No-Fault Case Law
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.
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.