No-Fault Case Law
Searay Med., P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51383(U))
July 26, 2012
The court considered the facts that the defendant-insurer had timely and properly mailed notices for independent medical examinations to the plaintiff's assignor, and the assignor failed to appear for the examinations. The main issue decided was whether the defendant-insurer was entitled to summary judgment dismissing the action for first-party no-fault benefits. The court held that the defendant-insurer made a prima facie showing of entitlement to summary judgment by establishing proper mailing of the notices for the examinations and the assignor's failure to appear. The court found that the plaintiff did not raise a triable issue in opposition to the defendant's showing, and therefore granted the defendant's motion for summary judgment and dismissed the complaint.
Gaba Med., P.C. v Progressive Specialty Ins. Co. (2012 NY Slip Op 51448(U))
July 25, 2012
The relevant facts the court considered were the denial of first-party no-fault benefits to Gaba Medical, P.C., as well as the reduction of claims and unilateral determination of the appropriate CPT code by Progressive Specialty Ins. Co. The main issues decided were whether the denial and reduction of plaintiff's claims were proper and whether the unilateral determination of the appropriate CPT code was valid. The holding of the case was that the appellate court reversed the lower court's decision and granted plaintiff's motion for summary judgment, remitting the matter to the Civil Court for the calculation of statutory interest and assessment of attorney's fees. The court found that defendant did not raise a triable issue of fact in opposition to plaintiff's motion, and that the reduction of the claim by defendant without sufficient documentation was not warranted.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51447(U))
July 25, 2012
The relevant facts considered by the court in this case were related to a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided was whether the insurance company had timely denied the claim and whether there was a lack of medical necessity for the billed-for services. The holding of the court was that the denial of claim forms had been timely mailed by the insurance company, and that the insurance company's showing of lack of medical necessity was unrebutted by the provider. As a result, the court affirmed the order granting the insurance company's cross motion for summary judgment dismissing the complaint.
Hillside Surgicare Diagnostic & Treatment Ctr., LLC v Utica Mut. Ins. Co. (2012 NY Slip Op 51371(U))
July 24, 2012
The court considered the fact that the defendant-insurer made a prima facie showing of entitlement to judgment as a matter of law by submitting an orthopedist's peer review report, which detailed a factual basis and medical rationale for concluding that the medical services in question lacked medical necessity. The main issue decided was whether the defendant-insurer was entitled to summary judgment dismissing the complaint, and the court held that the defendant-insurer was entitled to summary judgment. The court found that the plaintiff's opposing submission, consisting solely of an attorney's affirmation together with unsworn, and thus inadmissible, medical reports was insufficient to withstand summary judgment. Therefore, the court reversed the order denying the defendant's motion for summary judgment, granted the motion, and dismissed the complaint.
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.