No-Fault Case Law
Matter of Chin v State Farm Ins. Co. (2010 NY Slip Op 04186)
May 11, 2010
The Appellate Division of the Supreme Court in the Second Department denied an appeal from a lower proceeding, which means the lower court's decision was sustained. The case involved a petition to vacate an arbitration award arising from a previous dispute between Judy Chin and State Farm Insurance Company. The court affirmed the arbitrator's award, rejecting petitioner's claims that it was based on insufficient evidence or failed to address specific evidence. The court found that the award was reasonably based and supported by the evidence, and therefore not subject to being vacated. Consequently, the court held that the arbitration award, as modified, was justified and did not violate the standards for vacating or modifying arbitration awards.
We Care Med., P.C. v GEICO Ins. Co. (2010 NY Slip Op 50831(U))
May 10, 2010
The relevant facts considered in this case were that We Care Medical had filed a lawsuit against GEICO Insurance Company to recover assigned first-party no-fault benefits. We Care Medical moved for summary judgment, while GEICO cross-moved for summary judgment dismissing the complaint. The main issues decided were whether the documents annexed to We Care Medical's motion for summary judgment were admissible as business records, and whether GEICO had timely denied the claim at issue based on lack of medical necessity. The holding of the case was that We Care Medical established its prima facie case and was awarded summary judgment on its first cause of action. However, GEICO established its prima facie entitlement to summary judgment with respect to We Care Medical's third cause of action, and We Care Medical failed to raise a triable issue of fact with respect to this cause of action, therefore GEICO's cross motion for summary judgment was granted.
Elmont Open MRI & Diagnostic Radiology, P.C. v State Farm Ins. Co. (2010 NY Slip Op 50829(U))
May 10, 2010
The main issue in this case was whether the services provided by the plaintiff were medically necessary, as the defendant argued that they were not. The court considered the affidavit of the plaintiff's billing collection supervisor, as well as the affirmed peer review reports submitted by the plaintiff in support of their motion for summary judgment. The District Court initially granted the plaintiff's motion, but the Appellate Term reversed the decision, finding that the peer review reports provided a sufficient factual basis and medical rationale to demonstrate the existence of an issue of fact as to medical necessity. Therefore, the plaintiff's motion for summary judgment was denied, and the decision of the District Court was reversed.
Beal-Medea Prods., Inc. v GEICO Gen. Ins. Co. (2010 NY Slip Op 50800(U))
May 6, 2010
The relevant facts considered by the court were that Beal-Medea Products, Inc. was seeking to recover first party no-fault benefits from GEICO General Insurance Co. The main issue decided was whether the supplies provided to Beal-Medea Products' assignor, Michael Perez, were medically necessary. The court held that the defendant, GEICO, failed to establish a factual basis and medical rationale for its asserted lack of medical necessity. The court also discussed the admissibility of testimony by substitute peer doctors, and held that the substitute peer doctor's testimony is permissible if limited to the basis for denial as set forth in the original peer review. The court ultimately ruled in favor of the plaintiff, Beal-Medea Products, awarding them $563.04, plus costs, disbursements, statutory interest, and statutory attorneys fees.
Alev Med. Supply, Inc. v Progressive Ins. Co. (2010 NY Slip Op 50813(U))
May 3, 2010
The court considered the defendant's motion to compel Valadimir Alexsandrovich to appear for a deposition and answer questions concerning Bener Wholesale, a non-party, as well as the defendant's demand for discovery regarding claims that Alev Medical Supply, Inc. was involved in a scheme to defraud insurance companies through Bener. The main issue decided was the extent to which a defendant can obtain discovery on defenses that may be precluded from being raised at trial of an action for seeking payment of first party no-fault benefits. The court held that unless a no-fault carrier seeks verification, it has 30 days from the date of receipt of the claim to pay or deny a claim in whole or in part, and that a carrier who fails to deny a claim within 30 days of receipt is precluded from asserting most defenses to the claim. Progressive Insurance Company's motion for discovery was denied by the court with leave to renew upon proper papers, including a copy of the claim and a copy of the denial.
Mandracchia v Allstate Ins. Co. (2010 NY Slip Op 50882(U))
April 28, 2010
The court considered a motion to dismiss or for summary judgment by defendant Allstate Insurance Company on the grounds that the action was barred by the six-year Statute of Limitation. The plaintiff, a medical service provider, sought to recover $320.30 for services provided to his assignor for injuries sustained in an automobile accident. The relevant issue was whether the action was time-barred and the main issue decided was whether the action was commenced within the applicable statute of limitations. The court held that the complaint was dismissed as it was determined that the action was commenced way beyond the six-year statute of limitations, as the cause of action accrued once the claim became overdue. The court found that the action was not timely and therefore dismissed the complaint.
Crotona Hgts. Med., P.C. v Farm Family Cas. Ins. Co. (2010 NY Slip Op 50716(U))
April 16, 2010
The relevant facts considered in this case were that the defendant denied the plaintiff's claim after requesting the plaintiff to appear for an examination under oath and the plaintiff failed to appear for the examination. The main issue decided in this case was whether the plaintiff's failure to appear for the examination under oath was a proper basis for the defendant to deny the claim. The holding of the case was that the defendant's cross motion for summary judgment dismissing the complaint was granted because the plaintiff's failure to appear for the examination under oath was a condition precedent to the insurer's liability on the policy, and the claims were timely denied after the plaintiff's failure to appear. Therefore, the court reversed the denial of the defendant's cross motion for summary judgment.
Speciality Surgical Servs. v Travelers Ins. Co. (2010 NY Slip Op 50715(U))
April 16, 2010
The main issue in this case was whether the plaintiff had standing to recover no-fault benefits for medical services rendered, as the assignment executed by the plaintiff's assignor was in favor of another entity. The court considered the fact that the assignment discrepancy was apparent on its face, but the defendant did not seek verification of the assignment and its denial of the claim did not deny it on the ground that the assignment was defective. Therefore, the court held that the defendant was precluded from litigating this issue. The defendant's doctor testified that the services provided were not medically necessary, and the defendant also admitted a copy of the doctor's affirmed peer review report, which supported this conclusion. The court disagreed with the lower court's finding, and reversed the judgment in favor of plaintiff, directing judgment to be entered in favor of the defendant dismissing the complaint.
AR Med. Rehabilitation, P.C. v American Tr. Ins. Co. (2010 NY Slip Op 50708(U))
April 13, 2010
The court considered a dispute between a medical provider and an insurance company regarding the eligibility of the plaintiff's assignor for workers' compensation benefits. The insurance company moved for summary judgment to dismiss the complaint, claiming that the assignor was eligible for workers' compensation benefits. The court denied the motion without prejudice and ordered for the defendant's motion for summary judgment to be remitted to the Workers' Compensation Board. The main issue was whether the assignor was eligible for workers' compensation benefits, which was determined to be a matter within the jurisdiction of the Workers' Compensation Board. The holding of the case was that the defendant's motion for summary judgment should have been held in abeyance pending a determination by the Workers' Compensation Board, and that a prompt application to the Board was required in order to determine the parties' rights under the Workers' Compensation Law.
A.B. Med. Servs., PLLC v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 50702(U))
April 13, 2010
The relevant facts of this case involve an action by three providers seeking to recover assigned first-party no-fault benefits. The defendant moved to dismiss the complaint on the ground of res judicata, arguing that the plaintiffs had previously commenced an identical action, which had been dismissed for failure to comply with a discovery order. The main issue considered by the court was whether the dismissal of the prior action barred the plaintiffs from commencing a second action. The holding of the court was that where a plaintiff's noncompliance with a disclosure order does not result in a dismissal with prejudice, the dismissal resulting from the noncompliance is not a merits determination so as to bar commencement of a second action. As a result, the District Court properly denied the defendant's pre-answer motion to dismiss the complaint based on the doctrine of res judicata.