No-Fault Case Law

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.

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.