No-Fault Case Law

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.

The appellate division considered a case in which the defendant appealed from an order denying a motion to dismiss a complaint related to first-party no-fault benefits pursuant to a policy of insurance. The main issue was whether the appellate division should express views on the applicability of the Workers' Compensation Law before a determination is made by the Workers' Compensation Board. The holding was that the matter should have been referred to the Workers' Compensation Board for a hearing and determination as to whether the plaintiff is relegated to benefits under the Workers' Compensation Law. As a result, the order was reversed and the matter was remitted to the Supreme Court for a new determination following an application by the plaintiff to the Workers' Compensation Board.

The relevant facts of the case were that Eden Medical, P.C. sought to recover assigned first-party no-fault benefits from Eveready Insurance Company. Plaintiff moved for an order compelling defendant to appear for an examination before trial, while defendant cross-moved for summary judgment dismissing the complaint based on an affirmed peer review report which claimed that the services rendered were not medically necessary. Plaintiff argued that the peer review report contained a stamped facsimile signature, but defendant submitted an affidavit from the peer reviewer stating that she had personally applied the signature. The main issue decided was whether the peer review report contained a stamped signature, and the court held that plaintiff's mere assertion of a stamped signature, without any indication as to why it was believed to be a stamped facsimile signature, was insufficient to raise an issue of fact. As a result, the court affirmed the order granting defendant's cross motion for summary judgment dismissing the complaint.

The relevant facts the court considered in this case were that a medical services provider, as an assignee of a patient, filed a lawsuit to recover unpaid first-party no-fault benefits from the insurance company. The provider alleged five unpaid claims, and the Civil Court granted summary judgment as to four of the claims. The insurance company then moved to modify the proposed judgment to limit the award of attorney's fees to $850, arguing that fees should be calculated on an aggregate basis. The main issue in the case was whether attorney's fees in no-fault insurance cases should be calculated on a per claim basis or on an aggregate basis. The holding of the case was that as per the opinion of the Court of Appeals in LMK Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co., attorney's fees in no-fault insurance cases should be calculated based on the aggregate of all bills for each insured, with a maximum of $850. Therefore, the court reduced the award of attorney's fees to the medical services provider from $1,745.47 to $850.

The court considered the fact that the plaintiff is a professional service corporation owned by a licensed physician, but the physician was not certified to perform acupuncture at the time the services at issue were provided. The court also considered that the services were provided by a licensed acupuncturist employed by the plaintiff. The main issues were whether the plaintiff had standing to recover no-fault benefits for acupuncture services and whether a professional service corporation owned solely by a doctor, who is not a certified acupuncturist at the time the services were rendered, is entitled to reimbursement of assigned no-fault benefits for such services. The holding was that a professional service corporation owned solely by a doctor who is not a certified acupuncturist at the time the services were rendered is not entitled to reimbursement of assigned no-fault benefits for such services, even if the services were rendered by a licensed acupuncturist employed by the corporation. Therefore, the judgment was reversed and the complaint was dismissed.

In this case, the plaintiff offered into evidence a notice to admit asking the defendant to admit receiving the plaintiff's claim for no-fault medical provider services. The defendant did not respond to this notice and presented no alternative evidence. The issue presented to the court was whether a no-fault medical service provider can establish its section 5106 (a) prima facie cause of action through a notice to admit, which the court ruled that it can. The court found that the plaintiff had established a prima facie cause of action pursuant to Insurance Law § 5106 (a) as the defendant failed to rebut the claim. Therefore, the court entered judgment for the plaintiff in the sum of $1,184.66 plus statutory interest from 30 days after its claim date, statutory attorneys fees, and costs.

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits, where the plaintiff had moved for summary judgment or, in the alternative, for an order pursuant to CPLR 3212 (g) limiting issues of fact for trial. The District Court had denied the branch of plaintiff's motion seeking summary judgment, and upon reargument, denied the branch seeking an order limiting issues of fact for trial. The main issue decided was whether the plaintiff had made a prima facie showing of entitlement to summary judgment, and the court held that they had failed to do so. Consequently, the court affirmed the District Court's denial of the motion seeking a determination pursuant to CPLR 3212 (g).