No-Fault Case Law
Westchester Med. Ctr. v American Tr. Ins. Co. (2009 NY Slip Op 01979)
March 17, 2009
The relevant facts that the court considered were that Westchester Medical Center (WMC) initiated an action to recover no-fault medical benefits owed to Daphne McPherson, and that the defendant, American Transit Insurance Company, did not pay or deny such benefits within the required 30 days. The main issue was whether the defendant's request for additional verification of the claim and subsequent denial of benefits was timely, based on alleged receipt of verification that McPherson was entitled to workers' compensation benefits. The holding of the court was that the defendant did make a timely request for additional verification of the claim, and that its denial of benefits was timely. As a result, the judgment in favor of WMC was reversed, and the defendant was awarded summary judgment dismissing WMC's cause of action.
Audobon Physical Med & Rehab, P.C. v GEICO Ins. Co. (2009 NY Slip Op 50456(U))
March 16, 2009
The relevant facts included a provider seeking to recover assigned first-party no-fault benefits, moving for summary judgment, and an insurance company opposing the motion. The main issues were whether payment of no-fault benefits was overdue and whether verification requests for independent medical examinations (IMEs) were properly mailed and whether the assignor failed to appear at the IMEs. The holding was that plaintiff's motion for summary judgment upon its first cause of action was granted, denying the defendant's summary judgment request on the second cause of action, and remanding the matter to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees upon said cause of action.
Park Slope Med. & Surgical Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2009 NY Slip Op 50441(U))
March 12, 2009
The court considered a case in which a medical supply provider sought to recover assigned first-party no-fault benefits. The provider moved for summary judgment, while the insurance company cross-moved for summary judgment, claiming lack of medical necessity for the supplies provided. The court denied both motions, finding that an issue of fact existed as to whether the supplies were medically necessary. The insurance company established a prima facie case of lack of medical necessity, but the provider's submission of an affidavit from a doctor demonstrated the existence of an issue of fact as to medical necessity. As a result, the court affirmed the decision to deny the insurance company's cross motion for summary judgment.
Daras v GEICO Ins. Co. (2009 NY Slip Op 50438(U))
March 10, 2009
The relevant facts the court considered in this case involved a medical provider seeking to recover no-fault benefits from an insurance company. The provider moved for summary judgment, but the insurance company argued that the provider did not establish a prima facie case and that the assignor failed to appear for scheduled independent medical examinations (IMEs). The court found that the provider had submitted claim forms and established the amount of the loss sustained, and that payment of the benefits was overdue, thus meeting the prima facie requirement for summary judgment. The insurance company did not provide proof that the IME requests were timely mailed to the assignor and that the assignor failed to appear for the examinations. As a result, the court granted the provider's motion for summary judgment and remanded the matter for the calculation of interest and an assessment of attorney's fees.
PDG Psychological, P.C. v Travelers Ins. Co. (2009 NY Slip Op 50437(U))
March 10, 2009
The court considered the fact that the plaintiff sought to recover assigned first-party no-fault benefits and attempted to lay a foundation for the admission of its claim forms by presenting the testimony of an employee. The main issue decided was whether the plaintiff provided sufficient evidence to prove its case. The holding of the case was that the plaintiff did not meet its burden to proffer evidence in admissible form and failed to demonstrate that the witness possessed sufficient personal knowledge of the office practices and procedures to lay a foundation for the admission of the documents as business records. Therefore, the court affirmed the judgment that dismissed the complaint due to the plaintiff's failure to make a prima facie showing.
PDG Psychological, P.C. v Progressive Cas. Ins. Co. (2009 NY Slip Op 50436(U))
March 10, 2009
The court considered the testimony of witnesses and the admissibility of plaintiff's purported claim form in an action to recover assigned first-party no-fault benefits. Plaintiff's file clerk testified and sought to admit the claim form, but defendant objected on hearsay grounds. The court also heard testimony from defendant's litigation specialist. Despite this, the Civil Court did not admit plaintiff's bill into evidence and granted defendant's motion for a directed verdict. The main issue was whether plaintiff had made a prima facie case to recover the benefits. The court held that the testimony did not demonstrate sufficient personal knowledge to establish the admissibility of the bill as a business record, and therefore plaintiff failed to establish a prima facie case. The judgment dismissing the complaint was affirmed.
Careplus Med. Supply, Inc. v Selective Ins. Co. of Am. (2009 NY Slip Op 29109)
March 10, 2009
The case involves an insurance dispute where Careplus Medical Supply Inc. tried to recover assigned first party no-fault benefits. The insurance company Selective Insurance Company of America denied the claim, arguing that the supplies provided were not medically necessary under New Jersey law. The main issue in this case was the conflict of law between New York and New Jersey law. The Court decided that since most of the factors such as the place of contracting and the domicile of the insurance policyholder were in New Jersey, the law of New Jersey regarding medical necessity should control. Therefore, the Court held that the insurance company could raise the defense of lack of medical necessity as per New Jersey law, meaning that Selective Insurance Company of America could raise a triable issue of fact regarding their denial of the claim. The court affirmed the District Court's decision.
Midwood Acupuncture, P.C. v Allstate Ins. Co. (2009 NY Slip Op 50459(U))
March 6, 2009
The relevant facts in this case included Midwood Acupuncture, P.C. seeking to recover no-fault benefits from Allstate Insurance Company for acupuncture services performed by its licensed acupuncturist for its assignor, Yensi Alan. The defendant contended that it was entitled to remit payment at the chiropractic rate indicated in the Workers' Compensation Fee Schedule, as it did not specifically address licensed acupuncturists. The plaintiff argued that the defendant was required to reveal its procedures for choosing the rate and the calculation of the amount. The main issue was whether the defendant had proper grounds for denying full payment of the no-fault benefits based upon the Workers' Compensation Fee Schedule for chiropractic services. The court held that based on the credible evidence submitted, the defendant had shouldered its burden of producing a proper grounds for denying full payment of the no-fault benefits, and therefore, judgment was in favor of the defendant and the complaint was dismissed.
Dilon Med. Supply Corp. v Travelers Ins. Co. (2009 NY Slip Op 50389(U))
March 5, 2009
The main issue in this case was whether the provider had established a prima facie case to recover assigned first-party no-fault benefits. The court considered the fact that at trial, the provider did not call any witnesses and instead relied on documents and exhibits to establish their case. However, the court held that without testimony from a witness to establish the admissibility of the documents, the provider failed to establish a prima facie case. As a result, the court affirmed the judgment dismissing the complaint, stating that it remained the provider's burden to proffer evidence in admissible form, such as by introducing the claim forms in question and calling a witness to lay a foundation for their admissibility as business records. The court's holding was that the provider did not establish a prima facie case and the insurer was entitled to judgment dismissing the complaint.
Prime Psychological Servs., P.C. v Nationwide Prop. & Cas. Ins. Co. (2009 NY Slip Op 29100)
March 5, 2009
The relevant facts in this case pertain to a hospital's claims for reimbursement for medical services provided to a patient involved in an automobile accident. The insurance company seeks to deny the claim based on the patient's failure to attend Examination Under Oath (EUO) requests sent prior to the receipt of a completed claim form. The main issue in the case is whether the notice requirements for verification requests applied to the EUOs noticed prior to the insurance company's receipt of claim forms. The court's holding is that the notice requirements for verification requests do not apply to preclaim EUOs, and that the insurance company was within its rights to request an EUO before receiving the completed claim form. The court also decides that an insurer's timely denial of a claim, based on an insured's failure to appear for a preclaim EUO, constitutes a breach of a condition precedent to payment and is a valid ground upon which to award summary judgment to the defendant.