No-Fault Case Law

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.

The court considered an appeal from a judgment in favor of Jesa Medical Supply, Inc. as an assignee to recover first-party no-fault benefits from American Transit Ins. Co. The main issue decided was whether defendant had timely mailed its request for verification and if plaintiff had provided such verification to defendant prior to commencing the action. The court held that the defendant had demonstrated that it had timely mailed its request for verification and that plaintiff did not show that the verification had been provided to defendant. Consequently, the 30-day period within which defendant was required to pay or deny the claims did not begin to run, making plaintiff's action premature, and therefore the judgment in favor of Jesa Medical Supply, Inc. was reversed.

The court considered the 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 main issue was whether the denial of claim form, which denied the claim at issue on the ground of lack of medical necessity, had been timely mailed and whether defendant had provided sufficient evidence to support its determination that the medical supplies at issue were not medically necessary. The court held that defendant's affidavit, along with the chiropractor/acupuncturist's peer review report, established a factual basis and medical rationale for the determination that there was a lack of medical necessity for the supplies, and that the plaintiff did not rebut this showing. As a result, the court reversed the order and granted the defendant's motion for summary judgment dismissing the complaint.

Facts: This case involves an appeal by the defendant insurance company after an action by a healthcare provider to recover assigned first-party no-fault benefits. The provider moved for summary judgment and the defendant cross-moved for summary judgment to dismiss the complaint. Issues: The main issues were whether the provider failed to submit proof of claim to the insurer within the required 45-day period, whether defendant's claims of excessive fees charged by the provider were sufficient for summary judgment, and whether an independent medical examination found further acupuncture treatment unnecessary, justifying the denial of a portion of plaintiff's claim. Holding: The court ordered that the branch of the defendant's cross-motion seeking summary judgment dismissing the portion of the plaintiff's claim for dates of service from August 29, 2007, to September 6, 2007 is granted. They found that there was no issue of fact about the date that the claim form was mailed, entitling the defendant to summary judgment dismissing the claim for treatment on May 23, 2007 and May 24, 2007. Additionally, the decision explicitly stated that a lower court should be obliged to take notice of the rates set forth in the workers' compensation fee schedule, and that defendant's allegations of excessive fees charged by plaintiff were insufficient to establish the defendant's contention. Therefore, the defendant was not entitled to summary judgment for these claims.

The court considered an appeal from a denial of a motion for summary judgment in a case involving a disputed claim for first-party no-fault benefits. The main issue was whether the defendant insurance company had established prima facie evidence that it had properly notified the policyholder of an independent medical examination (IME) and that the policyholder had failed to attend. The court held that the defendant's submissions had indeed established prima facie that it had mailed the notices of the IMEs and that the policyholder had failed to attend. The court reversed the lower court's decision, granted the motion for summary judgment, and dismissed the complaint. Therefore, the defendant insurance company was not liable to pay the first-party no-fault benefits claimed by the plaintiff medical provider.

The case involved a dispute between Allstate Insurance Company and Alicia A. Jackson in regards to a default judgment entered against her in a negligence case. Allstate claimed that Jackson and Kevin D. Hudson were responsible for injuries sustained by their insured individuals due to a car accident. After a default judgment was entered against Hudson for failure to appear or answer, and against Jackson for failure to appear at trial, Jackson moved to vacate the default judgment against her, asserting that she was not driving the car at the time of the accident. The main issue decided by the court was whether Jackson had a reasonable excuse for her default and whether she had a meritorious defense to the action. The court determined that Jackson failed to offer any evidence to rebut the presumption that Hudson drove the vehicle with her consent, and her assertion that she was not driving the vehicle did not constitute a meritorious defense to the action. Therefore, the court reversed the order and denied Jackson's motion to vacate the default judgment entered against her.

The relevant facts in the case include a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company timely denied the claim on the ground of lack of medical necessity. The main issue decided in this case was whether the insurance company's peer reviewer's report demonstrated a lack of medical necessity for the services at issue, which would shift the burden to the provider to rebut the insurance company's showing. The holding of the court was that the insurance company's peer reviewer's report did set forth a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity, and the provider failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity. Therefore, the court reversed the order denying the insurance company's motion for summary judgment and granted the motion for summary judgment dismissing the complaint.