No-Fault Case Law

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.

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.

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.

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.

The court considered a case involving a provider seeking to recover assigned first-party no-fault benefits against an insurance company. The insurance company appealed an order that granted the provider's motion for summary judgment on all claims except for one and denied the insurance company's cross motion seeking summary judgment on the same claims. The insurance company submitted evidence to show that it had timely denied claim forms and fully paid the provider for certain services. It also submitted an independent medical examination (IME) report that concluded there was no medical necessity for additional services. The provider failed to meaningfully rebut the conclusions in the IME report. The court held that the insurance company was entitled to summary judgment dismissing the provider's claims for services based on the evidence presented, and therefore reversed the lower court's order.

The court considered a cross motion for summary judgment by defendant GEICO Insurance Company seeking to dismiss claims for services rendered by plaintiff Gentle Care Acupuncture, P.C. The main issue decided was whether GEICO had timely denied the claims and whether there was a lack of medical necessity for the services. The court reversed the order of the Civil Court and granted the branches of the defendant's cross motion seeking summary judgment. It was held that GEICO had timely denied the claims for services rendered by Gentle Care Acupuncture, P.C. based on exceeding the workers' compensation fee schedule, and that there was a lack of medical necessity for further acupuncture services as determined by an independent medical examination performed by defendant's acupuncturist. Therefore, GEICO's cross motion for summary judgment dismissing the claims was granted.

The court considered the facts of an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the doctrine of collateral estoppel barred the plaintiff from relitigating the issue of whether the injuries arose from an insured incident. The holding of the court was that the defendant established that the issue was identical to the issue previously decided by the jury in an earlier personal injury action. Therefore, the plaintiff was ineligible to receive reimbursement of no-fault benefits because the injuries did not result from an insured incident. The order was affirmed.

The case involved a medical provider seeking to recover no-fault benefits from an insurance company. The insurance company appealed an order from the Civil Court that denied its motion to strike the complaint due to the plaintiff's failure to comply with a discovery stipulation. The stipulation, which was not "so-ordered," provided that if the plaintiff failed to respond to the defendant's outstanding discovery demands within 30 days, it would be precluded from offering evidence or contesting any defense as to the items demanded but not provided. The court found that since the stipulation was subscribed by the attorneys, it was an independent contract subject to contract law principles. As the plaintiff failed to respond to the defendant's discovery demands, the court decided in favor of the insurance company, reversing the previous order and granting the motion to strike the complaint.

The main issue in this case was whether the supplies provided by the plaintiff, Yklik, Inc. as Assignee of TREVARE WHITE, were medically necessary and therefore covered under a no-fault benefits policy. The court considered the fact that the defendant, Electric Insurance Co., had submitted affirmed peer review reports with factual basis and medical rationale for their determination that there was a lack of medical necessity for the supplies provided. In opposition, the plaintiff submitted an affirmation from a doctor, which did not meaningfully refer to, let alone rebut, the conclusions set forth in the peer review reports. The court held that as the plaintiff did not challenge the finding that the defendant was otherwise entitled to judgment, the defendant's cross motion for summary judgment dismissing the complaint was granted. Therefore, the order denying the defendant's cross motion for summary judgment was reversed and the defendant's cross motion for summary judgment dismissing the complaint was granted.

The court considered the fact that the defendant was first notified of the accident through the receipt of the claimant's form, which was dated September 25, 2007, even though the accident occurred on July 11, 2007. The defendant denied the plaintiff's claims on the basis that proper notice of the claim in writing had not been received within 30 days from the date of the accident. The main issue decided was whether the plaintiff had provided sufficient proof to demonstrate a triable issue of fact regarding the timely notice of the accident. The holding of the case was that the plaintiff had failed to provide any proof to demonstrate the existence of a triable issue of fact and had also failed to provide a reasonable justification for the lateness of the notice. Therefore, the District Court had properly granted the defendant's cross motion for summary judgment dismissing the complaint.