No-Fault Case Law
All Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 50137(U))
January 31, 2012
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.
Diagnostic Medicine, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 50102(U))
January 25, 2012
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.
Elmont Open MRI & Diagnostic Radiology, P.C. v Tri-State Ins. Co. (2012 NY Slip Op 50170(U))
January 24, 2012
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.
B.Y., M.D., P.C. v Global Liberty Ins. Co. of N.Y. (2012 NY Slip Op 50156(U))
January 24, 2012
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.
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.