No-Fault Case Law

Bronxborough Med., P.C. v Travelers Ins. Co. (2008 NY Slip Op 28343)

The relevant facts in the case of Bronxborough Medical, P.C. v Travelers Insurance Co. involved a provider who sought to recover assigned first-party no-fault benefits from the insurance company. The issue at hand was that the provider wanted to serve a subpoena on the insurance company to produce an employee outside the City of New York, in which the lower court found that the provider did not offer a valid reason to permit service of the subpoena outside the city. The main issue decided by the court was whether the interests of justice would be served by allowing the provider to serve a subpoena outside the City of New York, and the court held that the provider's motion was properly denied because it failed to establish that the interests of justice would be served or set forth the location at which the subpoena was to be served. Additionally, the court noted that if the provider believed that the insurance company's response to its notice to admit was improper, its remedy lies in the procedure set forth in CPLR 3123 (c). The order was affirmed without costs.
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Eagle Surgical Supply, Inc. v Progressive Cas. Ins. Co. (2008 NY Slip Op 28342)

The relevant issues of the case were whether the insurer scheduled an examination under oath within 30 days of receiving a no-fault claim, and if the exclusion of the phrase "examination under oath" from the Insurance Department Regulations indicated a clear intention. The appellant, Eagle Surgical Supply, Inc., contended that it was not established by the defendant's Progressive Casualty Insurance Co. that they verified the outstanding no-fault claims because the initial EUO was not scheduled within 30 days of receiving the plaintiff's claim. The defendant demonstrated that the insurance policy in effect when the EUOs were sought contained an endorsement authorizing the verification and established that the EUO scheduling letters were timely mailed, as no additional verification was required. The court held that the insurer did not employ red tape dilatory practices and that the plaintiff's claims were not overdue, and defendant was properly granted summary judgment dismissing the action as premature.
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Careplus Med. Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 28341)

The case involved a dispute between a provider, Careplus Medical Supply, Inc., and an insurance company, New York Central Mutual Fire Insurance Company, regarding medical necessities for supplies provided. Careplus Medical moved for summary judgment to recover first-party no-fault benefits, claiming that the insurance company did not comply with their request for copies of the peer review reports that were the basis for the denial of their claim forms. The insurance company had defended its actions by stating they had timely denied the claims on the grounds that the supplies provided were not medically necessary. The Court held that an insurer's submission of a denial of claim form based on a peer review report is sufficient to raise the defense of lack of medical necessity even if the specific factual basis and medical rationale is not set out in the denial of claim form. The Appellate Division affirmed that defendant's opposition papers established a triable issue of fact based on a defense of medical necessity and therefore the lower court properly denied plaintiff's motion for summary judgment.
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One Beacon Ins. Group, LLC v Midland Med. Care, P.C. (2008 NY Slip Op 06813)

The case revolved around an insurance company's lawsuit against various medical service corporations and individuals, alleging fraud and unjust enrichment, and seeking a judgment declaring that they are not obligated to pay certain medical claims. The main issue was whether the radiology practice, Proscan Imaging, P.C., was fraudulently incorporated. The evidence demonstrated that Proscan may have been controlled by unlicensed individuals in violation of the Business Corporation Law. As a result, the court held that there was enough evidence to suggest fraudulent incorporation and that the defendant's motion for summary judgment was properly denied. They were also ordered to allow disclosure of financial documents relevant to the case.
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Manhattan Med. Imaging, P.C. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 51844(U))

The court considered whether the defendant insurer had presented sufficient evidence to support its late denial based upon fraud to withstand the granting of summary judgment to a plaintiff medical services provider in a no-fault case. The main issues decided were whether the defendant insurer's denials were untimely, and whether the defendant insurer was precluded from raising the defense that the plaintiff medical service provider was fraudulently incorporated. The court held that the plaintiff had made a prima facie showing and that the burden shifted to the defendant to show a triable issue of fact. The court also held that the defendant was not precluded from raising its defense that the plaintiff may be fraudulently incorporated, and that the defendant had articulated a "founded belief" that the plaintiff is fraudulently incorporated, raising an issue of fact.
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Ying E. Acupuncture, P.C. v Global Liberty Ins. (2008 NY Slip Op 51863(U))

The court considered the case of Ying Eastern Acupuncture, P.C. as assignee of Marina Lyalin v Global Liberty Insurance. The main issue was to determine whether the defendant's opposition papers failed to include a report showing the alleged concurrent care and therefore whether the plaintiff was entitled to summary judgment. The holding of the court was that the defendant did not establish that the denials of the claims were timely mailed, and therefore plaintiff was entitled to summary judgment on most claims. However, for a few other claims, plaintiff's motion for summary judgment should have been denied as the defendant failed to establish an issue of fact with respect to their defense. As a result, the plaintiff was awarded partial summary judgment on certain claims, with the matter being remanded to the lower court for further proceedings.
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Align for Health Chiropractic, P.C. v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 51862(U))

The relevant facts the court considered were that Align for Health Chiropractic filed suit to recover first-party no-fault benefits, based on their affidavit and documents they claimed as business records. The main issue was whether the affidavit and documents presented by Align for Health Chiropractic were sufficient to establish their right to summary judgment. The court found that the affidavit and documents were not sufficient to establish their right to summary judgment. The holding of the court was that the denial of Align for Health Chiropractic's motion for summary judgment was proper, but that the defendant failed to demonstrate that they timely mailed the verification and follow-up verification requests, and therefore, their cross motion for summary judgment should have been denied.
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Midisland Med., PLLC v Allstate Ins. Co. (2008 NY Slip Op 51861(U))

The main issues considered in this case were whether the insurance company, Allstate, had a valid defense of lack of medical necessity for four claims submitted by Midisland Medical, PLLC. The court found that Allstate had validly denied two of the claims based on lack of medical necessity, but had not addressed the mailing of the denials for the other two claims, therefore precluding the defense. As a result, the court granted summary judgment to Midisland Medical for the two claims that were not properly addressed by Allstate, and remanded the case for further proceedings on the remaining claim. The holding of the court was that Midisland Medical was entitled to summary judgment on two of the four claims and the case was remanded for further proceedings.
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A.B. Med. Servs., PLLC v Utica Mut. Ins. Co. (2008 NY Slip Op 51859(U))

The relevant facts the court considered in this case included an action by medical service providers to recover assigned first-party no-fault benefits, and the denial of the plaintiffs' motion for summary judgment by the court below. The main issue decided was whether the affidavit executed by plaintiffs' medical billing manager was sufficient to lay a foundation for the admission, as business records, of the documents annexed to plaintiffs' moving papers. The holding of the case was that the affidavits submitted by defendant's investigators were sufficient to demonstrate that defendant possessed a "founded belief that the alleged injuries do not arise out of an insured incident," therefore demonstrating the existence of a triable issue of fact as to whether there was a lack of coverage. Consequently, the order denying plaintiffs' motion for summary judgment was affirmed.
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Orthotic Surgical & Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 51858(U))

The main issue in this case was whether a medical equipment provider could recover assigned first-party no-fault benefits from an insurance company. The court considered the evidence presented by both parties, including a peer review report that determined the medical supplies were not medically necessary, and an affidavit from the chiropractor who conducted the peer review. The court ultimately held that the denial of the claim form was sufficient to avoid preclusion of the defense of lack of medical necessity, and that the evidence presented by the defendant demonstrated the existence of a triable issue of fact as to medical necessity. As a result, the court reversed the judgment, vacated the order granting the plaintiff's motion for summary judgment, and denied the motion for summary judgment.
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