No-Fault Case Law
Megacure Acupuncture, P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52199(U))
November 30, 2011
The court considered the argument by a provider to recover assigned first-party no-fault benefits from an insurance company which had reimbursed the provider using the workers' compensation medical fee schedule. The main issue decided was whether the insurance company had properly reimbursed the provider the amount to which it was entitled for the acupuncture services it had rendered. The court held that the insurance company's contention that the amounts charged by the provider exceeded the relevant rates set forth in the workers' compensation fee schedule was not sufficiently established. The court declined to take judicial notice of the workers' compensation fee schedule since the applicable portion of the fee schedule was not annexed to the defendant's papers. As a result, the court denied the plaintiff's cross motion for summary judgment and modified the order accordingly.
Parsons Med. Supply, Inc. v Metropolitan Prop. & Cas. Ins. Co. (2011 NY Slip Op 52198(U))
November 30, 2011
The court considered the fact that defendant had timely mailed the NF-10 denial of claim forms based on standard office practices and procedures. It was also determined that defendant's peer reviewer's reliance on medical records of other providers did not render the peer review report inadmissible. Plaintiff challenged the peer reviewer's reliance on various medical records, but since some of the records were prepared by the plaintiff, they may not challenge the reliability of those records. The main issue decided was whether defendant was entitled to summary judgment dismissing the complaint, and the court held that the order to dismiss the complaint was affirmed. Plaintiff's cross motion was properly denied and the attorney's affirmation was insufficient to establish plaintiff's entitlement to judgment as a matter of law.
Five Boro Psychological Servs., P.C. v Allstate Ins. Co. (2011 NY Slip Op 52197(U))
November 30, 2011
The main issue in this case was whether the court should dismiss the complaint filed by Five Boro Psychological Services, P.C. as the assignee of David Ran, in their action to recover assigned first-party no-fault benefits from Allstate Ins. Co. Defendant Allstate Ins. Co. moved to dismiss the complaint pursuant to CPLR 3211 (a) (2) and to stay the trial pending resolution of the motion. The Civil Court granted a stay pending determination of the motion, and as the plaintiff submitted no papers in opposition to defendant's motion by the new return date, the order granting defendant's motion to dismiss the complaint was deemed to have been entered upon default. Therefore, the court held that plaintiff's appeal must be dismissed, as no appeal lies by the defaulting party.
Westchester Med. Ctr. v Progressive Cas. Ins. Co. (2011 NY Slip Op 08747)
November 29, 2011
The case of Westchester Med. Ctr. v Progressive Cas. Ins. Co. involved an action to recover no-fault benefits from an automobile insurance policy. The main issue to be decided was whether the plaintiff, Westchester Medical Center, was entitled to summary judgment in three causes of action, each seeking benefits as an assignee of a different individual. The court held that the plaintiff made a prima facie showing of entitlement to judgment on the second cause of action, as there was no opposition raised by the defendant. However, the court found that the defendant had submitted proof to deny the claim for the first cause of action, and records showed that the third cause of action was paid within the required 30-day period. Therefore, the court decided that the plaintiff was not entitled to summary judgment on the first and third causes of action. The order was therefore modified to reflect this decision.
State Farm Mut. Auto. Ins. Co. v Anikeyeva (2011 NY Slip Op 08580)
November 22, 2011
The court considered an action brought by State Farm Mutual Automobile Insurance Company seeking a judgment exempting them from paying no-fault claims submitted by numerous professional corporation defendants. The first cause of action challenged the legality of the professional corporation defendants, while the second cause of action claimed that the professional corporation defendants' services were performed by independent contractors or non-employees. The court affirmed the denial of the defendants' motion to dismiss the first and second causes of action. In affirming the denial, the court held that the allegations presented justiciable controversies sufficient to invoke the Supreme Court's power to render a declaratory judgment, and that State Farm's causes of action were sufficient to warrant a declaratory judgment. Therefore, the Supreme Court properly denied the defendant's motion to dismiss the first and second causes of action pursuant to CPLR 3211 (a) (7) for failure to state a cause of action.
Alrof, Inc. v Progressive Ins. Co. (2011 NY Slip Op 21419)
November 17, 2011
The relevant facts of the case include a dispute over whether the medical equipment supplied to a patient by a medical provider was medically necessary. Prior to trial, the plaintiff moved to preclude the defendant's doctor from testifying, which resulted in a directed verdict and judgment for the plaintiff. The main issue decided was whether the defendant's doctor should have been permitted to testify as to his opinion that the equipment was not medically necessary. The core holding of the case was that the defendant's doctor should have been allowed to testify as to his opinion that the equipment was not medically necessary, and that the matter should be remitted to the Civil Court for a new trial.
Lenox Hill Hosp. v Government Empls. Ins. Co. (2011 NY Slip Op 08330)
November 15, 2011
The main issue in this case was whether Lenox Hill Hospital was entitled to judgment as a matter of law on the ground that Government Employees Insurance Company did not pay or deny the subject claim within 30 days. The court considered the limited nature of the plaintiff's motion for summary judgment, as it only established the plaintiff's prima facie entitlement to judgment on this ground. The defendant's burden in opposition to the motion was to raise a triable issue of fact regarding its timely payment or denial of the claim, which it succeeded in doing by submitting evidence that it sent the plaintiff a denial of claim form within the 30-day time limit. Therefore, the court held that the denial of the plaintiff's motion for summary judgment was proper and affirmed the lower court's order.
Total Equip., LLC v Praetorian Ins. Co. (2011 NY Slip Op 21398)
November 9, 2011
In the case of Total Equipment, LLC, as Assignee of Latasha James v Praetorian Insurance Company, the court considered the fact that the defendant had filed a motion for summary judgment and the plaintiff had cross-moved to compel discovery. At the crux of the case was the issue of whether the medical equipment provided to Latasha James was medically necessary, based on a peer review report by Dr. Ronald A. Csillag, D.C. The defendant had timely denied the claim on this ground. The court held that the plaintiff had not had a reasonable opportunity to conduct discovery before the motion was made, and they needed to have the chance to obtain and review the full no-fault file. As a result, the defendant's motion for summary judgment was denied without prejudice, and the plaintiff's cross motion to compel discovery was granted, with the defendant being required to serve answers to the plaintiff's demand for interrogatories and a response to the document demand within 45 days of service of the order.
Foster Diagnostic Imaging, P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52074(U))
November 4, 2011
The court considered the motion for summary judgment by the defendant, who submitted a sworn peer review report showing a lack of medical necessity for the services at issue in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should be granted. The court held that the defendant's showing that the services were not medically necessary was not rebutted by the plaintiff, and the Civil Court's implicit finding that the defendant had timely denied the claim based on a lack of medical necessity was not challenged by the plaintiff. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted.
AKS Med., P.C. v Clarendon Ins. Co. (2011 NY Slip Op 52072(U))
November 4, 2011
The court considered whether a provider could recover assigned first-party no-fault benefits, and whether the defendant insurance company was entitled to summary judgment dismissing the complaint on the grounds of lack of medical necessity. The main issue was whether the defendant established its entitlement to summary judgment, and whether the plaintiff's treating physician's affidavit provided enough evidence to demonstrate a triable issue of fact as to medical necessity. The holding of the case was that the order denying the defendant's motion for summary judgment was affirmed, as the affidavit of the plaintiff's treating physician was determined to be sufficient to show that there was a triable issue of fact as to medical necessity. Therefore, the defendant's motion for summary judgment dismissing the complaint was denied.