No-Fault Case Law

The court considered the issue of whether a provider could recover assigned first-party no-fault benefits, specifically focusing on the medical necessity of the treatments in question. The defendant had timely denied the claim on the grounds of lack of medical necessity and supported its argument with an affirmed peer review report. The plaintiff's doctor's affirmation did not effectively rebut the conclusions set forth in the peer review report. The court held that the defendant's cross-motion for summary judgment dismissing the second cause of action should have been granted, and reversed the order denying the branch of the defendant's cross motion.

The relevant facts in this case include a medical provider, St. Vincent Medical Care, seeking to recover assigned first-party no-fault benefits from Travelers Insurance Company. The issue at hand was whether the insurer, Travelers, had properly toll its time to pay or deny the subject bills and whether the plaintiff had failed to appear for an examination under oath (EUO). The court held that while an EUO need not be scheduled to be held within 30 days of the receipt of the claim form, Travelers failed to demonstrate that the EUO scheduling letters were timely mailed. As a result, the court found that Travelers had failed to properly toll its time to pay or deny the subject bills, therefore affirming the Civil Court's decision to grant plaintiff's summary judgment on its first cause of action and deny defendant's cross motion seeking summary judgment dismissing the first cause of action.

The main issue in this case was whether the plaintiff had established a prima facie case to recover assigned first-party no-fault benefits in a medical billing dispute with the defendant insurance company. The plaintiff had initially been granted summary judgment by the Civil Court, but the defendant appealed the decision, arguing that there was a lack of medical necessity for the MRI in question and that they had already paid a portion of the claim. The Appellate Term ultimately reversed the judgment, vacated the order granting summary judgment, and denied the plaintiff's motion for summary judgment. The court found that the defendant had presented sufficient evidence to raise a question of fact regarding the lack of medical necessity and whether they had already paid a portion of the claim, and therefore warranted the denial of the plaintiff's motion for summary judgment.

The relevant facts in this case involved a medical care provider seeking to recover assigned first-party no-fault benefits from an insurance company. The provider moved for summary judgment, which was granted by the Civil Court, leading to a judgment in the provider's favor. The insurance company appealed this decision. The main issue decided by the Appellate Term was whether the provider was entitled to summary judgment. The court held that the insurance company had timely mailed initial requests for verification, and the provider had failed to provide the requested information in response. The court also found that the insurance company had timely denied certain claims on the ground that the services for which payment was sought were part of another service and were not separately reimbursable. As a result, the court reversed the judgment, granted the insurance company's motion seeking summary judgment dismissing certain causes of action, and remitted the case to the Civil Court for further proceedings on the remaining causes of action.

The relevant facts that the court considered in this case were that Leon Regis, plaintiffs' assignor, was injured in a car accident in New York while driving a vehicle registered to, and insured by, a New Jersey resident. The insurance company, GEICO, denied Regis' claims for no-fault benefits under the policy. The main issues decided were whether jurisdiction was proper in New York or New Jersey, and which state's law should control. The court held that, upon application of a "center of gravity" or "grouping of contacts" analysis, the dispositive factors weighed in favor of New Jersey, and that its law should control. Therefore, GEICO's cross motion for summary judgment dismissing the complaint was denied, and the case would proceed to trial.

The court considered the facts of a case in which a provider was seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the defendant was entitled to summary judgment dismissing plaintiff's second cause of action. The court held that the affidavit of the defendant's claims representative sufficiently established the timely mailing of the claim denial form, and they made a prima facie showing of entitlement to summary judgment. However, the plaintiff's submission of a doctor's affirmation raised a triable issue of fact as to medical necessity, leading the court to deny the defendant's cross motion seeking summary judgment dismissing the plaintiff's second cause of action.

The case involved an appeal from an order of the Civil Court of the City of New York, Queens County denying the defendant's motion for summary judgment dismissing the complaint by a provider to recover assigned first-party no-fault benefits. The defendant had moved for summary judgment on the ground of lack of medical necessity, and the court had found that the plaintiff's doctor's affirmation raised a triable issue of fact as to whether the services provided were medically necessary. However, the defendant had made a prima facie showing that it had properly and timely denied the claim based on lack of medical necessity, and the burden shifted to the plaintiff to raise a triable issue of fact. In opposition to the defendant's motion, the plaintiff submitted an affirmation executed by their own medical director, which was found to be improper and the Civil Court should not have considered any facts set forth in said affirmation. As plaintiff failed to proffer any evidence in admissible form to raise an issue of fact, the defendant was entitled to summary judgment and the lower court's decision was reversed.

The court considered whether the provider's claims for first-party no-fault benefits for services rendered on October 5, 2006 and from November 12 to 16, 2006 were medically necessary. Defendant submitted an affidavit and an independent medical examination (IME) report showing a lack of medical necessity for the services. The Civil Court denied defendant's motion for summary judgment, finding that the sole issue for trial was the medical necessity of the denied bills based on the IME. However, the Appellate Term reversed this decision, holding that defendant's motion for summary judgment should have been granted because the affirmation of the plaintiff's supervising acupuncturist did not rebut the conclusions set forth in the IME report. Therefore, defendant's motion for summary judgment dismissing the claims at issue should have been granted, and the decision of the Civil Court was reversed.

The relevant facts the court considered in this case were that the defendant had moved for an order compelling the plaintiff to produce two witnesses, Drs. Livchits and Levin, for depositions. The plaintiff failed to comply with this order, and the defendant subsequently moved to strike the plaintiff's complaint based on this failure. The main issue decided was whether the court properly ordered the plaintiff to produce the witnesses for depositions and whether the penalty imposed by the court for the plaintiff's failure to comply with the order was appropriate. The holding of the case was that the court did not err in ordering the plaintiff to produce the witnesses for depositions, and the penalty of striking the plaintiff's complaint was justified due to the plaintiff's willful and contumacious failure to comply with the court's order.

The court considered the issue of whether an insurance company was required to notify the injured party when it sends a follow-up verification request to a plaintiff provider. Pursuant to Insurance Law § 5106 (a) and 11 NYCRR 65-3.8, an insurer is required to either pay or deny a claim for no-fault automobile insurance benefits within a certain timeframe. The court interpreted the term "applicant" in the regulation to include both the provider/assignee and injured persons who submit a claim for no-fault benefits. The court held that the plaintiff provider was the applicant in the matter and since they did not provide the verification sought by the defendant, the 30-day period for the defendant to either pay or deny the claim did not begin to run, therefore the defendant's motion was granted.