No-Fault Case Law
Med-Tech Prods., Inc. v Geico Ins. Co. (2009 NY Slip Op 52111(U))
October 13, 2009
The main issue in this case was whether the equipment provided to the plaintiff's assignors was medically necessary, and whether the plaintiff was entitled to recover no-fault benefits. The court considered the affidavits of the plaintiff's president and the denial of the claims by defendant based on peer review reports. The court held that the plaintiff made a prima facie showing of entitlement to summary judgment by submitting the statutory claim forms and proofs of overdue payment. However, the defendant's timely denial of the claims based on peer review reports, which provided a factual basis and medical rationale for the doctor's opinion that the supplies were not medically necessary, established a triable issue of fact. The court affirmed the denial of plaintiff's motion for summary judgment.
A.B. Med. Servs., PLLC v American Tr. Ins. Co. (2009 NY Slip Op 52067(U))
October 6, 2009
The main issues in the case were whether the provider was entitled to summary judgment to recover assigned first-party no-fault benefits and whether the insurance company was entitled to summary judgment due to the assignor's failure to appear for scheduled examinations under oath. The court considered the fact that the insurance company had established that the EUO notices were mailed and that the assignor failed to appear. Additionally, the court considered the argument that an EUO was not necessary and that the EUO notices were defective. The holding of the case was that the insurance company's cross motion for summary judgment was properly granted, as they had established that the EUO notices were mailed and that the assignor failed to appear. The provider's motion for summary judgment was properly denied because they failed to make a prima facie showing of their entitlement to summary judgment.
Sunshine Imaging Assn./WNY MRI v Government Empls. Ins. Co. (2009 NY Slip Op 06984)
October 2, 2009
The court considered the denial of plaintiff's motion for summary judgment and the granting of defendant's motion to sever the causes of action. The main issue decided was whether plaintiff was entitled to summary judgment as a matter of law to recover no-fault benefits against defendant insurer. The holding was that the trial court properly denied plaintiff's motion for summary judgment and properly granted defendant's motion to sever the 14 causes of action. Plaintiff made a prima facie showing of entitlement to judgment as a matter of law, but defendant raised a triable issue of fact by submitting its denial of claim forms setting forth that the services for which plaintiff sought to recover no-fault benefits were not medically necessary. The court did not abuse its discretion in granting defendant's motion to sever the 14 causes of action.
Administrative Assets v Zurich Am. Ins. Co. (2009 NY Slip Op 52261(U))
October 1, 2009
The court considered a dispute between a medical service provider and an insurance company regarding the payment of services rendered to an individual injured in an automobile accident. The insurance company claimed that the injured individual was entitled to workers compensation and therefore coverage for the medical services should be decided by the Workers Compensation Board. The main issue considered was whether the insurance company provided sufficient evidence to support their claim that workers compensation was primary in this case. The court ultimately held that the insurance company failed to provide admissible evidence to prove that the injured individual was employed at the time of the accident and therefore workers compensation was primary. As a result, the court denied the insurance company's motion for summary judgment, allowing the case to proceed to trial.
Lincoln Gen. Ins. Co. v Alev Med. Supply Inc. (2009 NY Slip Op 29389)
September 28, 2009
The court considered the relevant facts of the case, which involved a no-fault insurance carrier seeking to recover no-fault benefits paid on a fraudulent claim from a provider. The central issue decided in this case was whether a no-fault insurance carrier can sue a provider to recover benefits paid on a fraudulent claim. The holding of the case was that the carrier was not entitled to enter a default judgment and recover the money paid to the provider, as the carrier had not raised the issue of fraud in a timely denial but had paid the claim in part and denied it in part. The court's decision was based on the fact that the No-Fault Law and regulations require insurers to promptly investigate and pay claims, and any defense, including fraud, must be raised in a timely denial in accordance with the time restrictions of the law and regulations. Therefore, since the carrier failed to timely deny the claim on the grounds of fraud, it was not entitled to recover the previously paid benefits and to sue the provider.
Buffalo Gen. Hosp. v Erie Ins. Co. (2009 NY Slip Op 29438)
September 24, 2009
The relevant facts the court considered in Buffalo General Hospital v Erie Ins. Co. involved health care providers who provided medical care to various patients. These patients were insured by the respondents, who denied the patients' first-party no-fault insurance claims, leading the claims of the patients to be assigned to the appellants. The appellants then served the Superintendent of Insurance in Albany with Buffalo City Court summonses and complaints, and the respondents argued that this did not constitute proper personal jurisdiction over them. The court decided that in accordance with Insurance Law § 1212, the respondents were properly served, and the orders of Buffalo City Court (No. E14033/2008 and No. E12518/2008) to dismiss the matters for lack of personal service were reversed. The holding of the court was that the respondents' motions to dismiss were improperly granted, and the case was remanded to Buffalo City Court for further proceedings not inconsistent with this decision.
Jesa Med. Supply, Inc. v GEICO Ins. Co. (2009 NY Slip Op 29386)
September 22, 2009
The main issue of the case is whether plaintiff Jesa Med. Supply, Inc., can recover first-party no-fault benefits from defendant GEICO Ins. Co. for medical services rendered by plaintiff. The court found that plaintiff had established its prima facie case as to the mailing of its claims for no-fault benefits. Despite defects in the defendant's attorney affirmation, the court did not find them to be substantive enough to warrant summary judgment being granted in favor of the plaintiff. Ultimately, plaintiff's motion for summary judgment was denied in part and granted in part, resulting in a judgment in favor of plaintiff and against defendant in the amount of $16.46, plus statutory costs, interest and attorney fees. Additionally, defendant's cross motion was denied in part and granted in part, resulting in the dismissal of the cause of action for no-fault benefits in the amount of $780.
Vega Chiropractic, P.C. v Clarendon Natl. Ins. Co. (2009 NY Slip Op 52536(U))
August 31, 2009
The relevant facts the court considered in this case were related to a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided was whether the provider's assignor failed to attend scheduled chiropractic/acupuncture independent medical examinations (IMEs) and if the letters scheduling said IMEs were timely sent. The holding of the case was that the defendant's motion for summary judgment was granted and the plaintiff's cross motion for summary judgment was denied. The court found that the defendant's motion for summary judgment established that the assignor failed to attend scheduled IMEs and that the letters scheduling the IMEs were timely sent, therefore properly granting defendant's motion for summary judgment and denying plaintiff's cross motion for summary judgment.
Great Wall Acupuncture, P.C. v GEICO Ins. Co. (2009 NY Slip Op 52308(U))
August 31, 2009
The Court considered the issue of whether Great Wall Acupuncture, as the assignee of certain individuals, was entitled to full reimbursement for acupuncture services rendered under a first-party no-fault benefits insurance claim. The main issue was whether the amounts charged by Great Wall Acupuncture for the acupuncture services were reasonable and within the range of the prevailing fees in the geographic area. The Court ultimately held that the insurance company, GEICO, failed to establish that it timely denied the unpaid portion of certain claims and that it was proper for the company to use the workers' compensation fee schedule to determine the amount that Great Wall Acupuncture was entitled to receive for services rendered by its acupuncturist. The judgment in favor of the insurance company was reversed and remitted for a calculation of statutory interest and an assessment of attorney's fees.
Urban Radiology, P.C. v American Tr. Ins. Co. (2009 NY Slip Op 51734(U))
July 31, 2009
The relevant facts considered by the court were that the defendant in this case had lost the file containing the summons and complaint and did not find out about the default judgment until a later date. The main issue decided was whether the defendant had a reasonable excuse for its delay in appearing and answering the complaint, as well as a meritorious defense to the action, and whether the default judgment should be vacated. The holding of the court was that the defendant's failure to answer the complaint was excusable, and the defendant demonstrated a potentially meritorious defense to the claim for services rendered to assignor Patrick Seraphin. Therefore, the court found that the Civil Court had improvidently exercised its discretion in denying the defendant's motion to vacate the default judgment and compel the plaintiff to accept a late answer with respect to the claim for services rendered to Patrick Seraphin.