No-Fault Case Law

The court considered the evidence submitted in the case, including affidavits from the president of Media Referral, Inc., the doctor and chiropractor scheduled to perform independent medical examinations (IMEs), and a no-fault claims examiner. The main issue decided was whether the defendant insurance company properly denied the plaintiff's claim for first-party no-fault benefits based on the assignor's failure to appear for scheduled IMEs. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint should have been granted, as the evidence demonstrated that the IME requests had been timely mailed, the assignor had failed to appear for the scheduled IMEs, and the claim denial form had been timely mailed based on the assignor's nonappearance at the IMEs. Therefore, the defendant was not precluded from raising the issue of the assignor's failure to satisfy a condition precedent to coverage, and the denial of the claim was proper.

The relevant facts considered by the court were that the plaintiff, Parkway Imaging & Diagnostic, P.C., was seeking to recover first-party no-fault benefits from the defendant, Clarendon National Insurance Co., as an assignment of benefits from Miguel Zayas. The defendant had denied the claim based on Zayas' failure to appear for scheduled independent medical examinations (IMEs). The main issues decided in this case were whether the defendant had provided sufficient proof of Zayas' nonappearance at the IMEs, and whether the defendant had timely denied the claim based on this nonappearance. The holding of the court was that the defendant had presented sufficient evidence, including the affirmation of the independent medical examination (IME) doctor and the submission of timely mailed IME requests and claim denial forms, to demonstrate Zayas' failure to satisfy a condition precedent to coverage. Therefore, the court reversed the judgment in favor of the plaintiff, vacated the order, and granted the defendant's motion for summary judgment dismissing the complaint.

The relevant facts of the case are that PMR Physical Therapy, as the assignee of Kelly Ortega, appealed to recover first-party no-fault benefits from GEICO General Insurance Company. The main issue decided by the court was whether PMR's motion for summary judgment was correctly denied. The court held that PMR's motion was properly denied, as it failed to make a prima facie showing of its entitlement to summary judgment. The court found that the affidavit submitted in support of PMR's motion did not demonstrate personal knowledge of PMR's business practices, and therefore did not constitute admissible evidence. As a result, the court affirmed the order denying PMR's motion for summary judgment.

The court considered the timely mailing and medical rationale of denial of claim forms, as well as affirmed peer review reports to establish a lack of medical necessity for the medical equipment in question. The main issue was whether the denial of claim forms were timely submitted and whether the peer review reports provided a factual basis and medical rationale for the lack of medical necessity. The holding was that the denial of claim forms were timely submitted and the peer review reports provided the necessary rationale for the lack of medical necessity, shifting the burden to the plaintiff to rebut the defendant's showing, which the plaintiff failed to do. Therefore, the defendant's cross motion for summary judgment was properly granted and the complaint was dismissed.

The court considered a petition to vacate an award of a master arbitrator, which upheld the award of an arbitrator denying the claim for assigned first-party no-fault benefits. The main issue was whether the determination of the master arbitrator had a rational basis and was not arbitrary, capricious, or contrary to settled law. The holding of the court was that the determination of the master arbitrator had a rational basis and was not arbitrary, capricious, or contrary to settled law, so the Civil Court properly denied the petition to vacate the master arbitrator's award. Additionally, the court noted that upon denying the petition, the court was required to confirm the award, and that a special proceeding should terminate in a judgment, not an order.

Facts: In this no-fault insurance case, Fine Healing Acupuncture, P.C., as Assignee of John Miller, appealed a judgment based on a Civil Court ruling that granted Country-Wide Insurance Company's cross motion for summary judgment. Country-Wide Insurance Company had denied reimbursement for the acupuncture services plaintiff sought based on an independent medical examination by its neurologist, who found a lack of medical necessity for further treatment. The provider moved for summary judgment and the insurance company filed a cross motion for summary judgment claiming they had timely denied the services. Issues: The main issue was whether defendant's neurologist, who conducted an independent medical examination, was competent to give an opinion on the medical necessity of the acupuncture services. Additionally, the court had to consider if the Insurance Department's opinion letter stating there is no requirement that a claim denial be based upon a medical examination conducted by a health provider of the same specialty area as the treating provider was relevant. Holding: The judgment was reversed, the order granting defendant's cross motion for summary judgment dismissing the complaint was vacated, and defendant's cross motion for summary judgment was denied. The court found that the plaintiff's affidavit was sufficient to raise a triable issue of fact as to whether the acupuncture services rendered were medically necessary, and that there was a factual basis and medical rationale for the doctor's determination that there was a lack of medical necessity for the services.

The court considered the fact that the plaintiff, a medical service provider, was seeking to recover no-fault benefits from the defendant, an insurance company, but had failed to appear for an examination under oath (EUO) as required by the defendant. The main issue decided was whether the defendant's EUO scheduling letters were sufficient and whether the plaintiff's failure to appear at the EUOs was a valid reason for the defendant to deny the claim. The court held that the defendant's EUO scheduling letters and the denial of claim form were timely mailed, and the plaintiff's failure to appear at the scheduled EUOs was a valid reason for the defendant to deny the claim. Therefore, the order granting the plaintiff's motion for summary judgment was reversed, and the defendant's cross motion for summary judgment dismissing the complaint was granted.

The main issues in this case were whether defendant had properly reimbursed plaintiff for acupuncture services by using the workers' compensation fee schedule applicable to chiropractors and whether defendant's denial of claim forms had been timely mailed in accordance with its standard office practices and procedures. The court found that the workers' compensation fee schedule is authentic and reliable and may be given judicial notice and that defendant had fully paid plaintiff for the services billed under specific codes. Therefore, the defendant’s cross motion for summary judgment dismissing the complaint as to these claims was granted. However, defendant did not proffer any evidence or argument to warrant the dismissal of plaintiff's $160.56 claim for the initial acupuncture visit, so the branch of plaintiff's motion seeking summary judgment as to this claim was granted. Therefore, the court modified the order by granting plaintiff's motion for summary judgment only to the extent of awarding plaintiff summary judgment in the sum of $160.56 for the initial acupuncture visit on October 6, 2005 and by granting defendant's cross motion for summary judgment dismissing the remaining claims.

The case involved a dispute between Points of Health Acupuncture, P.C. and GEICO Insurance Company regarding reimbursement for acupuncture services provided. GEICO had reimbursed Points of Health based on the workers' compensation fee schedule applicable to chiropractors, and also denied reimbursement for services rendered on the grounds of lack of medical necessity. Points of Health moved for summary judgment, which was granted in part by the Civil Court, and GEICO's cross-motion for summary judgment was denied. On appeal, the court found that GEICO had fully paid for some of the services in accordance with the fee schedule and had issued partial denials on that ground, so the denial of summary judgment for those claims was affirmed. However, the court also found that GEICO failed to demonstrate why they changed the fee schedule treatment code for other services, and therefore those claims were properly denied. Additionally, the court found in favor of GEICO on the claims denied based on lack of medical necessity, as there was no evidence submitted to establish the medical necessity of those services. As a result, the court modified the lower court's order and dismissed some of the claims while denying others.

The court considered a lawsuit by Z.A. Acupuncture, P.C. seeking to recover assigned first-party no-fault benefits. The defendant, GEICO Insurance Company, cross-moved for summary judgment dismissing the complaint, alleging that it had properly reimbursed the plaintiff for acupuncture services rendered between November 17, 2005 and January 19, 2006. The plaintiff admitted in its motion for summary judgment that the defendant had issued timely partial payments and denial of claim forms. The relevant workers' compensation fee schedule was found to be of sufficient authenticity and reliability and demonstrated that the defendant had fully paid the plaintiff for the services rendered between November 17, 2005 and January 19, 2006. The defendant's submissions also demonstrated that the services billed under former fee schedule treatment code 97780 were properly re-coded accordingly. Additionally, the services rendered between January 23, 2006 and March 9, 2006, were denied on the ground of lack of medical necessity. The defendant successfully established a lack of medical necessity for these services. Therefore, the court reversed the order, denied the plaintiff's motion for summary judgment as to claims for services rendered between November 17, 2005 and January 19, 2006, and granted the defendant's cross motion for summary judgment dismissing the complaint.