No-Fault Case Law

The main issue in this case was whether the medical services at issue were medically necessary, and this issue was decided in the negative. The court considered evidence submitted by the defendant, including denial of claim forms and affirmed peer review reports, which established a lack of medical necessity for the services. Plaintiff failed to submit written opposition to the cross motion for summary judgment, and therefore, failed to rebut defendant's showing of lack of medical necessity. As a result, the court reversed the order and granted defendant's cross motion for summary judgment dismissing the complaint. This decision was made by the Appellate Term, Second Department on December 10, 2010.

The court considered the denial of a claim for medical supplies on the basis of lack of medical necessity, which was timely mailed in accordance with the defendant's standard office practices and procedures. The defendant submitted an affirmed peer review report with a factual basis and medical rationale for the doctor's opinion that there was a lack of medical necessity for the supplies at issue. Plaintiff did not oppose the cross motion, and therefore failed to raise a triable issue of fact as to whether the supplies were medically necessary. The main issue decided was whether the denial of the claim for medical supplies was based on a lack of medical necessity, and whether the plaintiff had raised a triable issue of fact on that issue. The holding was that the defendant's cross motion for summary judgment dismissing the complaint was granted, reversing the prior decision.

The relevant facts that the court considered were that the plaintiff sought to recover assigned first-party no-fault benefits and moved for summary judgment. The defendant opposed the motion, arguing that the plaintiff failed to establish prima facie entitlement to judgment as a matter of law. The main issue decided was whether the plaintiff made a prima facie showing of entitlement to summary judgment. The court determined that the plaintiff failed to do so and reversed the judgment, vacated the previous orders, and remitted the matter to the Civil Court for all further proceedings on the complaint. The holding of the court was that the plaintiff's motion for summary judgment should have been denied, and that defendant's motion and plaintiff's cross motion regarding the proper method of calculating attorney's fees and statutory interest should have been denied as academic.

The court considered a dispute between a medical provider and an insurance company regarding first-party no-fault benefits. The provider claimed that the insurance company failed to pay claims, while the insurance company argued that the fees charged were in excess of the workers' compensation fee schedule and that the treatments were not medically necessary. The main issues decided were whether the documents submitted by the provider were admissible, whether the insurance company's denials of claim forms were timely mailed, and whether the fees charged and treatments provided were in accordance with the workers' compensation fee schedule and medically necessary. The holding of the case was that the insurance company failed to specify the reimbursement rates that formed the basis for its determination of excess billing, and that the provider failed to rebut the conclusions set forth in the independent medical examination report regarding the medical necessity of the treatments. Therefore, the insurance company's cross motion for summary judgment dismissing the claims was granted, while certain branches of the provider's motion for summary judgment were vacated and denied.

The main issues in this case were whether personal jurisdiction was properly obtained over the defendant, a Florida insurance company, in an action to recover assigned first-party no-fault benefits, and whether the defendant's motion to dismiss pursuant to CPLR 3211 (a) (8) was improperly made after defendant had served its answer. The court considered that the plaintiff had the burden of proving that jurisdiction had been properly obtained and that the defendant's motion was mislabeled as a motion to dismiss pursuant to CPLR 3211 instead of CPLR 3212. The holding of the court was that the plaintiff failed to establish jurisdiction over the defendant and that the defendant's motion to dismiss was improperly made after serving its answer, but that the defect should be disregarded if it caused the plaintiff no prejudice. The court also held that the Civil Court did not improvidently exercise its discretion in refusing to allow the plaintiff to submit a late notice of claim to Motor Vehicle Accident Indemnification Corporation (MVAIC) because MVAIC is not a party to the instant action and the Civil Court has no jurisdiction over it. Therefore, the order was affirmed without costs.

The main issues in this case included whether the court had personal jurisdiction over the defendant, United Automobile Ins. Co. who was a Florida insurance company accused of failing to pay first-party no-fault benefits in the State of New York. The plaintiff, Viviane Etienne Medical Care, P.C., attempted to prove personal jurisdiction by serving the summons and complaint to the Chief Financial Officer of the State of Florida pursuant to the long-arm statute. However, the defendant denied conducting any business in the State of New York and moved to dismiss the complaint based on lack of personal jurisdiction. The plaintiff failed to establish that proper jurisdiction existed, and the court found no merit to the plaintiff's contention regarding the defendant's motion to dismiss. The court affirmed the order without costs and upheld the decision to dismiss the complaint due to lack of personal jurisdiction over the defendant. In summary, the court considered the lack of personal jurisdiction over the defendant and the plaintiff's failure to prove that jurisdiction had been properly obtained. The main issue decided was whether the court had jurisdiction over a Florida insurance company being accused of failing to pay first-party no-fault benefits in the State of New York. The holding of the case was that the court did not have personal jurisdiction over the defendant, and the order to dismiss the complaint was affirmed without costs.

The relevant facts considered by the court were that the defendant was a Florida insurance company and the plaintiff was seeking to recover first-party no-fault benefits from the defendant. The main issue decided was whether the court had personal jurisdiction to hear the case. The holding of the court was that the defendant's motion to dismiss based on lack of personal jurisdiction had merit, and the burden was on the plaintiff to prove jurisdiction had been properly obtained. The court found that the plaintiff failed to show a basis for jurisdiction and did not establish essential facts justifying opposition to the motion, and therefore, affirmed the order dismissing the complaint without costs. Additionally, the court ruled that the defendant's motion to dismiss, which was misunderstood as a motion for summary judgment, did not cause the plaintiff any prejudice and was properly overlooked by the Civil Court. Finally, the Civil Court's decision to refuse to allow plaintiff to submit a late notice of claim to MVAIC was not considered an abuse of discretion.

The court considered whether defendant's submissions in support of its cross motion for summary judgment dismissing the complaint presented an issue of fact as to the applicability of the Workers' Compensation Law to the subject loss, which defendant alleged occurred during the course of the assignor's employment. The main issue decided was whether the determination as to the applicability of the Workers' Compensation Law should be made by the Workers' Compensation Board, given its expertise in the area. The holding of the court was that the resolution of the factual question presented on the record was best suited for determination by the Workers' Compensation Board, and the parties' respective summary judgment motions should have been held in abeyance pending a determination by the Workers' Compensation Board as to the applicability of the Workers' Compensation Law to plaintiffs' claim. Additionally, the court noted that defendant established that its denials were timely mailed within the prescribed 30-day period.

The court considered two cases for recovery of unpaid no-fault medical bills. The defendant, GEICO General Insurance Company, denied reimbursement for medical services rendered to the assignors of A-Quality Medical Supply, based on a lack of medical necessity. Defendant's denials were based on peer reviews, but the court was presented with issues regarding the admissibility of defendant's documents. The main issue decided was the admissibility of peer reviews as evidence in medical necessity defenses. The holding of the case was that defendant did not establish its prima facie case and judgment was entered in favor of plaintiff, as the peer reviews not admitted into evidence did not constitute admissible evidence and could not be used to support a lack of medical necessity defense.

The court considered the plaintiff's motion for summary judgment on a cause of action to recover no-fault medical payments from the defendant under an insurance contract. The main issue was whether the defendant should be allowed to modify the amount of the judgment because it exceeded the limits of the policy covering the plaintiff, based on payments made to other health care providers. The court held that the defendant was not collaterally estopped from seeking to modify the amount of the judgment, because the only issues decided on the motion for summary judgment were whether the defendant had failed to pay or deny the claim within the statutory time frame, and whether the defendant had received verification of the claim. The court affirmed the order, but did not pass upon the propriety of the procedural mechanism utilized by the defendant, to which the plaintiff did not object.