No-Fault Case Law
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.
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.