No-Fault Case Law

The relevant facts considered by the court were that the plaintiff was seeking to recover first-party no-fault benefits as an assignee of Johnie Daniels. The main issue decided in the case was whether there was a lack of medical necessity for the services rendered to the plaintiff's assignor. The court ultimately held in favor of the defendant, granting their cross motion for summary judgement dismissing the complaint. This decision was based on the fact that the defendant submitted an affirmed peer review report and an affirmed independent medical examination (IME) report, both of which provided a factual basis and medical rationale for the determination of a lack of medical necessity. Additionally, the plaintiff's affidavit from a doctor failed to meaningfully refer to the conclusions set forth in the peer review report or the IME report. Therefore, the defendant was entitled to summary judgement dismissing the complaint.

The relevant facts of this case involve a provider seeking to recover assigned first-party no-fault benefits and the defendant insurance company's assertion that there was a lack of medical necessity for the supplies provided to the plaintiff's assignor. The main issue decided in this case was whether or not the defendant's cross motion for summary judgment dismissing the complaint should be granted. The court held that the defendant's cross motion for summary judgment dismissing the complaint should be granted based on the lack of medical necessity for the supplies provided to the plaintiff's assignor, as supported by sworn peer review reports from a chiropractor and the failure of the plaintiff to meaningfully address or rebut these conclusions. As a result, the order of the Civil Court implicitly denying the cross motion for summary judgment dismissing the complaint was reversed.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, which denied defendant's cross motion for summary judgment. The main issue in the case was whether plaintiff's assignor was eligible for workers' compensation benefits and if such benefits were available after a car accident. The court held that the defendant had provided sufficient evidence which gave rise to a triable issue as to whether the plaintiff's assignor had been acting as an employee at the time of the accident, and that therefore workers' compensation benefits might be available. The case was remitted to the Civil Court for a new determination after final resolution of a prompt application to the Workers' Compensation Board to determine the parties' rights under the Workers' Compensation Law. The Civil Court was directed to grant defendant's cross motion for summary judgment dismissing the complaint unless plaintiff showed good cause why it should not be dismissed.

In the case of W.H.O. Acupuncture, P.C. v National Cont. Ins. Co., the provider, W.H.O. Acupuncture, P.C., appealed from an order granting the insurer's motion for summary judgment and denying the provider's cross motion for summary judgment. The judgment was entered dismissing the complaint for first-party no-fault benefits. The court found that the insurer had fully paid the provider for some of the acupuncture services rendered, and the provider failed to raise a triable issue of fact in response. Therefore, the court held that the insurer properly granted summary judgment dismissing the complaint for those services. Additionally, the insurer denied payment for other acupuncture services based on a sworn independent medical examination report establishing a prima facie showing of lack of medical necessity. The court affirmed the judgment, as the issue of medical necessity was not properly raised on appeal. The main issues decided in this case were whether the insurer properly denied payment for specific acupuncture services based on lack of medical necessity and whether the provider had raised a triable issue of fact in response to the insurer's motion for summary judgment. The holding of the court was that the insurer had established lack of medical necessity for certain services and had fully paid the provider for other services, and the provider had failed to raise a triable issue of fact in response. Therefore, the judgment dismissing the complaint was affirmed.

The main issue in this case was whether the defendant, GEICO Ins. Co., had timely denied the plaintiff's claim on the ground of lack of medical necessity. The court considered the affidavit of the defendant's claims examiner and an affirmed peer review report which concluded that there was no medical necessity for the services rendered. The record did not contain an affidavit from a health care practitioner on behalf of the plaintiff to rebut the conclusion set forth in the peer review report. Ultimately, the court reversed the judgment, vacated the order, denied the plaintiff's motion for summary judgment, and granted the defendant's cross motion for summary judgment dismissing the complaint. Consequently, the plaintiff's claim for assigned first-party no-fault benefits was denied.

The court considered an appeal from an order denying the defendant's motion for summary judgment in a case involving a provider seeking to recover first-party no-fault benefits. The main issue was whether the defendant was entitled to summary judgment dismissing the complaint due to lack of written notice of the accident, as required by the insurance policy. The court held that compliance with the notice requirement of the policy is a condition precedent to coverage, and since the plaintiff failed to demonstrate the existence of a triable issue of fact, the defendant was entitled to summary judgment dismissing the complaint. Therefore, the order was reversed, and the defendant's motion was granted.

The court considered the denial of first-party no-fault benefits for acupuncture services rendered to an individual by Apple Tree Acupuncture, P.C. as Assignee of BILLY McLAUGHLIN from February 1, 2007 through June 27, 2007 and from August 6, 2007 through September 4, 2007 by Interboro Ins. Co. The main issue decided was whether Interboro Ins. Co. was entitled to partial summary judgment with respect to the claims for the acupuncture services. The holding was that Interboro Ins. Co. was not entitled to partial summary judgment on the ground that the amounts sought by Apple Tree Acupuncture exceeded the amounts permitted by the fee schedule, as the denial of the claim forms did not apprise Apple Tree Acupuncture of the ground asserted with "a high degree of specificity." Additionally, Interboro Ins. Co. was not entitled to summary judgment as there were triable issues of fact regarding the medical necessity of the treatment rendered for the remaining claims.

The main issue in the case was whether the defendant's original discovery demands sought production of documents pertaining to a defense that the plaintiff, a provider seeking first-party no-fault benefits, was ineligible to recover such benefits due to being a professional service corporation which failed to comply with applicable state or local licensing laws. The court considered that defendant's original discovery demands did not seek production of documents pertaining to such a defense and determined that the branch of defendant's motion seeking to compel plaintiff to respond to defendant's supplemental discovery demands was premature and should not have been granted. Therefore, the court modified the order to deny that branch of the defendant's motion as premature and affirmed the order in all other aspects. Hence, the holding was that the defendant's motion to compel the plaintiff to respond to supplemental discovery demands was denied as premature.

The court considered the motion for summary judgment made by the defendant to dismiss the complaint filed by Heights Medical Care, P.C., related to a first-party no-fault claim. The main issue decided was whether the defendant was entitled to summary judgment dismissing the claim. The holding of the court was that the defendant was entitled to summary judgment dismissing the plaintiff's claim in the sum of $395.69 since the plaintiff failed to respond to the defendant's timely and proper verification request. The court also determined that the plaintiff's remaining no-fault claims were not ripe for summary disposition, as there were triable issues regarding the defendant's verification and fraud defenses.

The court considered the fact that the plaintiff, Friendly Physician, P.C., as the assignee of Lloy Welds, had filed a motion for summary judgment in order to recover assigned first-party no-fault benefits from the defendant, GEICO Ins. Co. The issue decided in this case was whether the plaintiff had demonstrated its entitlement to judgment as a matter of law. The holding of the court was that while the plaintiff had shown that the bills were submitted to the defendant and set forth the fact and amount of the loss sustained, the sworn statements submitted by the defendant were sufficient to raise a triable issue of fact as to whether the alleged injuries arose out of an insured incident. Therefore, the court reversed the order granting the plaintiff's motion for summary judgment and denied the motion.