No-Fault Case Law

The main issues in this case were whether the denial of claim forms, which denied the plaintiffs' claims on the grounds of lack of medical necessity and that payment had been made in accordance with the workers' compensation fee schedule, had been timely mailed, and whether the grounds for the denials were conclusory, vague or without merit as a matter of law. The court considered the evidence presented by both parties and found that the denial of claim forms had been timely mailed, and that the plaintiffs failed to show that the grounds for the denials were conclusory, vague or without merit. As a result, the court affirmed the denial of the plaintiffs' motion for summary judgment and denied the defendant's cross-motion for summary judgment dismissing the complaint. Therefore, the holding of the case was that the defendant's denial of claim forms were valid, and the plaintiffs failed to show their entitlement to judgment as a matter of law.

The relevant facts the court considered in this case include a lawsuit by a medical provider to recover first-party no-fault benefits and a motion by the defendant to dismiss the complaint on the grounds that the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs). The defendant's motion was denied by the Civil Court, as they found that the exhibits submitted by the defendant raised triable issues of fact. The court found that the defendant had established its prima facie entitlement to judgment as a matter of law only with respect to certain claims, and therefore, summary judgment was awarded in favor of the defendant for those claims. The main issues decided were whether the defendant had properly submitted evidence to dismiss the complaint and whether the denial of claim forms had been timely mailed in accordance with the standard office practices and procedures. The holding of the case was that the order was modified to grant summary judgment in favor of the defendant for certain claims.

The relevant facts considered by the court in Delta Diagnostic Radiology, P.C. v Autoone Ins. Co. were that the defendant moved for summary judgment dismissing the complaint based on the failure of the plaintiff's assignor to appear for independent medical examinations (IMEs). The plaintiff cross-moved for summary judgment, but both motions were denied by the Civil Court. In support of its motion, the defendant submitted an affidavit of a manager employed by the company retained by defendant to schedule the IMEs. The main issue decided by the court was whether the failure of the plaintiff's assignor to appear for the scheduled IMEs justified the defendant's motion for summary judgment dismissing the complaint. The court held that the appearance of the assignor at an IME is a condition precedent to the insurer's liability on the policy, and since the assignor had failed to appear, the judgment of the Civil Court was affirmed. Therefore, the holding of the case was that the defendant's motion for summary judgment dismissing the complaint was justified, and the judgment of the Civil Court was affirmed.

The relevant facts considered in this case were that the plaintiff, a medical care provider, failed to respond to the defendant's discovery requests within the time ordered by the Civil Court. The main issue decided was whether the plaintiff's failure to comply with the court's order justified the dismissal of their complaint. The holding of the case was that the plaintiff's failure to timely and sufficiently comply with the court's order led to a conditional order of preclusion becoming absolute. As a result, the plaintiff was unable to offer any evidence at trial, and the Civil Court properly granted the defendant's cross motion to dismiss the complaint. The court affirmed the order without costs.

The court considered the issue of whether defendant's denial of claim forms were timely mailed and whether they advised the plaintiff that late submission of proofs of claim would be excused if a reasonable justification was provided. The main issue was whether defendant's motion for summary judgment dismissing the complaint should be granted. The court held that although the denial of claim forms were timely mailed, defendant failed to establish its entitlement to summary judgment as they did not advise the plaintiff that late submission of proofs of claim would be excused if a reasonable justification was provided. Therefore, the court reversed the order and denied defendant's motion for summary judgment dismissing the complaint.

The main issue in this case was whether a prior arbitration proceeding involving a different claimant provider precluded another provider from commencing its own action seeking reimbursement of assigned no-fault benefits, even though the claims may arise from the same accident. The Court held that pursuant to Insurance Law § 5106 (b), each claimant provider may independently exercise the right to elect to submit their respective claims to arbitration. They determined that a prior arbitration proceeding involving a different claimant provider did not preclude another provider from commencing its own action seeking reimbursement of assigned no-fault benefits since there was no showing of privity between the providers. Additionally, the Court found that the defendant did not establish its prima facie entitlement to summary judgment based on its lack of coverage defense. Consequently, defendant's motion should have been denied in its entirety. The order was reversed, defendant's motion to dismiss the complaint was denied, and the complaint was reinstated.

The court considered the request made by Dr. John Kraft, D.C., as assignee of Dana Schepanski, for payment for chiropractic services provided to the assignor. The main issue decided by the court was whether the medical necessity of the chiropractic manipulation under anesthesia performed by Dr. Kraft was appropriate. The court held that manipulation under anesthesia is a procedure within the lawful scope of chiropractic services, provided the anesthesia is administered by a licensed professional and not by the chiropractor. The court also found that Dr. Kraft was authorized to perform manipulation of the bilateral hip areas under anesthesia, as the treatment was for the purpose of nerve interference related to the vertebral column, and thus was within the scope of lawful chiropractic practice as defined in the Education Law. The court further held that the defendant failed to rebut the presumption of medical necessity of these procedures by a fair preponderance of the credible evidence and awarded judgment in favor of Dr. Kraft, D.C, in the amount of $1,594.10, with statutory interest, attorney fees, costs and disbursements.

The main issues in the case were whether the medical supply company adequately responded to the insurance company's verification requests, and whether the insurance company was entitled to summary judgment dismissing the complaint. The court considered the timeliness of the mailings of the insurance company's request and follow-up request for verification and whether the medical supply company provided the information requested. The holding was that the court reversed the lower court's order, denied the medical supply company's motion for summary judgment, and granted the insurance company's cross motion for summary judgment dismissing the complaint. The court found that the medical supply company failed to provide the information requested by the insurance company in response to the verification requests, and therefore, the insurance company's time to pay or deny the claim had not begun to run. As a result, the medical supply company was not entitled to summary judgment in its favor.

The court considered an appeal from a judgment of the Civil Court of the City of New York, Kings County, which awarded the plaintiff, Radiology Today, P.C., the principal sum of $912 in a case to recover assigned first-party no-fault benefits. The main issue was the admissibility of a peer review report and the testimony of the defendant's expert witness in a nonjury trial limited to the issue of the medical necessity of the billed-for services. The court held that the defendant's expert medical witness should have been permitted to testify, and that the judgment was reversed and remitted to the Civil Court for a new trial due to the preclusion of the admission of the peer review report into evidence and the testimony of the defendant's expert witness.

The relevant facts of the case were that a healthcare provider had rendered acupuncture services and sought to recover payments from an insurance company. The insurance company had reimbursed the healthcare provider using the workers' compensation fee schedule applicable to chiropractors who render the same services. The main issue was whether the insurance company had properly reimbursed the healthcare provider for the services rendered. The holding of the case was that the workers' compensation fee schedule was of sufficient authenticity and reliability to be given judicial notice. The insurance company had fully paid the healthcare provider for the services billed under certain codes in accordance with the fee schedule, so the complaint was dismissed for these claims. However, the healthcare provider's claim for the initial acupuncture visit on a specific date was granted, and the insurance company's cross-motion for summary judgment was granted in dismissing the remaining claims.