No-Fault Case Law
Viviane Etienne Med. Care, P.C. v Country-Wide Ins. Co. (2011 NY Slip Op 21039)
February 8, 2011
The court considered the fact that a medical care provider was seeking to recover assigned first-party no-fault benefits and had submitted claim forms to the defendant in order to establish its prima facie entitlement to summary judgment. The main issue decided by the court was whether the medical care provider had provided sufficient foundation to establish that the claim forms submitted were admissible under the business records exception to the hearsay rule. The holding of the court was that the medical care provider failed to make the necessary showing that its billing company incorporated its medical records into its own and relied upon them, therefore, its medical records did not meet the test of the business records exception to the hearsay rule. As a result, the claim forms created by the billing company did not fall within the business records exception to the hearsay rule, and plaintiff failed to demonstrate its prima facie entitlement to summary judgment. Therefore, the Civil Court's order was affirmed.
Mount Sinai Hosp. v Country Wide Ins. Co. (2011 NY Slip Op 01008)
February 8, 2011
In this case, the plaintiff, Mount Sinai Hospital, sought to recover no-fault medical payments from the defendant, Country Wide Insurance Company, under an insurance contract. The hospital had previously been awarded a judgment by the Supreme Court, which amounted to $25,327.50. The insurance company then moved to modify the judgment because it claimed that the policy limits were nearly exhausted. However, the court held that the insurer's motion to modify the judgment under CPLR 5019(a) was not the appropriate procedural mechanism as it was trying to change substantive matters rather than just correcting an error. Based on this decision, the insurer's motion to modify the judgment was denied and the original judgment of $25,327.50 stood.
Jamaica Med. Supply, Inc. v Kemper Cas. Ins. Co. (2011 NY Slip Op 50315(U))
January 28, 2011
The relevant facts of the case involved a provider seeking to recover assigned first-party no-fault benefits for supplies allegedly delivered to its assignor. The main issue decided by the court was whether the affidavit submitted by the plaintiff's "sole shareholder, corporate officer and employee" in support of the motion for summary judgment made out a prima facie case. The court held that the billing records submitted by the plaintiff did not assert that the supplies at issue had been delivered to the assignor, and the affidavit did not specify which method of delivery was used in this case. The court concluded that plaintiff's moving papers failed to demonstrate its prima facie entitlement to summary judgment. The order denying plaintiff's motion for summary judgment was affirmed on the ground that the plaintiff failed to make out a prima facie case.
Sung Bok Lee v Metropolitan Prop. & Cas. Ins. Co. (2011 NY Slip Op 50110(U))
January 26, 2011
The court considered the fact that defendant reimbursed the plaintiff for services rendered by a licensed acupuncturist to the plaintiff's assignor. Defendant used the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount that plaintiff was entitled to receive for the services rendered. The main issue decided was whether it was proper for the defendant to use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount owed to the plaintiff. The court held that it was proper for the defendant to use this fee schedule, and as a result, granted the defendant's motion for summary judgment and dismissed the complaint. The judgment was affirmed without costs.
B.Y., M.D., P.C. v Progressive N. Ins. Co. (2011 NY Slip Op 50081(U))
January 18, 2011
The court considered the issue of whether a demand for a trial de novo could be made by a party who participated in mandatory arbitration, but whose evidence was ruled inadmissible by the arbitrator. The main issue decided was whether the defendant was in default for the purposes of making a demand for a trial de novo. The court held that a party's failure to appear for an arbitration hearing constitutes a default, as does an appearance by counsel who refuses to participate in the hearing. However, where a party's attorney appears at the arbitration, participates in the hearing, and submits evidence that would have tended to rebut the plaintiff's case if admissible, there is no default within the contemplation of the Rules of the Chief Judge. Therefore, the District Court properly denied the plaintiff's motion to strike the defendant's demand for a trial de novo.
B.Y., M.D., P.C. v Progressive Direct Ins. Co. (2011 NY Slip Op 50080(U))
January 18, 2011
The relevant facts in this case involved an action by medical providers to recover first-party no-fault benefits, with the parties participating in mandatory arbitration. The arbitration resulted in a ruling in the plaintiffs' favor, but the defendant then served and filed a demand for a trial de novo. The plaintiffs argued that the defendant's limited participation in the arbitration amounted to a default, barring them from demanding a trial de novo, but the District Court denied the motion. The main issue was whether the defendant's limited participation in the arbitration constituted a default. The holding of the case was that where a party's attorney appears at the arbitration, participates in the hearing, and submits evidence that, if admissible, would have tended to rebut the plaintiff's case, there is no default within the contemplation of the rules, and therefore the District Court properly denied the motion to strike the demand for a trial de novo.
Richard Morgan DO, P.C. v Progressive Northeastern Ins. Co. (2011 NY Slip Op 50079(U))
January 18, 2011
The court considered the circumstances of a dispute between a healthcare provider and an insurance company over the payment of no-fault benefits. The provider had filed a motion to strike the insurance company's demand for a trial de novo after the insurer had participated in mandatory arbitration, but the motion was denied by the District Court. The main issue decided was whether the insurance company's limited participation in the arbitration constituted a default, barring them from demanding a trial de novo. The holding of the court was that the insurance company had not defaulted, as their attorney had appeared at the arbitration, participated in the hearing, and submitted evidence, which, if admissible, would have tended to rebut the provider's case. Therefore, the District Court had properly denied the provider's motion to strike the insurance company's demand for a trial de novo.
Westchester Med. Ctr. v Allstate Ins. Co. (2011 NY Slip Op 00377)
January 18, 2011
The Supreme Court, Nassau County ruled in favor of the plaintiff and against the defendant in the medical payment case. The defendant failed to appear or answer the complaint, resulting in a judgment against them. The defendant appealed and argued that they had a reasonable excuse for their delay and that they had a potentially meritorious defense to the action. The Supreme Court denied the defendant's motion to vacate the judgment and compel the acceptance of their answer. The Appellate Division reversed the decision, holding that the defendant had a reasonable excuse for their brief delay and demonstrated a potentially meritorious defense to the action. Therefore, the defendant's motion was granted, and the judgment was vacated.
Natural Acupuncture Health, P.C. v Praetorian Ins. Co. (2011 NY Slip Op 50040(U))
January 14, 2011
The main issue decided in this case was whether defendant was entitled to summary judgment dismissing the claims of plaintiff Spring Medical, P.C. for assigned first-party no-fault benefits. The court held that defendant made a prima facie showing of entitlement to judgment as a matter of law dismissing Spring Medical, P.C.'s claims, as the fees charged by Spring for the medical services exceeded the relevant rates set forth in the fee schedule. Defendant's motion for summary judgment dismissing the claim of plaintiff Right Aid Diagnostic Medicine, P.C. based on lack of medical necessity was properly denied, as defendant did not demonstrate as a matter of law that it timely denied the claim within the statutory 30-day period or that the 30-day period was tolled by a proper verification request. Therefore, the court modified the order to grant defendant summary judgment dismissing the claims of plaintiff Spring Medical, P.C., and affirmed the order as modified.
Westchester Med. Ctr. v GMAC Ins. Co. Online, Inc. (2011 NY Slip Op 00217)
January 11, 2011
The Supreme Court granted a New York hospital's motion for summary judgment, ordering GMAC Ins. Co. to pay no-fault benefits at the request of plaintiff, New York and Presbyterian Hospital. The hospital had demonstrated that billing documents were sent and received by GMAC, and payment was overdue. GMAC was unable to raise a triable issue of fact showing timely denial of the claim, as they could not show copy of the bill received on the date claimed. Moreover, GMAC was precluded from asserting a residency misrepresentation defense as a result of untimely claim denial. GMAC was also not able to argue that North Carolina law applied to the case, as they had not raised this argument in court. Therefore, the order was affirmed, and GMAC was held liable to pay the benefits requested.