No-Fault Case Law
St. Vincent Med. Care, P.C. v Country Wide Ins. Co. (2011 NY Slip Op 00214)
January 11, 2011
The case involved an action to recover first party no-fault medical payments under an insurance contract. The defendant appealed from an order which had modified a judgment in favor of the plaintiff and against the defendant. The issue was whether the defendant insurer's submission of follow-up verification requests to the plaintiff medical provider 30 days after its initial verification requests was premature. The court decided that the follow-up requests were not premature and did not fully comply with the defendant's verification requests, thus the 30-day period within which the defendant was required to pay or deny the claim did not commence to run. As a result, the action was commenced prematurely. The court held that the plaintiff's motion for summary judgment should have been denied and the defendant's cross motion for summary judgment dismissing the complaint should have been granted, without prejudice to the commencement of a new action.
Delta Diagnostic Radiology, P.C. v Country Wide Ins. Co. (2011 NY Slip Op 00174)
January 11, 2011
The court considered the defendant's appeal from an order of the Appellate Term, Second, Eleventh, and Thirteenth Judicial Districts, which affirmed a lower order denying the defendant's motion for summary judgment. The main issue in the case was whether the defendant insurer's submission of follow-up verification requests to the plaintiff medical provider on the 30th day after the initial verification requests was premature or "without effect." The court held that under the circumstances of the case, the defendant insurer's submission of follow-up verification requests was not premature or "without effect" and therefore the defendant's motion for summary judgment dismissing the complaint should have been granted. The court reversed the lower orders and granted the defendant's motion for summary judgment without prejudice to the commencement of a new action by the plaintiff.
Sound Shore Med. Ctr. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 50033(U))
January 10, 2011
The relevant facts that the court considered were around a medical center seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company had requested verification documents from the medical center, which they failed to provide. The main issues decided were whether the insurance company had sent the verification requests in a timely manner and whether the medical center had failed to respond to them. The holding of the court was that the insurance company's initial and follow-up verification requests were found to be timely, and the medical center had failed to respond to them, thus the insurance company's motion for summary judgment was granted, and the medical center's cross motion for summary judgment was denied.
62-41 Woodhaven Med., P.C. v Adirondack Ins. Exch. (2011 NY Slip Op 50026(U))
January 10, 2011
The main issue in this case was whether the plaintiff, 62-41 Woodhaven Medical, P.C., should be compelled to produce copies of its corporate tax returns and tax records regarding its professional employees. The defendant had argued that the plaintiff was ineligible to recover no-fault benefits because it failed to meet applicable state and local licensing requirements. The court found that the defendant's cross motion papers were sufficient to establish that special circumstances exist which warrant the disclosure of the plaintiff's corporate tax returns and its professional employees' tax records. As a result, the court affirmed the order, without costs, granting the branch of defendant's cross motion seeking to compel plaintiff to produce these documents. The complaint would be dismissed in the event plaintiff failed to produce these documents.
Lincoln Gen. Ins. Co. v Alev Med. Supply, Inc. (2011 NY Slip Op 21012)
January 10, 2011
The facts of the case involve a plaintiff insurer who commenced a lawsuit against the defendant, a provider of medical equipment, seeking to recover $2,846.18 in no-fault benefits. The defendant had been paid as an assignee of a patient for whom the benefits had been paid. The plaintiff determined through investigation that the patient was never supplied with the equipment for which the defendant had billed and been reimbursed. The plaintiff moved for leave to enter a default judgment after the defendant failed to appear or answer the complaint. The main legal issue was whether the insurer was precluded from seeking to recover the amounts paid on the claim based on a theory of unjust enrichment since the insurer had paid the no-fault benefits within the 30-day claim determination period. The holding of the case was that the plaintiff was not barred from bringing the action to recover the amount it paid to the defendant because the defendant had secured the payment through fraudulent means. Thus, the District Court should have granted the plaintiff's motion for leave to enter a default judgment.
Allstate Social Work & Psychological Servs., PLLC v Utica Mut. Ins. Co. (2011 NY Slip Op 21010)
January 10, 2011
The court considered whether the assignors of the plaintiff failed to attend independent medical examinations (IMEs) for psychological services rendered to them. The main issue was whether the insurance policy's mandatory personal injury protection endorsement required that IMEs of eligible injured persons be conducted only by physicians to the exclusion of other health care providers, even when the health services were provided by nonphysicians. The court decided that the requirement for an EIP to submit to medical examinations should not be strictly limited to examinations by physicians and could properly have been conducted by the psychologist retained by the defendant. Therefore, the Civil Court's order granting the defendant's motion for summary judgment dismissing the complaint was affirmed.
Bedford Med. Care, P.C. v Encompass Ins. Co. (2011 NY Slip Op 21023)
January 3, 2011
Facts: The case arises from an incident wherein plaintiff's assignor allegedly sustained personal injuries and received treatment from plaintiff health services provider. Before this lawsuit was commenced, defendants initiated and won a default judgment in a declaratory judgment action in Kings County Supreme Court. This judgment declared that the defendant had no coverage requirement for any lawsuit claiming no-fault benefits related to the incident.
Issues: The main issue is whether the declaratory judgment order, issued on a default, applies as collateral estoppel in other actions seeking to litigate the same issue.
Decision: The court held that the doctrine of collateral estoppel does not apply if there has been a default judgment in the previous action. They argued for a case-specific evaluation rather than a rigid rule approach to determine whether the issue had been "actually litigated." This conclusion prevented the defendant from using the declaratory judgment order as a basis for dismissal of this lawsuit.
Enko Enters. Intl., Inc. v Clarendon Natl. Ins. Co. (2010 NY Slip Op52267(U))
December 30, 2010
The main issue of the case was whether the defendant-insurer was entitled to summary judgment dismissing the complaint, which asserted claims to recover assigned first-party no-fault benefits. The court considered the affirmed peer review report of a physician, which demonstrated that the medical supplies provided to the assignor were not medically necessary, as the assignor was already receiving physical and chiropractic therapy for his injuries, which the physician concluded was sufficient. The court held that the defendant made a prima facie showing of entitlement to judgment as a matter of law, and that the plaintiff failed to submit any evidence regarding the medical necessity of the supplies, therefore failing to raise a triable issue. As a result, the court reversed the order, granting the defendant's motion for summary judgment and dismissing the complaint.
Lenox Hill Radiology, P.C. v Tri-State Consumer Ins. Co. (2010 NY Slip Op 20530)
December 30, 2010
The relevant facts of the case is that Lenox Hill Radiology, P.C. sought to recover payment for first-party no-fault benefits for four MRIs it performed, and the insurance company, Tri-State Consumer Insurance Company, argued the claims were premature because the radiology center failed to respond to a request for verification. At trial, the insurance company presented the testimony of an experienced claims examiner, Jennifer Piccolo, who testified to the company's mailing procedures. The court reversed the original judgment in favor of the radiology center, agreeing with the insurance company's argument that the claims were premature and dismissing the case. However, a dissenting opinion was raised, arguing that the burden was on the insurer to establish proper and timely mailing of verification requests, and the testimony presented did not thoroughly establish this. The dissent argued that a change is needed in no-fault litigation to ensure more substantive, timely results.
Bath Med. Supply, Inc. v GEICO Ins. Co. (2010 NY Slip Op 52316(U))
December 23, 2010
The main issue in this case was the medical necessity of medical supplies being claimed under first-party no-fault benefits. The court considered the peer review reports submitted by the defendant, which stated that there was a lack of medical necessity for the supplies in question. The plaintiff, as the assignee of the patient, failed to demonstrate that it needed certain documents to raise a triable issue of fact regarding medical necessity. Additionally, the plaintiff failed to rebut the defendant's showing that there was a lack of medical necessity for the supplies. Due to this, the court held that the defendant was entitled to summary judgment dismissing the complaint.