No-Fault Case Law
Point of Health Acupuncture, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51724(U))
October 1, 2010
The relevant facts in this case involved a provider seeking to recover unpaid portions of five claim forms for acupuncture services. The insurance company had paid portions of each claim but denied the remainder, stating that the provider sought to recover fees in excess of the proper rate of reimbursement for acupuncture services performed by chiropractors. The main issue was whether the denial of the claim forms had been timely mailed and if the insurance company had used the appropriate fee schedule to determine the amount the provider was entitled to receive. The court held that the insurance company's denial of claim forms had been timely mailed and that they had properly used the workers' compensation fee schedule for acupuncture services. Therefore, the court reversed the lower court's decision, denied the provider's motion for summary judgment on the unpaid portions of the claim forms, and granted the insurance company's cross-motion for summary judgment.
Aminov v Travelers Prop. Cas. Ins. Co. (2010 NY Slip Op 51723(U))
October 1, 2010
The court considered a claim by a medical provider seeking to recover assigned first-party no-fault benefits for medical services provided from October 7, 2004 through December 29, 2004. The insurance company argued that the claim forms were not submitted within the required 45 days of the services being provided, while the provider argued that the insurance company must have received the claim forms as it knew the dates and the total amount of the claims. The main issue decided was whether the insurance company was entitled to summary judgment dismissing the complaint based on the claim forms not being submitted within the required timeframe. The holding of the court was that the insurance company did not make a prima facie showing of its entitlement to judgment as a matter of law, and therefore the decision to grant the insurance company's motion for summary judgment was reversed and the motion was denied.
Altair Med., P.C. v Clarendon Natl. Ins. Co. (2010 NY Slip Op 51721(U))
October 1, 2010
The court considered a case where providers were seeking to recover assigned first-party no-fault benefits. The main issue was whether the services provided were medically necessary. The court found in favor of the defendant, Clarendon National Insurance Company, in part, granting their cross motion for summary judgment and dismissing the complaint with respect to the claim by plaintiff S & R Medical, P.C. in the amount of $2,831.08. The court determined that the denial of claim forms were timely mailed and that there was a lack of medical necessity for the services provided by S & R Medical, P.C. in the amount of $2,831.08. However, the court also ruled that the claim by plaintiff Altair Medical, P.C. and the claim by plaintiff S & R Medical, P.C. in the amount of $793.24 should not be dismissed, as the "peer review report" pertaining to these claims was unsigned, and therefore the defendant failed to establish its entitlement to summary judgment dismissing these claims.
Chiro Care Chiropractic Assoc. v GEICO Gen. Ins. Co. (2010 NY Slip Op 20404)
September 24, 2010
In this no-fault case, the court considered the issue of whether defendant's expert, Dr. Nicholas Berbari, was competent to challenge the necessity of the electrodiagnostic tests prescribed by claimant's treating chiropractor. Defendant presented proof from Dr. Berbari to establish that the services in question were not necessary when viewed in the context of generally accepted medical practices. Dr. Berbari's qualifications and expertise in internal medicine were not contested, but plaintiff argued that he was not competent to challenge the tests prescribed by a chiropractor. The court held that Dr. Berbari was competent to testify, and his opinion went to the weight of his testimony, not its admissibility. The court determined that the issue was whether the chiropractic services furnished were 'reasonable and necessary,' and any evidence that aided in deciding that question was proper. Therefore, the court denied plaintiff's motion to preclude consideration of Dr. Berbari's testimony.
Lenox Hill Radiology v Government Empls. Ins. Co. (2010 NY Slip Op 51638(U))
September 21, 2010
The relevant facts the court considered were that Lenox Hill Radiology submitted a claim to Government Employees Insurance Company (GEICO) for medical services rendered to their assignor, Julia Higginbotham, which was denied on coverage grounds. GEICO asserted that Higginbotham was a pedestrian struck by a vehicle in Louisiana, where there is no no-fault coverage. The main issues decided were whether GEICO's lack of coverage defense was valid and if they were obligated to produce a witness with personal knowledge of the underlying accident. The holding of the case was that the court disagreed with the trial court's conclusions and reversed the judgment in favor of the plaintiff, directing a judgment in favor of the defendant instead. The court found that GEICO had demonstrated that the claim did not arise out of an insured incident, and therefore established its lack of coverage defense, leading to the dismissal of the complaint.
Elmont Open MRI & Diagnostic Radiology, PC v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 51588(U))
August 31, 2010
The court considered the fact that the plaintiff brought a no-fault action against the defendant for failure to pay for several MRIs and the defendant's defense that the MRIs were not medically necessary. The main issues decided in the case were whether the plaintiff proved its prima facie case and whether the defendant's defense of the medical necessity of the MRIs was valid. The court held that the plaintiff adequately proved its prima facie case through unrefuted testimony from its medical biller and defendant's previous proof of receipt and denial of the bills, and that the defendant failed to prove the lack of medical necessity of the MRIs by a preponderance of evidence, resulting in judgment for the plaintiff.
VIT Acupuncture, P.C. v State Farm Auto. Ins. Co. (2010 NY Slip Op 51560(U))
August 25, 2010
The relevant facts the court considered in this case were that the defendant insurance provider moved to dismiss all causes of action in the complaint based on the plaintiff's alleged failure to attend two requested Examinations Under Oath (EUOs). The main issues addressed were the sufficiency of the defendant's evidence to support the motion to dismiss, and whether the plaintiff's complaint stated a cause of action. The court held that the defendant's affidavits were not documentary evidence as required under CPLR 3211(a)(1), and that the plaintiff's complaint did state a cause of action. The court also rejected the defendant's argument that the action should be dismissed as premature due to the plaintiff's alleged failure to comply with verification requests, as the defendant had already issued a denial for the claim, inviting the plaintiff's subsequent proceedings to challenge the denial. Therefore, the defendant's motion to dismiss was denied, and the plaintiff was given 30 days to serve and file an answer.
Urban Radiology, P.C. v GEICO Ins. Co. (2010 NY Slip Op 51554(U))
August 23, 2010
The court considered a motion to consolidate a provider's claim against an insurance company with forty-five other pending cases, the amendment of the insurance company's answer to include a fraudulent incorporation defense, additional discovery, and a stay pending resolution of the fraudulent incorporation issue in all the cases. The main issue decided was whether the cases should be consolidated and a stay granted, and if the insurance company should be allowed to amend its answers and have additional discovery. The court held that the cases should not be consolidated, as they did not arise from a common set of facts or accident, and consolidation would be unwieldy and prejudicial to the plaintiff. The court also denied a stay, as the insurance company did not have a good faith basis to allege fraudulent incorporation and the request for a stay was based on speculation rather than specific proof. The court denied the request for leave to amend and for additional discovery without prejudice to renew upon a proper showing in each case.
Quality Psychological Servs., P.C. v GEICO Ins. Co. (2010 NY Slip Op 51423(U))
August 16, 2010
The court considered the defendant's application to amend its answers to interpose counterclaims for fraud and unjust enrichment in an action to recover assigned first party no-fault benefits. The defendant sought to strike the notices of trial, compel discovery, including a deposition, and to consolidate 19 captioned actions. The main issue decided was whether the defendant's counterclaims for fraud and unjust enrichment were palpably insufficient and patently devoid of merit because the claims were not denied on the grounds of fraudulent billing. The court held that the counterclaims were palpably insufficient and patently devoid of merit, and denied the defendant's application to amend the answers. Therefore, the remaining parts of the order to show cause to strike the notices of trial, compel discovery, including a deposition, and to consolidate all 19 captioned actions were also denied as moot.
Hillcrest Radiology Assoc. v State Farm Mut. Auto. Ins. Co. (2010 NY Slip Op 51467(U))
August 13, 2010
The main issue of this case was whether a medical provider was entitled to recover assigned first-party no-fault benefits. The relevant facts considered by the court included a motion made by the defendant for summary judgment dismissing the complaint on the grounds that the services billed were not medically necessary, as well as contradictory reports submitted by the defendant as part of their motion. The decision of the court was to affirm the order without costs, as the defendant had failed to establish its prima facie entitlement to summary judgment as a matter of law due to contradictory evidence submitted as part of their motion. One judge concurred in part and dissented in part, agreeing with the majority's decision but stating that a specific MRI study was not subject to summary judgment due to conflicting evidence, while granting summary judgment for other MRIs that were found to be medically unnecessary.