No-Fault Case Law
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.
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.