No-Fault Case Law
EMC Health Prods., Inc. v Geico Ins. Co. (2014 NY Slip Op 50786(U))
April 30, 2014
The insurer's denials admitted receipt of the bills, and the provider did not need a CPLR 4518 foundation for them. After denying the provider summary judgment, the Civil Court made CPLR 3212 (g) findings in its favor and limited trial to medical necessity. The insurer failed to establish a basis to strike those findings. Following Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co., a business-records foundation was unnecessary. The order's direction for trial also showed that it did not conclusively establish that the denials were untimely, conclusory, vague, or legally meritless. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, preserving the provider's favorable findings.
Mount Sinai Hosp. of Queens v Country Wide Ins. Co. (2014 NY Slip Op 50780(U))
April 30, 2014
The provider's claim was submitted more than 45 days after the services, and the provider offered no justification for the delay. The insurer's litigation supervisor's affidavit established both the late submission under 11 NYCRR 65-1.1 and timely mailing of the denial. The denial adequately identified its basis and advised that reasonable justification could excuse the lateness under 11 NYCRR 65-3.3 (e). The provider supplied no reason for the delay. The Appellate Term, Second Department, affirmed the order granting the insurer's cross motion for summary judgment dismissing the complaint and implicitly denying the provider's motion for summary judgment.
New Way Med. Supply Corp. v Geico Ins. Co. (2014 NY Slip Op 50776(U))
April 30, 2014
The insurer's summary judgment cross motion on medical necessity was denied, and the provider's CPLR 3212 (g) findings were upheld. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, finding a triable medical-necessity issue. It preserved the findings for the reasons stated in EMC Health Prods., Inc. v Geico Ins. Co., companion appeal No. 2012-1208 K C, decided the same day.
High Quality Med. Supplies, Inc. v Praetorian Ins. Co. (2014 NY Slip Op 50775(U))
April 30, 2014
The insurer's summary judgment cross motion on medical necessity was denied, and the provider's CPLR 3212 (g) findings were upheld. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, finding a triable issue concerning the supplies' medical necessity. It cited EMC Health Prods. v Geico Ins. Co., companion appeal No. 2012-1208 K C, decided the same day, in preserving the findings.
J.C. Healing Touch Rehab, P.C. v Eveready Ins. Co. (2014 NY Slip Op 50774(U))
April 30, 2014
The insurer's summary judgment cross motion was denied because requested verification presented a triable issue. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, finding a factual issue whether verification remained outstanding. It upheld the provider's CPLR 3212 (g) findings for the reasons stated in EMC Health Prods., Inc. v Geico Ins. Co., companion appeal No. 2012-1208 K C, decided the same day.
Promed Durable Equip., Inc. v Geico Ins. (2014 NY Slip Op 50773(U))
April 30, 2014
The provider failed to rebut peer review findings that the EMS items, back massager, and heating pad were superfluous. The reviewers relied on the assignor's receipt of physical therapy and chiropractic and acupuncture treatment. The provider's doctor's affirmation raised factual issues for the other supplies but did not meaningfully address those findings. The Appellate Term, Second Department, modified the order, insofar as appealed from, to grant the insurer summary judgment dismissing claims for the E.M.S., EMS Accessories, EMS Supply, back massager, and heating pad; it affirmed denial for the remaining supplies. It preserved the provider's CPLR 3212 (g) findings, citing EMC Health Prods. v Geico Ins. Co., companion appeal No. 2012-1208 K C, decided the same day.
Promed Durable Equip., Inc. v Geico Ins. (2014 NY Slip Op 50772(U))
April 30, 2014
The provider failed to rebut a peer review finding that an existing physical therapy plan rendered the disputed supplies unnecessary. The insurer's report supplied a factual basis and medical rationale, while the provider's doctor's affirmation did not meaningfully address that determination. The provider did not challenge the finding that the insurer was otherwise entitled to judgment. The Appellate Term, Second Department, modified the order, insofar as appealed from, to grant the insurer summary judgment on those supplies; denial remained for the other supplies, whose medical necessity presented a factual issue. The provider's CPLR 3212 (g) findings remained intact, citing EMC Health Prods. v Geico Ins. Co., companion appeal No. 2012-1208 K C, decided the same day.
Promed Durable Equip., Inc. v Geico Ins. (2014 NY Slip Op 50771(U))
April 30, 2014
The insurer's summary judgment cross motion on medical necessity was denied, and the provider's CPLR 3212 (g) findings were upheld. The Appellate Term, Second Department, affirmed the order, insofar as appealed from, finding a triable medical-necessity issue. It preserved the findings for the reasons stated in EMC Health Prods., Inc. v Geico Ins. Co., companion appeal No. 2012-1208 K C, decided the same day.
Imperium Ins. Co. v Innovative Chiropractic Servs., P.C. (2014 NY Slip Op 50697(U))
April 30, 2014
An insurer may obtain plenary judicial adjudication of a no-fault dispute only if the master arbitrator's award is at least $5,000. The insurer sought declaratory relief and trial de novo concerning five awards favoring providers, then moved for default judgments. Under Insurance Law § 5106 (b) and Matter of Greenberg, none qualified for plenary review because each award fell below the threshold; review was limited to CPLR article 75 grounds. Although the Civil Court had jurisdiction under CCA 212-a, the complaints stated no viable cause of action. The Appellate Term, First Department, affirmed denial of the default-judgment motion and sustained dismissal of the consolidated actions.
IDS Prop. Cas. Ins. Co. v Stracar Med. Servs., P.C. (2014 NY Slip Op 02902)
April 30, 2014
The providers' unexcused EUO nonappearances breached a condition precedent to coverage and warranted summary judgment for the insurer. On renewal, the insurer proved two duly demanded EUOs, two failures to appear, and timely denials. The providers offered no reasonable excuse or evidence of partial performance and raised no factual issue concerning the demands' reasonableness or propriety. Their willingness to cooperate, expressed more than two years after the loss and only in response to the summary judgment motion, did not cure the breach. The Appellate Division, Second Department, reversed the order, insofar as appealed from, granted the insurer summary judgment, and remitted for a declaration of no obligation to pay the subject claims; it did not reach the insurer's remaining contention.