No-Fault Case Law

The court considered a case involving a provider seeking to recover first-party no-fault benefits from the defendant insurance company. The insurance company had partially paid the plaintiff's claim but denied the unpaid portion, alleging that the charges for acupuncture treatments exceeded the maximum fees under the appropriate fee schedule. At trial, the parties stipulated to plaintiff's prima facie case and agreed that the defendant had timely denied the unpaid portion of the claim. The main issue was whether the insurer could use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount a licensed acupuncturist is entitled to receive for such services. The court held that an insurer could use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount a licensed acupuncturist is entitled to receive for such acupuncture services, and since the defendant reimbursed the plaintiff pursuant to this schedule, the plaintiff was not entitled to any additional reimbursement. Therefore, the judgment dismissing the complaint was affirmed.

The court considered a case in which an insurance carrier failed to pay or deny a claim for medical supplies under a no-fault insurance policy within 30 days, seeking further verification of the claim. The insurance carrier had contacted the medical supplier, but after not receiving a response, sent a second verification request after 27 days. The main issue decided in this case was whether the insurance carrier was required to pay or deny the claim within 30 days of the original verification requests. The holding of the court was that although the insurance carrier did not strictly comply with the time limitations for submitting a second verification request, due to circumstances of the case, the plaintiff was estopped from claiming the defendant is precluded from asserting in defense to the claim, but without prejudice to the commencement of a new action.

The court considered the appeal of an order denying a motion for summary judgment and granting a cross motion for summary judgment in a case of a medical provider seeking to recover first-party no-fault benefits. The main issue decided was whether or not the services rendered to the plaintiff's assignor were medically necessary. The court held that the defendant demonstrated that they had timely sent denial of claim forms and that the report of an independent chiropractic/acupuncture examination provided a factual basis and medical rationale for the conclusion that the services were not medically necessary. Additionally, the court found that the affidavit of the plaintiff's chiropractor was insufficient to rebut the defendant's showing, and therefore the defendant's motion for summary judgment dismissing the complaint should have been granted.

The court considered whether an expert witness called by a defendant insurance company may rely upon medical records, prepared by an entity other than the plaintiff medical service provider, to formulate an opinion as to the medical necessity of services provided by the plaintiff. Plaintiff Popular Imaging, P.C. sought to recover payments from defendant State Farm Insurance Co. for an MRI of the lumbar spine that it provided to the assignor Belquis Perez as a result of injuries sustained in an automobile accident. The main issue was whether the medical services provided were medically necessary. The holding of the case was that judgment was rendered in favor of the defendant, as the plaintiff failed to produce evidence to rebut the lack of medical necessity for the lumbar MRI, and therefore failed to refute the expert testimony and opinion.

The relevant facts the court considered were that the plaintiff, Bath Medical Supply, Inc., was seeking to recover assigned first-party no-fault benefits, but the defendant, Harco National Insurance Company, had denied the claim based on the assignor's eligibility for workers' compensation benefits. The main issue decided was whether the Workers' Compensation Board had the authority to determine whether the assignor was entitled to workers' compensation benefits. The holding of the case was that the Workers' Compensation Board did have the authority to make this determination, but the District Court should not have dismissed the complaint and referred the matter to the Board. Instead, the court ordered that the complaint be reinstated and the plaintiff's motion be held in abeyance pending a prompt application to the Workers' Compensation Board for a determination of the parties' rights under the Workers' Compensation Law.

The court considered the denial of claim forms by the defendant which were based on lack of medical necessity and were timely mailed according to the defendant's standard office practice. In support of defendant's motion for summary judgment dismissing the complaint, defendant provided an affirmed peer review report by a doctor as well as an affidavit executed by the chiropractor who performed the second peer review. The documents set forth a factual basis and medical rationale for the peer reviewers' opinions that the medical equipment provided was not medically necessary. Defendant's motion for summary judgment dismissing the complaint was granted, as plaintiff failed to submit any evidence to rebut defendant's showing of a lack of medical necessity and as plaintiff's objections to defendant's papers lack merit. Therefore, the order denying defendant's motion for summary judgment dismissing the complaint was reversed and defendant's motion for summary judgment dismissing the complaint was granted.

In this case, St. Barnabas Hospital sought to recover no-fault medical payments under two insurance contracts. Allstate Insurance Company issued a denial of claim within 30 days, but the denial was found to be defective. Allstate sought to vacate the judgment in favor of St. Barnabas Hospital, but the court held that the denial was defective, Allstate failed to demonstrate a meritorious defense, and the judgment in favor of St. Barnabas Hospital was upheld. Therefore, the Supreme Court ruled in favor of St. Barnabas Hospital in the amount of $4,309.64. The main issues decided were the timeliness and validity of Allstate's denial of claim, and the main holding of the case is that the denial was defective, and the judgment in favor of St. Barnabas Hospital was upheld.

The court considered the claim by Delta Diagnostic Radiology, P.C. as assignee of Frank Louigarde to recover assigned first-party no-fault benefits. The main issues decided were whether the claim was untimely because it was submitted more than 45 days after the services were rendered, and whether plaintiff's motion for summary judgment was premature due to failure to respond to defendant's discovery demands. The holding of the court was that although the claim was submitted late, the defendant waived its right to deny the claim based on the 45-day rule because it failed to communicate that late submission of the proof of claim could be excused. The court also found that defendant failed to demonstrate that discovery was needed to show the existence of a triable issue of fact, and as such, the judgment in favor of plaintiff was affirmed.

The main issues in this case were whether the defendant should be granted leave to amend its answer to include the defense of fraudulent incorporation and whether the plaintiff should be compelled to produce its owner, Valentina Anikeyeva, for a deposition. The court considered whether the proposed affirmative defense of fraudulent incorporation was devoid of merit or palpably insufficient as a matter of law, as well as whether the plaintiff's contention that the defense of fraudulent incorporation must be asserted in a timely denial of claim form was valid. The holding of the case was that the Civil Court did not err in granting the defendant's application for leave to amend its answer and in compelling the plaintiff to produce its owner for a deposition, as the proposed defense was not devoid of merit, and the deposition testimony of Ms. Anikeyeva regarding the plaintiff's corporate structure was considered material and necessary. The court held that prejudice or surprise resulting directly from the delay would be necessary to disallow the Mallela defense, and as such, the analysis regarding the defense of fraudulent incorporation was unwarranted.

The relevant facts involved in the case were a dispute over first-party no-fault benefits being sought by a medical provider. The main issues considered by the court were whether the plaintiff had established its entitlement to summary judgment in seeking these benefits, and whether the defendant had raised a triable issue of fact to dispute the plaintiff's claim. The holding of the case was that the plaintiff had not sufficiently established its entitlement to summary judgment, and that the defendant had indeed raised a triable issue of fact, therefore the plaintiff's motion for summary judgment was denied. The court declined the defendant's request to search the record and grant summary judgment in their favor.