgment on all claims except for specific dates, while the insurance company cross-moved for summary judgment dismissing all claims except for the specific dates. The main issues decided involved the payment for acupuncture services billed under different codes, with the insurance company demonstrating full payment in accordance with the workers' compensation fee schedule for some services and denial of payment for others. The court determined that the insurance company failed to establish its entitlement to summary judgment for the claims it had denied payment for, as it did not provide an explanation for its actions and did not give sufficient grounds for its denials. The holding was that the judgment was reversed, the branch of the cross motion seeking summary judgment dismissing the claims was vacated, and the matter was remitted to the lower court for further proceedings.
Park Slope Med. & Surgical Supply, Inc. v Travelers Ins. Co. (2012 NY Slip Op 22200)
July 12, 2012
The court considered the denial of a claim for no-fault benefits based on a peer review report that indicated a lack of medical necessity for the services or supplies provided. The main issue was whether the medical records submitted to the insurer by the injured person or their assignees should be admitted into evidence, to enable the insurer's expert witness to testify regarding her opinion that the medical supplies were not medically necessary. The court held that the medical documentation should have been admitted into evidence and the matter was remitted to the Civil Court for a new trial to afford the insurer an opportunity to establish its defense of lack of medical necessity. The court also held that it was the insurer's responsibility to prove, by a preponderance of the evidence, that the services or supplies were not medically necessary.
Matter of Philadelphia Ins. Co. (Utica Natl. Ins. Group) (2012 NY Slip Op 05470)
July 6, 2012
The relevant facts of the case were that there was a motor vehicle accident involving a vehicle owned by Rivershore and insured by petitioner. After the accident, the insurance company of the other involved vehicle sought reimbursement of the first-party benefits from the insurer, using the loss-transfer provisions of Insurance Law § 5105. The main issue before the court was whether the vehicle involved in the accident was "used principally for the transportation of persons or property for hire" as per the provisions of the law. The court held that by failing to apply for a stay before arbitration, the insurer waived its contention that the claim was not arbitrable under Insurance Law § 5105. Additionally, it could not be said that the arbitration panel's award was arbitrary and capricious and the award was confirmed.
Dr. Todd Goldman, D.C., P.C. v Kemper Cas. Ins. Co. (2012 NY Slip Op 51296(U))
June 28, 2012
The court considered the case of Dr. Todd Goldman, D.C., P.C. as Assignee of Rose Saunders v. Kemper Casualty Insurance Company. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint, which sought the recovery of first-party no-fault benefits. The court held that the defendant was entitled to summary judgment dismissing the claims for services rendered after March 22, 2008, as they had been timely denied for lack of medical necessity. However, the court granted the plaintiff's claims for $261.60 for services rendered on November 12, 2007, as the defendant failed to establish a lack of medical necessity for those services. The defendant also failed to address the plaintiff's claim for $33.70 for services rendered on September 5, 2008, which meant that they also failed to establish timely denial of that claim. Therefore, the court affirmed the order and granted the defendant's motion for summary judgment with respect to all claims except the two mentioned.
3 Star Acupuncture, P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51295(U))
June 28, 2012
The court considered the branches of the defendant's cross motion seeking summary judgment to dismiss the sixth through tenth causes of action in a case where a provider sought to recover assigned first-party no-fault benefits. The main issue decided was whether there was a triable issue of fact regarding the medical necessity of the acupuncture services at issue. The holding of the case was that the Civil Court properly denied the defendant's cross motion as there was a triable issue of fact regarding the medical necessity of the acupuncture services, and the order was affirmed.
Alev Med. Supply, Inc. v Allstate Prop. & Cas. Ins. Co. (2012 NY Slip Op 51294(U))
June 28, 2012
In this case, the court considered a dispute over a claim for first-party no-fault benefits, which involved a provider seeking reimbursement of assigned benefits. Defendant argued that arbitration was the proper forum for the dispute, as a claim had already been arbitrated by a different provider arising from the same accident. The main issue was whether the prior arbitration precluded another provider from commencing its own action seeking reimbursement of assigned no-fault benefits. The court held that a prior arbitration by a different provider did not preclude the plaintiff from filing its own action seeking reimbursement of assigned benefits, and that the defendant failed to demonstrate that it had timely denied the claims at issue. Therefore, the order to dismiss the complaint was reversed, and defendant's motion was denied.
Richmond Radiology, P.C. v State Farm Ins. Co. (2012 NY Slip Op 51293(U))
June 28, 2012
The relevant facts the court considered were that the appellant was a provider seeking first-party no-fault benefits, and the respondent had timely denied the claims in question due to a lack of medical necessity. The main issue decided was whether the judgment of the Civil Court should be reversed and defendant's cross motion for summary judgment denying the complaint should be vacated. The holding of the court was that defendant's cross motion for summary judgment was denied, as plaintiff's submission, although affirmed and not sworn, demonstrated the existence of a question of fact as to medical necessity, and therefore defendant's objection to the form of plaintiff's submission was waived.
Olga Bard Acupuncture, P.C. v GEICO Ins. Co. (2012 NY Slip Op 51292(U))
June 28, 2012
The main issue in this case was whether the provider, Olga Bard Acupuncture, P.C., was entitled to recover first-party no-fault benefits from GEICO Ins. Co. The court considered the fact that defendant had timely denied the claims at issue based upon the workers' compensation fee schedule, and had fully paid plaintiff for the claims for acupuncture services billed under CPT codes 97810 and 97811. The court ultimately held that defendant had fully paid plaintiff for the claims in accordance with the workers' compensation fee schedule, and therefore the branches of plaintiff's motion seeking summary judgment were denied, while the branches of defendant's cross motion seeking summary judgment were granted.