No-Fault Case Law

The appellate court considered a case where Ava Acupuncture, P.C. was seeking to recover no-fault benefits for medical services provided to its assignors. The defendant, NY Central Mutual Fire Ins. Co., had previously obtained a declaratory judgment from the Supreme Court, stating that they had no obligation to furnish benefits to the parties involved. Ava Acupuncture, P.C. then filed a motion to compel discovery and the defendant cross-moved for summary judgment to dismiss the complaint, citing the previous declaratory judgment. The main issue decided was whether the previous order of the Supreme Court, which declared that the defendant had no present or future obligation to furnish benefits, would bar the instant action. The court held that the instant action was barred under the doctrine of res judicata, as to hold otherwise could result in a judgment that would impair rights established by the order rendered by the Supreme Court. The court further emphasized that the Supreme Court's order constituted a conclusive final determination, and therefore, the plaintiff's motion to compel discovery or strike defendant's answer was rendered moot and properly denied. The order of the Civil Court was affirmed.

The court considered a case in which Ave T MPC Corp., as assignee, sought to recover assigned first-party no-fault benefits from Travelers Property Casualty Ins. Co. The main issues decided were whether the plaintiff's action should be struck from the trial calendar and whether the plaintiff's owner should be compelled to undergo an examination before trial. The court held that because the notice of trial and certificate of readiness filed by the plaintiff contained the erroneous statement that discovery had been completed, the Civil Court properly granted the branch of defendant's motion seeking to strike the matter from the trial calendar. The court also found no basis to disturb the Civil Court's order compelling the plaintiff's owner to undergo an examination before trial, and therefore denied the plaintiff's cross motions seeking costs and sanctions.

The relevant facts considered by the court were that the Civil Court granted the plaintiffs' motion to restore the action to the trial calendar pursuant to Uniform Rules for New York City Civil Court. The owner of plaintiff Exact Medical Services, P.C. had passed away and an administrator had been appointed to preserve the estate's value. The main issue decided was whether the action should be restored to the trial calendar, and the holding was that the order granting the restoration was affirmed by the court. The decision was made based on similar reasons as another case, and the judges Weston, Pesce, and Rios all concurred with the decision.

The relevant facts the court considered were that the plaintiff, Upper E. Side Surgical, PLLC, sought reimbursement for medical services provided to an insured individual from the defendant, State Farm Insurance Company. The plaintiff claimed the defendant timely denied their claim and cited that the fees claimed were not in compliance with the New York Workers' Compensation Board Schedule of Medical Fees. The main issue was whether the plaintiff was entitled to reimbursement under the no-fault insurance law and what rate of reimbursement they were entitled to. The court held that while the plaintiff was entitled to reimbursement for the medical services provided, the facility fees set forth by the NY State Workers' Compensation Board were not applicable to the plaintiff as they were not listed as a Public Health Law Article 28 facility. The court also held that a trial of the issue was necessary to determine the amount of the charge for services. As a result, the defendant's motion for summary judgment was denied on the fee schedule issue and granted on the issue of timely denial of claim.

The defendant insurance company had refused to pay first-party no-fault benefits to the plaintiffs, which were providers in this case. Their claims had been marked off the trial calendar but were later moved to restore the action to trial. However, the defendant argued that prosecution of the claims of the plaintiff Painless Medical, P.C. could not be pursued due to the death of the sole shareholder, officer, and director of the company. The defense claimed that the appointed administrator, Anna Val, did not have the authority to pursue pending litigation or collect settlements and judgments involving this provider. The court ruled that Ms. Val had the authority and power to recover property belonging to the estate, prosecute an action to recover assets belonging to the estate, and settle claims for money owed to the estate, and she did not have to be a member of the profession in which the professional corporation was authorized to practice. The main issue decided was whether Anna Val had the authority to pursue pending litigation or collect settlements and judgments involving the provider after being appointed as administrator of the estate, and the court ruled that she did have the authority. The holding of the court was that the motion to restore the action was made within a year after it had been marked off the trial calendar, and counsel's affirmation satisfactory justified the reason, showing a readiness to proceed to trial, and the order was affirmed.

The relevant facts the court considered for this case involved a dispute over first-party no-fault benefits for psychological services provided to an individual involved in a motor vehicle accident. The plaintiff sought reimbursement for several psychological services, but the defendant denied them as medically unnecessary. The main issue decided in the case was whether the defendant had proven the lack of medical necessity for the services for which reimbursement was sought. The court held that the defendant met its burden of proof in establishing the lack of medical necessity through a peer review report and medical records, and the plaintiff failed to rebut the evidence with its own. As a result, the court denied the plaintiff's motion for a directed verdict and granted judgment to the defendant, dismissing the complaint with prejudice.

The relevant facts the court considered were that the plaintiff sought to recover first-party no-fault benefits for psychological services provided to the subject assignor. The plaintiff was paid for the initial interview, but the rest of the services were denied by the defendant as medically unnecessary and for fees not in accordance with fee schedules. The main issues decided were lack of medical necessity and fees not in accordance with fee schedules. The holding of the court was that the defendant successfully proved lack of medical necessity for four of the six psychological services allegedly provided, as well as the review of records, and the explanation and interpretation of results. The court granted a partial judgment to the plaintiff in the amount of $266.61, plus interest, costs, and attorney's fees, and dismissed the balance of the claim with prejudice.

The main issue in this case was whether the defendant was entitled to summary judgment dismissing the complaint in an action to recover first-party no-fault benefits. The court considered the evidence provided by the defendant, including the timely mailing of denial of claim forms and competent medical evidence that the diagnostic testing giving rise to the plaintiff's claims lacked medical necessity. The main holding of the case was that the defendant was entitled to summary judgment, as they had made a prima facie showing of entitlement by establishing the proper and timely mailing of denial of claim forms and submitting competent medical evidence. The court found that the plaintiff's opposition, consisting of an attorney's affirmation unaccompanied by any medical evidence, was insufficient to raise a triable issue. Therefore, the court reversed the order of the Civil Court and granted the defendant's motion for summary judgment, dismissing the complaint.

The relevant facts considered in this case were that Elmont Open MRI & Diagnostic Radiology, as the assignee of Joanne Cunningham, sought to recover first-party no-fault benefits from Tri-State Insurance Company. Tri-State had denied the claims on the ground of lack of medical necessity and submitted a peer review report setting forth a factual basis and medical rationale for the conclusion that there was a lack of medical necessity for the services at issue. The main issue decided was whether defendant's motion for summary judgment dismissing the complaint should be granted. The holding of the court was that defendant had established its prima facie entitlement to summary judgment by demonstrating a lack of medical necessity for the services at issue, and as the plaintiff failed to rebut this showing, the defendant's motion for summary judgment dismissing the complaint was granted.

The relevant facts considered in this case were that providers had moved for summary judgment to recover assigned no-fault benefits, but the insurance company opposed the motion, stating that the claims were denied based on the assignor's eligibility for workers' compensation benefits. The main issue was whether the accident occurred during the course of the assignor's employment. The court found that there was a question of fact regarding this issue and held the action in abeyance pending a determination by the Workers' Compensation Board. The holding of the court was that the insurance company's proof was sufficient to raise a question of fact as to whether the assignor was acting as an employee at the time of the accident, and that this issue must be resolved by the Workers' Compensation Board before determining the provider's motion for summary judgment.