No-Fault Case Law
Allstate Ins. Co. v Belt Parkway Imaging, P.C. (2010 NY Slip Op 08783)
November 30, 2010
The relevant facts the court considered were that Allstate Insurance Company and other parties moved for partial summary judgment, and the defendants, Belt Parkway Imaging, P.C., et al., opposed the motion. The issue at hand was whether a provider of health care services is eligible for reimbursement under section 5102(a) (1) of the Insurance Law if the provider fails to meet any applicable New York State or local licensing requirement. The Court of Appeals held that "insurance carriers may withhold payment for medical services provided by fraudulently incorporated enterprises" (see State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313, 319, 321 [2005]). Mallela was decided on March 29, 2005. The Legislature subsequently enacted Insurance Law § 5109, which became effective on August 2, 2005. The holding of the case was that if the services rendered by the PC defendants were medically unnecessary, then plaintiffs have stated a cause of action for unjust enrichment. The court unanimously affirmed the denial of the motion for partial summary judgment.
St. Vincent’s Hosp. & Med. Ctr. v American Tr. Ins. Co. (2010 NY Slip Op 52063(U))
November 26, 2010
The Court considered a case involving an action to recover assigned first-party no-fault benefits, where the plaintiff moved for summary judgment upon the first and second causes of action, and the defendant cross-moved for summary judgment dismissing those causes of action on the ground of failure to comply with verification requests. The main issue decided was whether the defendant had established the mailing of its initial and follow-up verification requests, and whether the plaintiff had provided the requested verification. The Court held that the defendant's verification requests sought copies of NF-5 forms signed by plaintiff's assignors, but as the plaintiff had already provided the authorizations to release information and the assignments executed by the assignors, the plaintiff had complied with the requests. The Court also held that the defendant had failed to establish the mailing of its initial and follow-up verification requests. Therefore, the order was affirmed without costs.
Dynamic Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 52062(U))
November 26, 2010
The relevant facts of the case involved a medical imaging company seeking to recover first-party no-fault benefits from an insurance company for services rendered to a patient. The insurance company denied the claims on the grounds of lack of medical necessity. The main issue decided by the court was whether the insurance company's denial of the claims on the basis of lack of medical necessity was justified. The court held that the insurance company had provided a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity for the services at issue, shifting the burden to the medical imaging company to rebut the insurance company's showing. As the medical imaging company failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity, the court granted the insurance company's motion for summary judgment dismissing the complaint.
Elmont Open MRI & Diagnostic Radiology, P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 52061(U))
November 26, 2010
In the case, Elmont Open MRI & Diagnostic Radiology, P.C. v Clarendon Natl. Ins. Co., the main issue before the court was whether the peer review report provided by the defendant was sufficient to demonstrate a lack of medical necessity for the services at issue. The defendant had timely denied the plaintiff's claims on the ground of lack of medical necessity, and the District Court initially denied the defendant's motion for summary judgment, stating that the peer review report was insufficient. However, upon appeal, the Appellate Term reversed the decision, holding that the peer review report submitted by the defendant did provide a sufficient factual basis and medical rationale to demonstrate a lack of medical necessity. As a result, the defendant was entitled to summary judgment dismissing the complaint, as the plaintiff failed to submit any medical evidence to raise a triable issue of fact. Therefore, the Appellate Term reversed the lower court's decision and granted the defendant's motion for summary judgment.
Triangle R, Inc. v GEICO Ins. Co. (2010 NY Slip Op 52060(U))
November 26, 2010
The court considered the fact that the defendant's denial of claim form was "timely and proper," and that the sole issue to be determined at trial was the medical necessity of the medical equipment at issue. The main issue decided was whether the medical equipment at issue was medically necessary, and the holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint should have been granted because the defendant's showing that the equipment was not medically necessary was unrebutted by the plaintiff. The court referenced previous cases where similar issues were decided in favor of the insurance company based on lack of medical necessity. Therefore, the court reversed the order of the Civil Court and granted the defendant's cross motion for summary judgment dismissing the complaint.
Pomona Med. Diagnostics, P.C. v GEICO Ins. Co. (2010 NY Slip Op 52059(U))
November 26, 2010
The court considered the motion for summary judgment by the plaintiff to recover first-party no-fault benefits, as well as the defendant's cross motion for summary judgment dismissing the complaint on the grounds of lack of medical necessity for the services rendered. The main issue decided was whether there was a lack of medical necessity for the medical services at issue. The holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint should have been granted, as the defendant had established that it mailed timely and valid denials, and the plaintiff did not dispute this finding on appeal. The court also found that the defendant's showing that the services were not medically necessary was unrebutted by the plaintiff, and therefore the motion was reversed and granted in favor of the defendant.
Triangle R Inc. v Praetorian Ins. Co. (2010 NY Slip Op 52041(U))
November 26, 2010
The court considered whether an insurer is obligated to pay or deny a claim for no-fault benefits until it has received verification of all the relevant information requested. It was determined that the defendant-insurer was not obligated to pay or deny the claim because it had not received a response to its verification requests for medical records. The main issue decided was whether the defendant's issuance of a general, blanket denial of benefits based on the assignor's failure to attend an independent medical examination was effective to deny the specific claim at issue. The court rejected the plaintiff's contention that the general, blanket denial precludes the defendant from asserting noncompliance with its verification requests. The holding of the court was that the summary judgment granting the defendant's motion to dismiss the complaint was reversed, and the defendant's motion for summary judgment was granted.
Pomona Med. Diagnostics, P.C. v Metropolitan Cas. Ins. Co. (2010 NY Slip Op 52039(U))
November 26, 2010
The main issue in this case was whether the defendant, Metropolitan Casualty Ins. Co., could deny all no-fault claims arising from injuries sustained by the plaintiff's assignor, Jarrod Ward, in a May 21, 2008 motor vehicle accident. The court considered the judgment from a separate action in which the Supreme Court, Kings County, declared that the defendant may deny all no-fault claims arising from the injuries sustained by the plaintiff's assignor. Based on this judgment, the underlying actions commenced by the plaintiff's medical diagnostics company to recover first-party no-fault benefits for medical services rendered to Jarrod Ward for injuries sustained in the accident are barred under the doctrine of res judicata. The court ultimately held the defendant's motion for summary judgment dismissing the complaints and granted the judgment accordingly. The court found that the Supreme Court judgment is a conclusive final determination, even though it was entered on the default of the plaintiff, since res judicata applies to a judgment taken by default that has not been vacated.
Delta Diagnostic Radiology, P.C. v Interboro Ins. Co. (2010 NY Slip Op 52022(U))
November 19, 2010
The court considered an appeal from an order deciding a motion for summary judgment in a no-fault benefits case. The main issues decided were whether the provider had established entitlement to summary judgment and whether the insurance company's request for verification of the claim had been timely and responded to. The holding of the case was that the insurance company's request for additional verification had been timely made and not responded to, so the 30-day period within which the company could pay or deny the claim did not commence. However, the court also held that the insurance company had timely denied the claim for lack of medical necessity, as supported by a peer review report that the provider did not rebut. Therefore, the insurance company's motion for summary judgment dismissing the complaint should have been granted.
Radiology Today, P.C. v Mercury Ins. Co. (2010 NY Slip Op 52020(U))
November 19, 2010
The court considered a motion for summary judgment filed by the defendant, which claimed that the medical services provided were not medically necessary, and that the plaintiff's bills were denied on these grounds. The defendant submitted peer review reports as evidence of the lack of medical necessity, which established their prima facie entitlement to summary judgment. The plaintiff failed to raise a triable issue of fact in opposition to the motion, as their submitted doctor's affirmation did not meaningfully refute the conclusions of the peer review reports. Despite the plaintiff's contention that the court had overlooked an affirmation by Dr. Shapiro, the court found that this affirmation was still insufficient to raise a triable issue of fact. Therefore, upon reargument, the court held that the order granting the defendant's motion for summary judgment dismissing the complaint is adhered to.