No-Fault Case Law
Bronx Expert Radiology, P.C. v Motor Veh. Acc. Indem. Corp. (2012 NY Slip Op 51617(U))
August 29, 2012
MVAIC failed to raise a coverage issue where the putative insurer's letter stated that the striking vehicle was uninsured on the accident date. The provider established prima facie entitlement to summary judgment for assigned first-party no-fault benefits. Under Matter of MVAIC v Interboro Med. Care & Diagnostic PC, MVAIC bore the burden of proving its lack-of-coverage defense. Given the denial letter, its submissions did not raise a triable issue whether an insurance policy was in effect when the accident occurred. The Appellate Term, First Department, affirmed the order granting the provider's motion and denying MVAIC's cross motion for summary judgment dismissing the complaint.
Dover Acupuncture, P.C. v Motor Veh. Acc. Indem. Corp. (2012 NY Slip Op 51619(U))
August 29, 2012
MVAIC's conflicting evidence of notice receipt and its own proof of absent insurance defeated its summary judgment motion. In the provider's action for first-party no-fault benefits, MVAIC failed to eliminate triable issues concerning timely filing of the assignor's notice of intention to file a claim because its evidence conflicted on the receipt date. It also failed to establish that the assignor was not a qualified person. Its submissions included the putative insurer's denial form stating that the vehicle carrying the assignor was uninsured on the accident date, defeating its threshold showing that coverage existed. The Appellate Term, First Department, affirmed the order denying MVAIC summary judgment dismissing the complaint.
VE Med. Care, P.C. v NY Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51659(U))
August 27, 2012
The insurer proved timely denials and an unrebutted lack of medical necessity through its litigation examiner's affidavit and IME report. The provider appealed an order granting the insurer summary judgment dismissing its action for assigned no-fault benefits. Contrary to the provider's arguments, the litigation examiner's affidavit established timely denial of the claims. The affirmed IME report supplied a factual basis and medical rationale for the doctor's determination that the services lacked medical necessity. The provider failed to rebut the insurer's prima facie showing. The Appellate Term, Second Department, affirmed the order granting the insurer's motion.
Jamaica Med. Supply, Inc. v NY City Tr. Auth. (2012 NY Slip Op 51660(U))
August 27, 2012
The transit authority established late accident notice, and the provider supplied neither contrary proof nor justification for the delay. The claims examiner proved timely mailing of the denial and first receipt of accident notice through an NF-2 submitted more than 30 days after the accident, contrary to 11 NYCRR 65-2.4. The provider merely speculated that notice arrived earlier and showed no use of the opportunity to provide clear and reasonable written justification under 11 NYCRR 65-1.1 and 65-2.4 (b). Referring to the person who could justify the delay as the applicant did not invalidate the denial because regulations use that term for providers and injured persons. The Appellate Term, Second Department, affirmed summary judgment dismissing the complaint.
North Bronx Med. Health Care v NY Cent. Mut. Ins. Co. (2012 NY Slip Op 51658(U))
August 24, 2012
The provider's medical affirmation failed to rebut the insurer's IME and peer review conclusions that the disputed services were unnecessary. The insurer appealed the denial of summary judgment on three claims for assigned no-fault benefits. Its affirmed reports each supplied a factual basis and medical rationale for finding a lack of medical necessity. The provider's doctor did not meaningfully address either report's conclusions, and the provider did not challenge the finding that the insurer was otherwise entitled to judgment on those claims. The Appellate Term, Second Department, reversed the order, insofar as appealed from, and granted summary judgment dismissing the three claims.
Viviane Etienne Med. Care, P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51655(U))
August 24, 2012
The insurer proved timely denials and lack of medical necessity for four claims, but failed to prove timely denials of two others. The provider appealed the grant of the insurer's cross motion for summary judgment dismissing its assigned no-fault action. A claims employee's affidavit established timely mailing of denials for two claims and the unpaid portions of two partially paid claims. Affirmed peer review and IME reports supported the medical-necessity defense, which the provider did not rebut. The Appellate Term, Second Department, modified the order, insofar as appealed from, to grant dismissal only of those two claims and unpaid portions, leaving the other two claims pending because timely denial was not established.
Acupuncture Works, P.C. v State Farm Mut. Auto. Ins. Co. (2012 NY Slip Op 51654(U))
August 24, 2012
The insurer established full payment under the applicable acupuncture fee schedule and unrebutted lack of medical necessity for other claims. Its moving papers proved timely mailing of the denials. For the fee-schedule claims, the insurer showed payment of the amounts allowed for acupuncture services rendered by a chiropractor, following Great Wall Acupuncture, P.C. v GEICO Ins. Co. For the remaining claims, its acupuncturist's sworn IME report established lack of medical necessity, and the provider's acupuncturist failed to meaningfully address the conclusions. The Appellate Term, Second Department, affirmed the judgment dismissing the complaint, upholding summary judgment for the insurer and denial of the provider's cross motion.
Neomy Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2012 NY Slip Op 51653(U))
August 24, 2012
The insurer proved timely IME notices and denials and the assignor's nonappearance, while the provider failed to raise a factual issue. The scheduling entity's employee established timely mailing of the IME letters, the examining chiropractor/acupuncturist confirmed nonappearance, and the insurer's litigation examiner established timely denials on that ground. Following Stephen Fogel Psychological, P.C. v Progressive Cas. Ins. Co., that proof established the insurer's entitlement to judgment. The provider submitted only a counsel affirmation that raised no triable issue. The Appellate Term, Second Department, reversed the order, denied the provider's summary judgment motion, and granted the insurer's cross motion dismissing the complaint, without reaching any other issue.
Li-Elle Servs., Inc. v Motor Veh. Acc. Indem. Corp. (2012 NY Slip Op 51588(U))
August 24, 2012
MVAIC's summary judgment motion was denied because it failed to establish that the assignor was not a qualified person entitled to no-fault coverage. The Appellate Term, First Department, affirmed, relying on MVAIC's failure to meet its initial burden, which required denial irrespective of the sufficiency of the provider's opposition.
Jamhil Med., P.C. v MVAIC (2012 NY Slip Op 51650(U))
August 24, 2012
MVAIC established that the assignor was not a covered person because no timely notice of claim was filed and no leave for late filing was sought. The failure to comply with Insurance Law § 5208 (a) and (c) defeated covered-person status under Insurance Law § 5221 (b) (2). A condition precedent to the provider's right to apply for payment of assigned no-fault benefits therefore remained unsatisfied. The Appellate Term, Second Department, reversed the order denying MVAIC's motion for summary judgment and granted the motion dismissing the complaint.