No-Fault Case Law
Supple Mind Acupuncture, P.C. v State Farm Ins. Co. (2008 NY Slip Op 51856(U))
September 2, 2008
The court considered a case in which Supple Mind Acupuncture, P.C. was seeking to recover assigned first-party no-fault benefits from State Farm Insurance Company. The parties stipulated that Supple Mind Acupuncture proved its prima facie case, but the sole issue at trial was whether the injuries sustained by the plaintiff's assignor were caused by the accident. State Farm's expert testified that the force of the impact was minimal and the injuries could not have been caused by the accident. However, the expert's testimony and report relied almost exclusively on hearsay evidence, and State Farm did not present any testimony to show that the material relied upon by the expert was accepted in the profession as reliable. As a result, the court held that the expert's testimony and report were inadmissible, and the judgment in favor of Supple Mind Acupuncture was affirmed.
Astoria Quality Med. Supply v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 51855(U))
September 2, 2008
The court considered the plaintiff's action to recover no-fault benefits as assignee of three individuals and the defendant's motion to sever the causes of action into separate actions due to three separate and distinct claims involving different questions of fact and law. The main issue was whether the claims, arising out of three separate motor vehicle accidents and three insurance policies, should be severed into separate actions. The court held that the decision to grant severance was an exercise of judicial discretion and that, in the absence of a party's showing of prejudice to a substantial right, should not be disturbed on appeal. The court further held that the particular facts relating to each claim at issue were likely to raise few, if any, common issues of law or fact, and that a single trial involving different sets of facts regarding three underlying accidents and injuries would pose the danger of being unwieldy and confusing. Therefore, the court affirmed the order granting defendant's motion to sever the causes of action.
Delta Diagnostic Radiology, P.C. v Unitrin Advantage Ins. Co. (2008 NY Slip Op 51854(U))
September 2, 2008
The relevant facts considered by the court were that Delta Diagnostic Radiology, P.C. was seeking to recover first-party no-fault benefits from Unitrin Advantage Insurance Company, and the court granted Delta Diagnostic Radiology's motion for summary judgment. However, Unitrin Advantage Insurance Company appealed the decision, arguing that the affidavit submitted by Delta Diagnostic Radiology's officer did not lay a proper foundation for the admission of the documents annexed to the moving papers, and therefore Delta Diagnostic Radiology failed to establish a prima facie case.
The main issue decided by the court was whether Delta Diagnostic Radiology had provided sufficient evidence to demonstrate its entitlement to summary judgment. The court held that the affidavit submitted by Delta Diagnostic Radiology's officer was insufficient to demonstrate personal knowledge of the company's practices and procedures, and thus failed to lay a proper foundation for the admission of the documents annexed to the moving papers. As a result, the court reversed the judgment, vacated the order granting Delta Diagnostic Radiology's motion for summary judgment, and denied Delta Diagnostic Radiology's motion for summary judgment, without costs.
A.T. Med., P.C. v American Tr. Ins. Co. (2008 NY Slip Op 51853(U))
September 2, 2008
The court considered whether the plaintiff, A.T. Medical, P.C., was entitled to summary judgment to recover assigned first-party no-fault benefits from American Transit Insurance Company. The main issue decided was whether the plaintiff made a prima facie showing that the claims were submitted to the defendant, as required by Insurance Law § 5106(a). The court held that the plaintiff failed to establish that the claims were mailed to the defendant, as the affidavit and post office ledger provided were insufficient to prove mailing, and the plaintiff's attorney's affirmation was unsubstantiated hearsay. Additionally, the affidavit by the plaintiff's corporate officer failed to lay a proper foundation for the admission of the documents annexed to the moving papers. Therefore, the plaintiff's motion for summary judgment was denied, and the judgment awarding the plaintiff the principal sum of $7,791.06 was reversed.
Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. (2008 NY Slip Op 51852(U))
September 2, 2008
The court considered the denial of first-party no-fault benefits by the insurance company based on peer review reports that found a lack of medical necessity for the services provided by the plaintiff. The main issue was whether the denial of the claims was valid and whether the insurer sufficiently informed the plaintiff of the reasons for the denial. The court held that the denial of the claims was not vague or misleading, as the insurer's NF-10 denial of claim forms clearly stated the basis for the denial and the accompanying explanation of benefits forms provided further explanation. The court also held that it was improper for the court to grant summary judgment to the defendant based on the issue of medical necessity since this was not the subject of the plaintiff's motion for summary judgment. Therefore, the judgment denying the plaintiff's motion for summary judgment and granting summary judgment to the defendant was reversed.
Complete Med. Care Servs. of NY, P.C. v State Farm Mut. Auto. Ins. Co. (2008 NY Slip Op 28324)
August 22, 2008
The court was asked to determine the medical necessity of electromyogram testing and nerve conduction velocity testing performed on the plaintiff's assignor, Vanessa Garcia, for injuries sustained in a motor vehicle accident. The main issue in the case was whether the testing was done in a manner that rendered the results medically unnecessary, despite the fact that the tests were prescribed correctly. The court relied on previous decisions in similar cases to define what constitutes "medical necessity" and ultimately held that even if the tests were not conducted properly, reimbursement is warranted as long as they were medically necessary. The court found in favor of the plaintiff, as the defendant did not meet the burden of demonstrating a lack of medical necessity for the services rendered. Therefore, the plaintiff was awarded $2,832.14, plus statutory interest, attorney fees, and costs and disbursements.
Crossbridge Diagnostic Radiology, P.C. v Progressive Ins. Co. (2008 NY Slip Op 51761(U))
August 19, 2008
The court considered an action by a provider to recover assigned first-party no-fault benefits for services rendered to three assignors. The main issues decided were the denial of the provider's claims for services rendered to two assignors and the denial of the third assignor's claim based on failure to appear at a scheduled examination. The holding of the case was that provider made a prima facie showing of its entitlement to summary judgment with respect to two of the assignor's claims. However, with respect to the third assignor's claim, the evidence of notice that was sent to the assignor for the examination had not been rebutted, so it was incumbent upon the provider to establish that the assignor complied with the condition precedent. The judgment affirmed the denial of plaintiff's cross motion for summary judgment on its first and third causes of action and the granting of partial summary judgment to the defendant on those causes of action. However, the judgment also provided that plaintiff's cross motion for summary judgment is granted to the extent of granting plaintiff summary judgment on its second cause of action, but was remanded back to the court below for further proceedings.
Midisland Med., PLLC v Allstate Ins. Co. (2008 NY Slip Op 51760(U))
August 19, 2008
The relevant facts considered in this case involved a provider seeking to recover assigned first-party no-fault benefits. The provider moved for summary judgment, which was initially granted by the court. The defendant insurance company subsequently appealed the decision, arguing that the affirmation submitted by the provider's officer did not lay a proper foundation for the admission of the documents annexed to the provider's moving papers. The main issue to be decided was whether the provider had established a prima facie case for entitlement to summary judgment by demonstrating that the no-fault claim forms were submitted to the defendant in admissible form as business records. The holding of the court was that the affirmation submitted by the provider's treating doctor was not sufficient to establish a foundation for the claim forms, and that the provider failed to make a prima facie showing of entitlement to summary judgment. Therefore, the judgment was reversed, and the provider's motion for summary judgment was denied.
Mid Atl. Med., P.C. v Victoria Select Ins. Co. (2008 NY Slip Op 51758(U))
August 19, 2008
In this case, Mid Atlantic Medical, P.C. sought to recover first-party no-fault benefits from Victoria Select Ins. Co. Plaintiff sought summary judgment, while the defendant cross-moved to dismiss the complaint based on a Virginia court's order rescinding the insurance policy. The court denied plaintiff's motion for summary judgment and granted defendant's cross-motion to dismiss the complaint. Plaintiff appealed the decision. Defendant was not allowed to invoke collateral estoppel against plaintiff since plaintiff was not a party to the Virginia proceeding. However, the court found that defendant raised a triable issue of fact as to whether there was coverage under the insurance policy. Therefore, the plaintiff's motion for summary judgment was properly denied. The decision was ultimately modified, with defendant's cross-motion to dismiss the complaint being denied and the order affirmed without costs.
Quality Health Prods., P.C. v Progressive Ins. Co. (2008 NY Slip Op 51757(U))
August 19, 2008
The main issue in this case was whether the plaintiff was entitled to summary judgment on its claim for first-party no-fault benefits from the defendant insurance company. The court considered whether the defendant's denial of the plaintiff's claims was timely and based on valid grounds, such as the supplies provided not being medically necessary and the assignor's failure to appear for two independent medical examinations (IMEs). The holding of the court was that the plaintiff's motion for summary judgment was granted on the claims for $1,021 and $289, as the defendant had failed to establish the assignor's nonappearance at the IMEs. However, the court denied the plaintiff's motion for summary judgment on the $694 claim, as the defendant had provided a sufficient and timely peer review report for denial. The case was remanded for the calculation of statutory interest and assessment of attorney's fees on the awarded claims.