No-Fault Case Law
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.
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.