No-Fault Case Law

The main issue in this case was whether Lenox Hill Hospital was entitled to judgment as a matter of law on the ground that Government Employees Insurance Company did not pay or deny the subject claim within 30 days. The court considered the limited nature of the plaintiff's motion for summary judgment, as it only established the plaintiff's prima facie entitlement to judgment on this ground. The defendant's burden in opposition to the motion was to raise a triable issue of fact regarding its timely payment or denial of the claim, which it succeeded in doing by submitting evidence that it sent the plaintiff a denial of claim form within the 30-day time limit. Therefore, the court held that the denial of the plaintiff's motion for summary judgment was proper and affirmed the lower court's order.

In the case of Total Equipment, LLC, as Assignee of Latasha James v Praetorian Insurance Company, the court considered the fact that the defendant had filed a motion for summary judgment and the plaintiff had cross-moved to compel discovery. At the crux of the case was the issue of whether the medical equipment provided to Latasha James was medically necessary, based on a peer review report by Dr. Ronald A. Csillag, D.C. The defendant had timely denied the claim on this ground. The court held that the plaintiff had not had a reasonable opportunity to conduct discovery before the motion was made, and they needed to have the chance to obtain and review the full no-fault file. As a result, the defendant's motion for summary judgment was denied without prejudice, and the plaintiff's cross motion to compel discovery was granted, with the defendant being required to serve answers to the plaintiff's demand for interrogatories and a response to the document demand within 45 days of service of the order.

The court considered the motion for summary judgment by the defendant, who submitted a sworn peer review report showing a lack of medical necessity for the services at issue in an action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should be granted. The court held that the defendant's showing that the services were not medically necessary was not rebutted by the plaintiff, and the Civil Court's implicit finding that the defendant had timely denied the claim based on a lack of medical necessity was not challenged by the plaintiff. Therefore, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered whether a provider could recover assigned first-party no-fault benefits, and whether the defendant insurance company was entitled to summary judgment dismissing the complaint on the grounds of lack of medical necessity. The main issue was whether the defendant established its entitlement to summary judgment, and whether the plaintiff's treating physician's affidavit provided enough evidence to demonstrate a triable issue of fact as to medical necessity. The holding of the case was that the order denying the defendant's motion for summary judgment was affirmed, as the affidavit of the plaintiff's treating physician was determined to be sufficient to show that there was a triable issue of fact as to medical necessity. Therefore, the defendant's motion for summary judgment dismissing the complaint was denied.

The court considered the fact that Excellassist Medical, P.C. was appealing an order from the Civil Court of the City of New York, Kings County, which had granted Clarendon National Ins. Co.'s motion for summary judgment dismissing the complaint. The main issue decided was whether defendant's peer review report was sufficient to establish defendant's entitlement to summary judgment on the ground of lack of medical necessity, with the plaintiff arguing that it was not. The court held that the peer review report was indeed sufficient to establish the defendant's entitlement to summary judgment and affirmed the order, without costs.

The main issue in this case was whether the plaintiff, Raz Acupuncture, P.C., had established its prima facie case for all purposes in the action to recover assigned first-party no-fault benefits. The court considered the fact that the affidavit supporting the plaintiff's motion for summary judgment did not demonstrate personal knowledge of the plaintiff's business practices and procedures. The court held that the branch of the plaintiff's motion seeking an order finding, for all purposes in the action, that plaintiff had established its prima facie case should have been denied. The decision was reversed, and the branch of the plaintiff's motion seeking a finding, pursuant to CPLR 3212 (g), that plaintiff had established its prima facie case for all purposes in the action was denied.

The court in this case considered a motion for summary judgment in a dispute over first-party no-fault benefits, involving eight claim forms for services provided to the plaintiff's assignor. The provider, the appellant, sought to establish its entitlement to summary judgment by proving that the defendant had failed to pay or deny the claim within the required 30-day period, or that the defendant had issued a timely denial of claim that was conclusory, vague, or without merit. The affidavit submitted by the plaintiff's billing clerk was deemed sufficient to establish that certain claims were admissible and had been mailed to the defendant, and that the defendant failed to pay or deny them within the required 30-day period. The court held that the plaintiff established its prima facie entitlement to summary judgment on some of the claims, but not on others. The motion for summary judgment was granted with respect to some claims seeking reimbursement, but denied with respect to others. The court found that the defendant had raised a triable issue of fact with regard to certain claims, and that the plaintiff had failed to demonstrate that the defendant had not paid or denied other claims within the requisite 30-day period. The decision was modified to grant summary judgment upon the claims in certain specified amounts.

The court considered a case brought by Park Slope Medical and Surgical Supply, Inc. as the assignee of Lindoro Castellanus against Praetorian Ins. Co. regarding recovery of assigned first-party no-fault benefits. The main issues decided in the case were whether defendant had timely mailed IME scheduling letters, whether plaintiff's assignor had failed to appear for scheduled IMEs, and whether denial of claim forms had been timely mailed after receiving requested verification. The holding of the case was that the plaintiff's motion for summary judgment was denied, and the defendant's cross motion for summary judgment dismissing the complaint was granted. The judgment in favor of the plaintiff was reversed, and it was determined that the defendant properly denied the claims based on the assignor's failure to satisfy a condition precedent to coverage.

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.

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.