No-Fault Case Law

The court considered the denial of claim form that was timely mailed by the defendant, which denied the claim on the ground of lack of medical necessity. The defendant submitted a sworn peer review report, which provided a factual basis and medical rationale for the conclusion that there was a lack of medical necessity for the services at issue. As a result, the defendant established its prima facie entitlement to judgment as a matter of law, shifting the burden to the plaintiff to rebut the defendant's showing. The main issue decided was whether the defendant had established that the services were not medically necessary, and whether the plaintiff had rebutted this showing. The court held that the defendant's showing that the services were not medically necessary was unrebutted by the plaintiff, and as a result, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the fact that the plaintiff appealed from an order granting the defendant's unopposed motion for summary judgment dismissing the complaint in an action to recover assigned first-party no-fault benefits. The plaintiff's attempt to submit opposition to the motion was rejected as untimely, so the court only considered the moving papers in making its decision. The main issue decided was whether the judgment entered pursuant to the order should be considered as having been entered on default, and therefore not subject to appeal by the defaulting party. The holding of the case was that the judgment entered on default was not subject to appeal, and therefore the appeal was dismissed.

The main issue in this case was whether the defendant, GEICO General Insurance Co., was entitled to summary judgment dismissing the complaint brought by the plaintiff, AVA Acupuncture, P.C. as Assignee of EGBUNIKE CHINWE and STEPHEN OSAGIEDE, to recover assigned first-party no-fault benefits. The court considered the timely mailing of claim denial forms by the defendant and the use of workers' compensation fee schedule for acupuncture services in determining the amount owed to the plaintiff. The court held that the defendant's motion for summary judgment should have been granted, as it had properly used the fee schedule for the services rendered and had paid the plaintiff the full amount they were entitled to prior to the commencement of the action. The plaintiff's remaining arguments were not considered by the court as they were raised for the first time on appeal. Therefore, the court reversed the order and granted the defendant's motion for summary judgment dismissing the complaint.

The main issues in this case involved a provider's attempt to recover assigned first-party no-fault benefits and the denial of the insurance company's motion for summary judgment. The court considered the failure of the assignor to appear for independent medical examinations (IMEs) and the sufficiency of the evidence provided by the insurance company to establish the nonappearance. The court held that the insurance company's submission of affidavits from the independent medical review service and the chiropractor were sufficient to establish the assignor's failure to appear for the scheduled IMEs. The court ultimately reversed the judgment, vacated the order, denied the plaintiff's motion for summary judgment, and granted the defendant's cross motion for summary judgment dismissing the complaint.

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.