No-Fault Case Law
Favorite Health Prods., Inc. v Geico Ins. Co. (2010 NY Slip Op 50453(U))
March 10, 2010
The court considered a case where a provider was seeking to recover first-party no-fault benefits, and defendant insurance company denying the claims on grounds of lack of medical necessity. The main issue was whether there was a lack of medical necessity for the medical supplies at issue, and whether the defendant was entitled to summary judgment dismissing the complaint. The court held that the defendant had established timely mailing of the denial of claim forms, and had submitted peer review reports showing lack of medical necessity, which was unrebutted by the plaintiff. Therefore, the defendant's cross motion for summary judgment dismissing the complaint was granted.
Co-Op City Chiropractic, P.C. v Mercury Ins. Group (2010 NY Slip Op 50452(U))
March 10, 2010
The court considered the motion for summary judgment filed by the defendant, who sought to dismiss the complaint on the ground of lack of medical necessity. The defendant's chiropractor provided an affidavit and peer review report that concluded there was a lack of medical necessity for the services rendered, in line with previous cases. However, the plaintiff's treating chiropractor submitted an affidavit in opposition to the motion that demonstrated the existence of a triable issue of fact as to the medical necessity of the services rendered. The main issue decided was whether there was sufficient evidence to demonstrate the medical necessity of the services rendered, and the court held that the plaintiff's affidavit created a triable issue of fact, leading to the affirmation of the order denying the defendant's motion for summary judgment.
Nursing Personnel Homecare v New York Cent. Mut. Fire Ins. Co. (2010 NY Slip Op 50450(U))
March 10, 2010
The relevant facts considered by the court were that the plaintiff was seeking to recover first-party no-fault benefits and the defendant had failed to appear in court, resulting in a default judgment. The main issue decided was whether the defendant had a reasonable excuse for the default and a meritorious defense in order to vacate the default judgment. The court held that the defendant had established that it did not receive actual notice of the summons in time to defend the action, and had also shown the existence of a meritorious defense to the action, as the assignor had cancelled her insurance policy with the defendant prior to the date of the accident. The court therefore reversed the decision of the Civil Court of New York and granted the defendant's motion to vacate the default judgment.
Prestige Med. & Surgical Supply, Inc. v Chubb Indem. Ins. Co. (2010 NY Slip Op 50449(U))
March 10, 2010
The relevant facts considered in the case included a provider's attempt to recover assigned first-party no-fault benefits from an insurance company. The main issue decided was whether the insurance company had waived its reliance on the 45-day rule for submitting the claim, and if the provider had provided a reasonable justification for their failure to submit the claim within the required timeframe. The holding of the case was that the insurance company had not waived its reliance on the 45-day rule, and the provider had failed to provide a reasonable justification for the delay in submitting the claim. Therefore, the insurance company's motion for summary judgment dismissing the complaint was affirmed by the court.
High Quality Med., P.C. v Mercury Ins. Co. (2010 NY Slip Op 50447(U))
March 10, 2010
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.
St. Vincent Med. Care, P.C. v Travelers Ins. Co. (2010 NY Slip Op 50446(U))
March 10, 2010
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.
Right Aid Diagnostic Medicine, P.C. v Geico Ins. Co. (2010 NY Slip Op 50445(U))
March 10, 2010
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.
St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. (2010 NY Slip Op 50444(U))
March 10, 2010
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.
A.B. Med. Servs., PLLC v GEICO Cas. Ins. Co. (2010 NY Slip Op 20094)
March 10, 2010
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.
Infinity Health Prods., Ltd. v Mercury Ins. Co. (2010 NY Slip Op 50385(U))
March 8, 2010
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.