No-Fault Case Law

The main issue in this case was whether the insurance company was justified in denying payment for certain acupuncture services on the grounds that the amounts charged exceeded the workers' compensation fee schedule. The court considered the affidavit submitted by the insurance company's claims examiner, which showed that the company had timely denied certain portions of the provider's claims. The court held that while the affidavit was sufficient to warrant the dismissal of some of the plaintiff's claims, it was not enough to warrant the dismissal of the claim for the initial acupuncture visit, nor to establish that the amounts charged exceeded the relevant rates set forth in the fee schedule. As a result, the court affirmed the decision to deny the insurance company's cross motion for summary judgment dismissing the complaint.

The court considered the plaintiff's motion for summary judgment in an action to recover assigned first-party no-fault benefits. The court found that the plaintiff failed to establish its prima facie entitlement to that relief by not proving the submission of a claim form and the fact and amount of the loss sustained. The main issue was whether the claim form submitted by the plaintiff constituted prima facie proof of the fact and amount of the loss sustained. The court held that in order for a claim form to constitute prima facie proof, the affidavit submitted by the plaintiff must establish that the claim form is admissible under the business records exception to the hearsay rule. As the plaintiff failed to demonstrate this, the court affirmed the denial of plaintiff's motion for summary judgment.

The Court considered the fact that the plaintiff had moved for summary judgment for recovery of first-party no-fault benefits, and the defendant had cross-moved for summary judgment to dismiss the complaint. The main issue was whether the services rendered to the plaintiff's assignor were medically necessary. The Court held that the defendant was entitled to summary judgment dismissing the complaint, as the plaintiff had not meaningfully rebutted the conclusions set forth in the peer review report submitted by the defendant. The Court also found that the facsimile signature on the report was admissible, as it was placed by the doctor who performed the peer review or at his direction. Therefore, the defendant's cross motion for summary judgment was granted, and the order was reversed.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County that granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment dismissing the complaint. The main issue decided was whether the defendant had timely denied the portion of the plaintiff's claims at issue based upon the workers' compensation fee schedule and whether the defendant had fully paid the plaintiff for the acupuncture services billed for, in accordance with the workers' compensation fee schedule. The holding of the case 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 court found that the defendant had timely denied the claims and had fully paid the plaintiff for the acupuncture services according to the fee schedule.

The main issue in this case was whether the denial of a claim for first-party no-fault benefits by Interboro Ins. Co. on the grounds of lack of medical necessity was justified. The court considered evidence from both the defendant and the plaintiff, with the defendant submitting an affirmed peer review report stating that the treatment provided by the plaintiff was not medically necessary. The plaintiff submitted an unsworn medical report in opposition to the defendant's motion. Ultimately, the court held that the purpose of the peer review report was not to prove the injury or treatment of the plaintiff's assignor but to establish that the treatment provided was not medically necessary. The court found that the defendant was not required to demonstrate that the records fell within an exception to the rule against hearsay and granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the fact that the defendant insurer properly mailed notices for an examination under oath to the plaintiff's assignor, but the assignor failed to appear. The main issue was whether the defendant was entitled to summary judgment dismissing the action for first-party no-fault benefits. The court held that the defendant made a prima facie showing of entitlement to summary judgment by establishing that it properly mailed the notices for the examination and that the assignor failed to appear. The court also held that the plaintiff failed to raise a triable issue as to the reasonableness of the requests or the assignor's failure to attend the examination, and that the defendant was not required to demonstrate that the assignor's failure to appear was willful. Therefore, the court reversed the order of the Civil Court and granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the judgment of the Civil Court of the City of New York, Queens County, which awarded the plaintiff $3,808.56 after a nonjury trial. The main issue decided by the court was whether defendant's expert medical witness should have been allowed to testify as to the medical necessity of the billed-for services, limited to the basis for the denial as set forth in the original peer review report. The holding of the court was to reverse the judgment and remit the matter to the Civil Court for a new trial on the limited issue of the medical necessity of the billed-for services. The court also discussed the admissibility and scope of expert testimony, as well as the implications of the ruling that set the only trial issue as medical necessity. Ultimately, the court held that the plaintiff had the burden to establish at trial that the billed-for services were medically necessary, as the presumption of medical necessity no longer existed in the case.

The court considered an appeal regarding a motion for summary judgment for a provider to recover assigned first-party no-fault benefits. Plaintiff had submitted the claim forms to defendant showing proof of loss and the amount of the loss sustained, and proof that defendant failed to pay or deny the claims within 30 days. Issue was whether the defendant raised a triable issue of fact. An insurer may not rely on a letter, even if denominated a verification request, that merely informs a claimant that a decision on the claim is delayed. The holding was that plaintiff's motion for summary judgment was granted, defendant's cross motion for summary judgment was denied and the case was remitted to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees.

The relevant facts the court considered were that the plaintiff, New Life Medical, P.C., was seeking to recover assigned first-party no-fault benefits from defendant Geico Ins. Co. Plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The Civil Court denied both motions, finding that the sole issue for trial was the medical necessity of the services provided to plaintiff's assignor. On appeal, defendant argued that it was entitled to summary judgment based on lack of medical necessity and submitted peer review reports to support this argument. The main issue decided by the court was whether the defendant was entitled to summary judgment based on lack of medical necessity for the services provided. The holding of the court was that defendant's cross motion for summary judgment dismissing the complaint was granted. The court found that the plaintiff's healthcare practitioner's affidavit failed to rebut the conclusions set forth in the peer review reports, and as plaintiff did not challenge the finding that defendant was otherwise entitled to judgment, defendant's motion for summary judgment was granted. Therefore, the court reversed the decision of the Civil Court and granted defendant's motion for summary judgment dismissing the complaint.

The court considered whether the defendant's motion for summary judgment to dismiss the complaint on the ground that there was no medical necessity for the services rendered should be granted. The main issue decided was whether there was a triable issue of fact as to the medical necessity of the services at issue. The court held that the affidavit of the plaintiff's psychologist submitted in opposition to the defendant's motion was sufficient to demonstrate the existence of a triable issue of fact as to the medical necessity of the services at issue, and therefore affirmed the order denying the defendant's motion for summary judgment.