No-Fault Case Law
Eagle Surgical Supply, Inc. v Geico Ins. Co. (2011 NY Slip Op 52142(U))
November 3, 2011
The court in this case considered the issue of whether identifiable confidential medical records could be admitted into a public civil judicial proceeding without a HIPAA authorization or Privacy Rule exception being demonstrated. This was a no-fault action for first party benefits where the defendant insurer had not obtained a HIPAA authorization from the plaintiff’s assignor, nor did they cite any statutory or regulatory scheme to allow disclosure of identifiable confidential health information. The court found that HIPAA regulations were applicable to the case and the information could not be disclosed in a public civil trial. Therefore, the court imposed the remedy of exclusion of medical testimonial evidence and entered judgment in favor of the plaintiff against the defendant insurer. The decision was based on the fact that the defendant had failed to comply with HIPAA and the Privacy Rule, and that lack of compliance justified the exclusion of evidence and judgment in favor of the plaintiff.
Dov Phil Anesthesiology Group v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 51959(U))
November 2, 2011
The relevant facts considered by the court were that the defendant had established that they had mailed notices of independent medical examinations (IME) to the assignor and his attorney, and that the assignor failed to appear. In response, the plaintiff was unable to raise a triable issue regarding the reasonableness of the requests for IMEs or the assignor's failure to attend. The main issue decided was whether the defendant had established a prima facie case for denial of the claim for no-fault benefits based on the assignor's failure to attend the IMEs. The holding of the court was that the defendant's motion for summary judgment should have been granted, and the complaint was dismissed.
Allstate Ins. Co. v Nalbandian (2011 NY Slip Op 07785)
November 1, 2011
The case involved a dispute over a claim for no-fault insurance benefits, with the plaintiff appealing the denial of their motion for summary judgment on the complaint and the granting of the defendant's cross motion for summary judgment dismissing the complaint and on his counterclaims, as well as to confirm the award of a master arbitrator. The appellate court held that the plaintiff was entitled to compel the adjudication of the insurance dispute, as the master arbitrator's award in favor of the defendant exceeded the statutory threshold sum. The court found that the denial of the plaintiff's motion for summary judgment and the granting of the defendant's cross motion were based on errors in the lower court's reasoning and that the matter must be reconsidered on its merits. Therefore, the Court reversed the lower court's decision and remitted the case for a new determination.
Mega Supplies Billing, Inc. v State Farm Mut. Auto. Ins. Co. (2011 NY Slip Op 52023(U))
October 28, 2011
The court considered the facts surrounding a provider's attempt to recover first-party no-fault benefits, ultimately being denied due to their failure to appear for two examinations before trial (EUOs). The main issue decided was whether the defendant's motion to dismiss should have been denied because it was not proven that the applicable automobile insurance policy contained a provision entitling the defendant to EUOs. The holding of the case was that the mandatory personal injury endorsement contained a provision providing for EUOs, and the underlying motor vehicle accident occurred after this provision was in place, so the applicable automobile insurance policy necessarily would have contained such a provision. Therefore, the defendant's motion to dismiss the complaint was properly granted and the judgment was affirmed.
Comfort Supply, Inc. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52018(U))
October 28, 2011
The court considered a denial of claim form by the insurance company, which stated that the claim was denied because the assignor had not submitted proper notice of the accident within 30 days, as per the company's standard practices. The insurance company first learned of the accident when it received an NF-2 form, more than 30 days after the accident occurred. The main issue was whether the insurance company had timely denied the claim, and if the plaintiff had presented evidence to prove otherwise. The holding of the court was that the insurance company had established its entitlement to judgment as a matter of law, and the burden shifted to the plaintiff. Since the plaintiff did not present any evidence to demonstrate the existence of a triable issue of fact, the court reversed the order and granted the insurance company's motion for summary judgment dismissing the complaint.
Q-B Jewish Med. Rehabilitation, P.C. v Allstate Ins. Co. (2011 NY Slip Op 21390)
October 28, 2011
The relevant facts of Q-B Jewish Med. Rehabilitation, P.C. v Allstate Ins. Co. are that plaintiff filed a certificate of readiness for trial, but its owner did not appear for scheduled EBT and there was outstanding documentary discovery. Defendant set forth detailed and specific reasons for believing that plaintiff is a professional service corporation which fails to comply with applicable state or local licensing laws and thus, ineligible to recover no-fault benefits. The main issue decided in the case was whether plaintiff had to respond to defendant's discovery demands and whether it was required to produce its owner for an examination before trial. The holding of the decision was that plaintiff was held to respond to certain discovery demands, including providing bank statements, tax records, and payroll tax filings, and the owner was required to undergo an examination before trial. The order was modified as such, and the branch of defendant's motion seeking to compel plaintiff to respond to defendant's discovery demands was granted.
Morris Park Chiropractic, P.C. v American Tr. Ins. Co. (2011 NY Slip Op 52017(U))
October 27, 2011
The main issue in this case was whether the defendant's cross motion seeking summary judgment dismissing the claims for dates of service from May 22, 2006 through June 7, 2006 should have been granted. The court considered the sworn independent medical examination (IME) report submitted by the defendant, which determined a lack of medical necessity for the services at issue. The affidavit from the plaintiff's chiropractor failed to meaningfully refer to or rebut the conclusions set forth in the IME report. The court found that the defendant had established that it had timely denied the claims, a finding which the plaintiff did not dispute, and therefore held that the defendant's cross motion seeking summary judgment dismissing the claims for those dates should have been granted. Ultimately, the court reversed the decision and held in favor of the defendant.
Complete Radiology, P.C. v Progressive Ins. Co. (2011 NY Slip Op 52015(U))
October 27, 2011
The relevant facts the court considered in this case were that Complete Radiology, P.C. as assignee of Renee Hamer, was seeking to recover first-party no-fault benefits from Progressive Insurance Company. The main issue decided by the court was whether the services rendered were medically necessary. The holding of the case was that the Civil Court did not err in denying both parties' motions for summary judgment, and that the only issue to be determined at trial was the medical necessity of the services rendered. The court also found that defendant's untimely cross motion was considered due to the plaintiff's failure to demonstrate prejudice, and that the peer review report provided by the defendant appropriately supported the denial of plaintiff's motion for summary judgment. The decision of the Civil Court was affirmed.
Trimed Med. Supply, Inc. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 52014(U))
October 27, 2011
The court considered the appeal from an order denying a defendant's cross-motion for summary judgment dismissing the complaint in an action by a medical supplier to recover assigned first-party no-fault benefits. The defendant had submitted an affirmed peer review report which stated that there was a lack of medical necessity for the supplies at issue. The court found that the defendant's showing that the supplies were not medically necessary was not rebutted by the plaintiff, and that the defendant had timely denied the claim based on a lack of medical necessity. The main issue decided was whether the defendant's cross-motion for summary judgment dismissing the complaint should have been granted, and the court held that it should have been granted, reversing the lower court's decision. Consequently, the defendant's cross-motion for summary judgment dismissing the complaint was granted.
Van Courtland Med. Care, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 52013(U))
October 27, 2011
The court considered the claim by a medical care provider seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company appealed from an order denying the branch of its motion for summary judgment seeking the dismissal of the provider's claim in the amount of $1,546.20. The main issue decided was whether the services provided by the medical care provider were medically necessary, as supported by an affirmed peer review report submitted by the insurance company. The court held that the insurance company's showing that the services were not medically necessary was not rebutted by the medical care provider, and therefore, the branch of the insurance company's motion seeking the dismissal of the claim in the amount of $1,546.20 should have been granted. Therefore, the court reversed the order and granted the insurance company's motion for summary judgment seeking the dismissal of the provider's claim.