No-Fault Case Law

The court considered that in an action by a healthcare provider to recover no-fault insurance benefits, the plaintiff moved for summary judgment and the defendant cross-moved for summary judgment dismissing the complaint. The Civil Court found that both parties had established their prima facie cases and that the only issue for trial was the medical necessity of the services rendered to the plaintiff's assignor. The defendant submitted peer review reports to support their cross motion, each of which provided a factual basis and medical rationale for the determination that there was a lack of medical necessity for the services rendered. In response, the plaintiff submitted an affirmation from a doctor that failed to meaningfully rebut the conclusions in the peer review reports. The court held that as the plaintiff had not challenged the finding that the defendant was otherwise entitled to judgment, the defendant's cross motion for summary judgment dismissing the complaint was granted.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, where the order denied the branch of the defendant's motion seeking summary judgment dismissing so much of the complaint as sought to recover upon a claim for $498. The main issue decided was related to whether the defendant had established that it had timely denied the claim for $498 on the ground of lack of medical necessity, and whether the defendant was required to annex to its motion papers copies of the medical records reviewed by the peer reviewer. The holding of the case was that the order, insofar as appealed from, was reversed and the branch of defendant's motion seeking summary judgment dismissing so much of the complaint as sought to recover upon the claim for $498 was granted.

The case involved an appeal from an order of the Civil Court of the City of New York, Kings County denying defendant's motion for summary judgment dismissing the complaint. The action was brought by a provider to recover assigned first-party no-fault benefits. The main issue for trial was the medical necessity of the services rendered to plaintiff's assignor. In support of its motion, defendant submitted an affirmed peer review report, while plaintiff submitted a doctor's affirmation and claim forms. The court ultimately reversed the order and granted defendant's motion for summary judgment dismissing the complaint, finding that plaintiff failed to proffer any evidence in admissible form which raised an issue of fact and that the doctor's affirmation did not meaningfully refer to, let alone rebut, the conclusions set forth in defendant's peer review report.

The court considered the timely denial of a claim on the grounds of lack of medical necessity, as established by the defendant through an affirmed peer review report. Defendant appealed from an order that denied its cross motion for summary judgment dismissing the complaint brought by the provider to recover assigned first-party no-fault benefits. The main issue was whether the provider had sufficiently demonstrated the existence of a question of fact as to medical necessity, with the burden shifted to the plaintiff to rebut defendant's prima facie showing. The holding was that defendant's cross motion for summary judgment was properly denied, as the plaintiff's submission of an affidavit of its doctor sufficiently demonstrated the existence of a question of fact as to medical necessity.

The court considered the background of the case, in which Lawrence Wilkes sustained injuries in a motor vehicle accident and Tri-State Consumer Insurance Company provided him with no-fault benefits. All County, LLC performed a thoracic MRI and submitted a claim for payment to Tri-State, which was denied by an Independent Medical Examination conducted by Dr. Kenneth Falvo. The main issue decided was whether the thoracic MRI was medically necessary, and the holding of the case was that defendant's motion for summary judgment was denied because they failed to show entitlement to judgment as a matter of law. The court found that questions of fact existed regarding who ordered the MRI, when it was ordered, and the condition of Wilkes' thoracic spine. Therefore, the motion for summary judgment was denied.

The Court considered the denial of claim forms sent by the defendant, which denied the claims on the ground of lack of medical necessity and excessive billing. The plaintiff failed to submit sufficient medical evidence to raise a triable issue of fact as to the medical necessity of the services rendered. The affirmed peer review report submitted in support of the defendant's motion demonstrated a lack of medical necessity for the services. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint due to lack of medical necessity. The holding of the case was that the order denying the defendant's motion for summary judgment was reversed, and the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the defendant's unopposed motion for summary judgment dismissing the complaint on the ground of lack of medical necessity in an action by a provider to recover assigned first-party no-fault benefits. The defendant submitted an affidavit of an employee of its claims division, as well as the affidavit of a chiropractor and his independent medical examination report, to demonstrate a lack of medical necessity for the equipment provided to the plaintiff's assignor. The main issue decided was whether the defendant's motion for summary judgment should be granted, and the court held that the defendant's motion should have been granted as the plaintiff did not submit papers opposing it. Therefore, the order denying the defendant's motion for summary judgment was reversed and the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered an appeal from a judgment entered after an order granting the plaintiffs' motion for leave to renew their prior motion for summary judgment, which had been previously denied, and granting the plaintiffs' motion for summary judgment and implicitly denying the defendant's cross motion for summary judgment. The main issue was whether the plaintiffs had presented new facts that would change the prior determination and set forth a reasonable justification for the failure to present such facts on the prior motion. The court held that the new facts offered in support of renewal were not sufficient, as they did not provide any personal knowledge that the assignor had made a proper application for workers' compensation benefits, and that the Board had actually rejected such application. The court also noted that the Board had primary jurisdiction to resolve the question of coverage, contrary to the conclusion of the District Court, and therefore reversed the judgment, vacated the order, denied the plaintiffs' motion for leave to renew, and reinstated the previous order.

The case of Stephen Matrangolo, D.C., P.C. v Allstate Ins. Co. involved the recovery of no-fault benefits for services rendered to individuals involved in a car accident. The defendant, an insurance company, had several affirmative defenses to the plaintiff's claim, including that the defendant lacked standing and that the referral was an improper self-referral. The court found that Public Health Law § 238-a did not apply to the electromuscular testing provided by the plaintiff. However, the court also found that the plaintiff was not entitled to compensation for services provided by another doctor who was associated with the referring provider. The court ultimately dismissed the case with prejudice, finding that Dr. Matrangolo, the plaintiff, was not entitled to payment because the evidence showed that the services were provided by another doctor. In summary, the main issues were whether Public Health Law § 238-a applied to the plaintiff and whether the plaintiff was entitled to compensation for the services provided. The court held that the law did not apply, but the plaintiff was not entitled to payment due to the services being provided by another doctor.

The relevant facts the court considered were that SI Medical and Surgical Supply, P.C. filed a lawsuit to recover assigned first-party no-fault benefits. The defendant, American Transit Insurance Company, cross-moved for summary judgment to dismiss the complaint. Both parties had established their prima facie cases, and the sole issue for trial was the medical necessity of the supplies rendered to plaintiff's assignor. Defendant appealed the denial of its cross motion for summary judgment. The main issue decided was whether the supplies provided by the plaintiff were medically necessary. In support of its cross motion, defendant submitted affirmed peer review reports which stated the medical rationale for the determination that there was a lack of medical necessity for the supplies at issue. Plaintiff did not rebut defendant's showing that the supplies were not medically necessary. The holding of the case was that defendant's cross motion for summary judgment was granted, and the order of the Civil Court, which denied defendant's cross motion, was reversed. The court found that there was a lack of medical necessity for the supplies provided and granted summary judgment in favor of the defendant dismissing the complaint.