No-Fault Case Law
Total Equip., LLC v Praetorian Ins. Co. (2012 NY Slip Op 50155(U))
January 24, 2012
The relevant facts considered by the court were that defendant had timely denied plaintiff's claim, and an independent medical examination (IME) report submitted by defendant established a lack of medical necessity for the supplies provided. The main issue decided was whether defendant's motion for summary judgment dismissing the complaint should be granted. The court held that defendant's showing of a lack of medical necessity was not rebutted by plaintiff, and therefore, the motion for summary judgment was granted, reversing the lower court's decision. The defendant's motion to dismiss the complaint was therefore granted.
A.B. Med. Servs., PLLC v National Grange Mut. Ins. Co. (2012 NY Slip Op 50154(U))
January 24, 2012
The court considered the standing of the provider to recover assigned first-party no-fault benefits, as the owner's license to practice medicine had been suspended. The main issue decided was whether the provider had standing to bring the action and seek to recover no-fault benefits for the services it rendered before the revocation of its owner's license. The holding of the case was that the provider was entitled to wind up its affairs and seek to recover the benefits, and therefore, plaintiff's motion for summary judgment should not have been denied, and defendant's cross motion for summary judgment dismissing the complaint should not have been granted on that ground. The order was reversed, and the case was remitted to the Civil Court for a new determination of plaintiff's motion for summary judgment and defendant's cross motion for summary judgment dismissing the complaint.
Q-B Jewish Med. Rehabilitation, P.C. v Allstate Ins. Co. (2012 NY Slip Op 50152(U))
January 24, 2012
The court considered the facts that Q-B Jewish Med. Rehabilitation, P.C. was suing Allstate Insurance Company to recover first-party no-fault benefits and Allstate had requested financial and tax records from the plaintiff during the discovery process to determine if the plaintiff was eligible to recover these benefits. The main issue was whether Q-B Jewish Med. Rehabilitation, P.C. could recover the benefits and whether the defendant was entitled to its requested discovery. The court held that the defendant's motion to vacate the notice of trial and compel plaintiff to provide responses to its discovery demands was granted, on the condition that the plaintiff provide the requested financial and tax records, including W-2 and 1099 forms for individuals who provided the services, in order for the case to proceed to trial.
Eagle Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2012 NY Slip Op 50151(U))
January 24, 2012
The relevant facts of the case involve a provider seeking to recover assigned first-party no-fault benefits, to which the insurance company denied the claims on the ground of lack of medical necessity. The main issue decided by the court was whether the insurance company's motion for summary judgment dismissing the complaint should be granted. The holding of the case was that the insurance company failed to make a prima facie showing of its entitlement to judgment as a matter of law, as the documents submitted by the chiropractor did not meet the requirements of CPLR 2309(b), and the affidavit of the plaintiff's osteopath was sufficient to rebut the peer review reports and raise a triable issue of fact. Therefore, the order denying the insurance company's motion for summary judgment dismissing the complaint was affirmed.
New Life Med., P.C. v Geico Ins. Co. (2012 NY Slip Op 50150(U))
January 24, 2012
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.
Ortho-Med Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2012 NY Slip Op 50149(U))
January 24, 2012
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.
Radiology Today, P.C. v Mercury Ins. Co. (2012 NY Slip Op 50148(U))
January 24, 2012
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.
Neomy Med., P.C. v Geico Ins. Co. (2012 NY Slip Op 50145(U))
January 24, 2012
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.
All County, LLC v Tri-State Consumer Ins. Co. (2012 NY Slip Op 50119(U))
January 23, 2012
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.
Elmont Open MRI & Diagnostic Radiology, P.C. v Tri State Consumer Ins. Co. (2012 NY Slip Op 50079(U))
January 17, 2012
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.