No-Fault Case Law
D.A.V. Chiropractic, P.C. v American Tr. Ins. Co. (2010 NY Slip Op 51738(U))
October 1, 2010
The relevant facts considered by the court in the case of D.A.V. Chiropractic, P.C. v American Tr. Ins. Co. were that the providers were seeking assigned first-party no-fault benefits. The main issue was whether the assignor of the benefits was eligible for workers' compensation benefits, and the court needed to determine the availability of compensation through the Workers' Compensation Board. The holding of the case was that because the Workers' Compensation Board has primary jurisdiction to determine factual issues concerning coverage under the Workers' Compensation Law, the matter needed to be remitted to the Board to be held in abeyance pending a prompt application to determine the parties' rights. The decision was ultimately made to reverse the judgment, vacate the order granting the providers' motion for summary judgment, and remit the matter to the Civil Court to be held in abeyance pending a prompt application to resolve the issues through the Workers' Compensation Board.
Manhattan Med. Imaging, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51737(U))
October 1, 2010
The pertinent facts of the case were that Manhattan Medical Imaging, P.C. moved for summary judgement to recover assigned first-party no-fault benefits. GEICO Ins. Co. opposed the motion on the grounds that the services rendered were not medically necessary. The Civil Court granted plaintiff's motion for summary judgment, and this appeal followed. However, the Appellate Term found that the defendant had provided enough evidence to demonstrate the existence of a triable issue of fact as to medical necessity. Consequently, the judgment was reversed, and plaintiff's motion for summary judgment was denied. Therefore, the main issue decided was whether the services rendered were medically necessary, and the holding of the case was that the defendant had provided sufficient evidence to demonstrate a triable issue of fact as to medical necessity, leading to the reversal of the judgment and denial of plaintiff's motion for summary judgment.
I.V. Med. Supply, Inc. v Mercury Ins. Group (2010 NY Slip Op 51736(U))
October 1, 2010
The court considered the motion by the defendant for summary judgment dismissing the complaint, arguing lack of medical necessity for first-party no-fault benefits. Plaintiff submitted only an affirmation from its counsel in opposition to the motion. The court denied the defendant's motion, finding that the only issue for trial was the medical necessity of the supplies at issue. On appeal, the court reversed the order and granted the defendant's motion for summary judgment dismissing the complaint. This decision was based on the sufficiency of the affidavit submitted by the defendant, as well as the lack of a meaningful rebuttal to the conclusions set forth in the peer review report by the plaintiff, leading the court to find in favor of the defendant.
Irina Kazanskaya, Ac v GEICO Ins. Co. (2010 NY Slip Op 51735(U))
October 1, 2010
The relevant facts considered by the court in this case were that an acupuncturist was seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided by the court was whether the insurance company had timely and properly reimbursed the acupuncturist. The holding of the case was that the court reversed the judgment, vacated the order granting the acupuncturist's motion for summary judgment, and granted summary judgment to the insurance company dismissing the complaint. This decision was based on the finding that the insurance company had timely mailed its claim denial and had properly reimbursed the acupuncturist using the workers' compensation fee schedule applicable to chiropractors.
Alfa Med. Supplies v Progressive Northeastern Ins. Co. (2010 NY Slip Op 51733(U))
October 1, 2010
The court considered the denial of a claim for first-party no-fault benefits by Progressive Northeastern Insurance Co. to Alfa Medical Supplies. The denial was based on lack of medical necessity for supplies totaling $1480. The main issue decided was whether the denial of the claim form was timely and whether there was a lack of medical necessity for the supplies. The holding was that the denial of the $455 claim was paid in full and therefore should have been granted as to that claim. Additionally, the court found that the denial of the $1480 claim for lack of medical necessity was timely and supported by an affirmed peer review report, and the plaintiff failed to rebut the conclusions set forth in the report, so the motion for summary judgment dismissing the complaint was granted for this claim as well.
MIA Acupuncture, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51731(U))
October 1, 2010
The relevant facts considered by the court were that MIA Acupuncture, P.C. brought an action against GEICO Ins. Co. to recover first-party no-fault benefits. MIA Acupuncture, P.C. moved for summary judgment, with defendant GEICO Ins. Co. opposing the motion based on timely denial of claim forms and reduced payment due to the workers' compensation fee schedule. The main issues decided by the court were whether MIA Acupuncture, P.C. was entitled to summary judgment, if there were triable issues of fact with respect to defendant's defense of lack of medical necessity, and whether defendant's use of the workers' compensation fee schedule was appropriate. The holding of the case was that MIA Acupuncture, P.C. was not entitled to summary judgment and that partial summary judgment was granted to defendant, dismissing certain claims and remitting the matter to the Civil Court for further proceedings.
PMR Physical Therapy v Country-Wide Ins. Co. (2010 NY Slip Op 51729(U))
October 1, 2010
The relevant facts considered by the court were that PMR Physical Therapy as the assignee of Jason Moralez, moved for summary judgment to recover assigned first-party no-fault benefits but was denied by the Civil Court. The main issue decided was whether PMR Physical Therapy made a prima facie showing of entitlement to summary judgment. The holding of the court was that PMR Physical Therapy failed to make a prima facie showing of its entitlement to summary judgment because the affidavit in support of their motion did not demonstrate personal knowledge of the plaintiff's business practices and procedures, and therefore, the order denying their motion for summary judgment was affirmed.
St. Vincent Med. Care, P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 51728(U))
October 1, 2010
The main issues in this case were that the defendant denied the plaintiff's claim for first-party no-fault benefits on the grounds of lack of medical necessity and the plaintiff's assignor's failure to appear for scheduled independent medical examinations (IMEs). The court held that the denial of claim forms were timely mailed and that the defendant sufficiently established the lack of medical necessity for the services provided. The court also held that the plaintiff's assignor's failure to appear at the scheduled IMEs was a condition precedent to the insurer's liability on the policy, and therefore, the defendant's motion for summary judgment dismissing the complaint was granted. The court also denied the plaintiff's motion seeking to deem certain facts established for all purposes in the action.
Neomy Med., P.C. v Auto One Ins. Co. (2010 NY Slip Op 51727(U))
October 1, 2010
The court considered an appeal from an order of the Civil Court of the City of New York, Kings County that had granted a provider's summary judgment upon a claim for first-party no-fault benefits. The main issue decided was whether there was a lack of medical necessity for the services at issue. The holding of the case was that the defendant had proffered sufficient evidence in admissible form to demonstrate the existence of a triable issue of fact as to medical necessity, and therefore the order granting the provider's motion for summary judgment was reversed and denied.
L & b Med., P.C. v Eveready Ins. Co. (2010 NY Slip Op 51725(U))
October 1, 2010
The case involves a petition to vacate an award of a master arbitrator which upheld an award of an arbitrator rendered pursuant to Insurance Law § 5106 (b). The court considered the grounds specified in CPLR 7511 for vacating or modifying a no-fault arbitration award. The main issue was whether the master arbitrator's award should be vacated, and the court found that the petitioner failed to demonstrate the existence of any of the statutory grounds for vacatur of the master arbitrator's award. The holding of the court was that the determination of the master arbitrator upholding the arbitrator's award had evidentiary support and a rational basis, was not arbitrary and capricious, and the Civil Court properly denied the petition to vacate the master arbitrator's award. The decision was affirmed without costs.