No-Fault Case Law

The court considered the denial of a motion for summary judgment and the granting of a cross motion for summary judgment by the Civil Court. The main issue in the case was whether the defendant had timely denied the claims for first-party no-fault benefits on the ground that the supplies at issue were not medically necessary, and whether the plaintiff had failed to rebut the defendant's evidence. The holding of the case was that the judgment to dismiss the complaint was affirmed, as defendant had established that it had timely denied the claims and plaintiff had failed to rebut the evidence. The court also decided that the defendant was not required to annex copies of the medical records reviewed by defendant's peer reviewer, and that the peer review report was admissible despite containing an electronic stamped facsimile of the peer reviewer's signature.

The relevant facts considered by the court in this case were related to the denial of first-party no-fault benefits sought by Midwood Total Rehabilitation Medical, P.C. as Assignee of Jenny Carmen Hernandez, based on the failure of Hernandez to appear for scheduled independent medical examinations (IMEs). The main issue decided in this case was whether the denial of the claims by State Farm Mutual Automobile Ins. Co. was justified due to the failure of Hernandez to attend the scheduled IMEs. The holding of the court was that State Farm Mutual Automobile Ins. Co. had timely mailed the IME scheduling letters and the denial of claim forms, and had provided affidavits from its examining physician, chiropractor, and acupuncturist, all of whom stated that Hernandez had failed to appear for the scheduled IMEs. As a result, the court determined that State Farm had established its entitlement to judgment as a matter of law and granted their motion for summary judgment dismissing the complaint.

The court considered the fact that the plaintiff, Med-Tech Product, Inc., was seeking to recover assigned first-party no-fault benefits from the defendant, Progressive Northeastern Insurance Co. The main issue in the case was whether the defendant had timely mailed requests and follow-up requests for verification to the plaintiff, and whether the plaintiff had failed to provide the requested verification. The court held that the affidavit of the defendant's claims examiner established that the defendant had timely mailed its requests and follow-up requests for verification to the plaintiff, and that the plaintiff had failed to provide the requested verification. As a result, the 30-day period within which the defendant was required to pay or deny the claims did not begin to run, and the plaintiff's causes of action upon these claims were premature. Therefore, the court affirmed the lower court's decision to grant the branches of the defendant's motion seeking summary judgment dismissing the third and sixth causes of action.

The main issue in this case was whether a provider was entitled to recover assigned first-party no-fault benefits from an insurance company. The court considered the fact that the insurance company had denied the claims on the grounds that the services provided were not medically necessary, and that the provider had failed to rebut the insurance company's evidence. The court found that the insurance company had established timely denial of the claims and that the provider had not provided sufficient evidence to counter this. As a result, the court affirmed the judgment in favor of the insurance company, dismissing the complaint brought by the provider. The holding of the case was that the insurance company was not required to provide copies of the medical records reviewed by its peer reviewer, as argued by the provider, and that the provider's contentions on appeal were without merit. As a result, the judgment in favor of the insurance company was affirmed.

The relevant facts the court considered in this case include that defendant denied the claim based on a sworn peer review report which set forth a factual basis and medical rationale for the peer reviewer's determination that there was a lack of medical necessity for the services provided. In support of its cross motion, defendant submitted affidavits from its claims division employees which showed that the claim denial forms had been timely mailed. The affidavits further established that defendant had properly used the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount plaintiff was entitled to receive for the services. The main issue decided was whether the denial of the bill underlying plaintiff's first cause of action was valid based on the sworn peer review report. The holding of the court was that the order was reversed, plaintiff's motion for summary judgment was denied, and defendant's cross motion for summary judgment dismissing the complaint was granted.

The main issue of the case was whether the defendant's motion for summary judgment dismissing the complaint should have been granted as to the services rendered from August 2, 2007 to August 9, 2007. The court considered the fact that the defendant had demonstrated, prima facie, that it had timely denied the claims at issue, but the plaintiff's employee's affidavit created a triable issue of fact as to whether the claim had been timely denied. As a result, the court held that the defendant's motion for summary judgment dismissing the complaint should not have been granted as to that claim. The judgment was reversed, and the branch of defendant's cross motion seeking summary judgment dismissing the complaint as to the services was vacated and denied. Therefore, the plaintiff's appeal was successful in this aspect.

The court considered the appeal of W.H.O. Acupuncture, P.C. as Assignee of Charles Rodriguez, who was seeking to recover first-party no-fault benefits from GEICO General Insurance Company. The main issue decided was whether there was a triable issue of fact as to whether GEICO denied any of the claims at issue, and the court ultimately found that the record did not demonstrate the existence of such an issue. As a result, the court affirmed the judgment of the Civil Court granting GEICO's cross motion for summary judgment, and dismissed the complaint. Therefore, the holding of the case was in favor of GEICO, and the judgment was affirmed.

In the case BLR Chiropractic, P.C. v American Tr. Ins. Co., the plaintiff, a provider seeking to recover first-party no-fault benefits, moved for summary judgment, while the defendant cross-moved for summary judgment dismissing the complaint. The defendant had timely denied the plaintiff's claim on the ground of lack of medical necessity and submitted evidence to support their decision, including a peer review report and affidavit executed by the chiropractor who performed the review. The court found that the evidence submitted by the defendant established a prima facie case of lack of medical necessity for the services at issue, shifting the burden to the plaintiff to rebut the defendant's showing, which they failed to do. As a result, the court reversed the order denying the defendant's cross motion and granted summary judgment dismissing the complaint.

The relevant facts the court considered involved BR Clinton Chiropractic, P.C. as the assignee of an individual, Doreen Polcano, seeking to recover assigned first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The main issue decided was whether defendant was entitled to summary judgment dismissing the complaint and granting plaintiff's cross motion for summary judgment. The court held that the branches of defendant's motion seeking summary judgment dismissing the first, second, fourth and fifth causes of action should be granted, and plaintiff's cross motion for summary judgment should be denied. Additionally, the court found that the denial of claim form was timely mailed and that plaintiff failed to demonstrate that it was conclusory, vague, or without merit as a matter of law.

The court considered an appeal from an order granting the defendant's motion for summary judgment in a case where a provider sought to recover assigned no-fault benefits. The main issue decided was whether there was a triable issue of fact as to the medical necessity of the supplies at issue. The court held that the judgment was reversed, the order granting the defendant's motion for summary judgment was vacated, and the defendant's motion was denied. The court did not find sufficient evidence to support the defendant's argument of lack of medical necessity, and therefore ruled in favor of the plaintiff.