No-Fault Case Law

The main issue in the case was whether Plaintiff sought a declaratory judgment pursuant to CPLR 3001 claiming they were not legally obligated to pay any claims submitted by the defendants due to their wrongful conduct. Specifically, the Plaintiff alleged that the defendants failed to comply with New York State statutes, submitted bills for services not provided, and failed to provide verification and attend EUOs. Plaintiff sought a declaration asserting it was under no obligation to pay any insurance claims submitted by the defendants. The court raised the issue of severance, at least insofar as relief is sought against each of the 12 PC Defendants and the main holding of the case was refusal to extend the "stay" contained in the Order to Show Cause. The court also raised the issue of the party submitting supplemental memoranda on the issue of severance.

The relevant facts considered by the court included an action by a provider to recover assigned first-party no-fault benefits. The provider moved for summary judgment, but the insurance company opposed the motion and cross-moved for summary judgment dismissing the complaint, arguing that the injuries sustained did not arise out of an insured incident. The main issue decided by the court was whether there was a lack of coverage due to the injuries not arising from an insured incident, possibly being sustained in a staged accident. The holding of the case was that while the insurance company demonstrated a "founded belief" to defeat the provider's motion for summary judgment, it failed to submit sufficient evidence to establish, as a matter of law, that the injuries did not arise from an insured incident. Therefore, neither the provider nor the insurance company was entitled to summary judgment. The amended order was modified to deny the insurance company's cross motion for summary judgment dismissing the complaint.

The relevant facts considered by the court in this case were that the defendant had moved for leave to reargue its prior motion for summary judgment dismissing the complaint, which was initially denied due to a lacking certificate of conformity. The main issue decided by the court was whether the defendant's insured's vehicle was involved in the accident in which the plaintiff's assignor was allegedly injured. The holding of the case was that the defendant had established its prima facie entitlement to judgment by showing that its insured's vehicle was not involved in the accident, and the plaintiff failed to rebut the assertions contained in the defendant's insured's affidavit. Therefore, the Civil Court properly granted the defendant's motion for summary judgment dismissing the complaint.

The court considered the issue of the rate of reimbursement for acupuncture treatments provided by licensed acupuncturists, specifically whether the defendant could use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which the plaintiff was entitled to receive for the acupuncture sessions. The main issues decided were whether the defendant had reimbursed the plaintiff at the appropriate rate and whether the plaintiff was entitled to reimbursement for the remaining claims that were denied on the grounds of untimely submission and lack of medical necessity. The holding of the case was that the judgment awarded to the plaintiff in the sum of $1,718.40 was correct and the appeal was dismissed. Therefore, the plaintiff was not aggrieved by the judgment and the appeal was dismissed.

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.