No-Fault Case Law

The relevant facts of the case were that a healthcare provider had rendered acupuncture services and sought to recover payments from an insurance company. The insurance company had reimbursed the healthcare provider using the workers' compensation fee schedule applicable to chiropractors who render the same services. The main issue was whether the insurance company had properly reimbursed the healthcare provider for the services rendered. The holding of the case was that the workers' compensation fee schedule was of sufficient authenticity and reliability to be given judicial notice. The insurance company had fully paid the healthcare provider for the services billed under certain codes in accordance with the fee schedule, so the complaint was dismissed for these claims. However, the healthcare provider's claim for the initial acupuncture visit on a specific date was granted, and the insurance company's cross-motion for summary judgment was granted in dismissing the remaining claims.

The relevant facts considered by the court were that an action was filed by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether the action was barred by the statute of limitations. The holding of the case was that the defendant had not met its initial burden of establishing that the time in which to sue had expired, and therefore the court reversed the order and denied the defendant's motion to dismiss the complaint. The court found that the defendant failed to demonstrate that the bills received were the subject of the action, and therefore the time in which to sue had not expired.

The case involved an action by a medical services provider to recover assigned first-party no-fault benefits. The provider moved for summary judgment, while the defendant insurance company cross-moved for summary judgment, arguing that the plaintiff's assignor had failed to attend independent medical examinations (IMEs). The Civil Court denied both motions, and the defendant appealed the denial of its cross motion for summary judgment. In support of its cross motion, the defendant submitted evidence that the IME requests had been timely mailed and that the plaintiff's assignor had failed to appear for the scheduled IMEs. The defendant also demonstrated that the claim denial forms had been timely mailed. The court held that the assignor's appearance at an IME was a condition precedent to the insurer's liability, and since the assignor failed to satisfy this condition precedent, the insurer properly denied the claims. Therefore, the court reversed the order, granted the defendant's cross motion for summary judgment, and held that the defendant was not precluded from raising the issue of the assignor's failure to satisfy the condition precedent to coverage. The remaining contentions raised on appeal were not reached in light of this determination.

A provider sued MVAIC for assigned first-party no-fault benefits and was granted summary judgment for $3,233.77. MVAIC argued that the assignor was not a qualified person because he failed to give it written proof of lack of insurance. The Appellate Term held that the assignor's qualified person status under Insurance Law 5202(b) does not depend on MVAIC's receipt of such documents, that the provider established its prima facie case, and that MVAIC's remaining contentions were raised for the first time on appeal and not properly before the court. The judgment was affirmed, with one justice concurring in the result in a separate memorandum.

After a nonjury trial of a provider's action for assigned first-party no-fault benefits, the sole issue was the medical necessity of chiropractic treatment. The defendant's expert, who had performed two independent medical examinations, testified that the treatment was not medically necessary, and the Civil Court found for the provider in the amount of $4,246.20. The Appellate Term affirmed. It deferred to the trial court's credibility assessment and found support for its conclusion that the insurer failed to meet its burden of proving that the services were not medically necessary. One justice dissented, arguing that the finding was erroneous and that the complaint should have been dismissed.

The court considered the defendant's appeal from an order of the Civil Court of the City of New York, Bronx County, which denied its motion for summary judgment dismissing the complaint. The main issue decided was whether the defendant properly mailed initial and follow-up notices of independent medical examinations (IMEs) to the assignor and her attorney, and if the assignor's failure to appear at the IME was reasonable. The court held that the defendant's submissions established prima facie evidence that it properly mailed the IME notices and that the assignor's failure to attend was not reasonable. Therefore, the court reversed the order, granted the defendant's motion for summary judgment, and dismissed the complaint.

The court considered the motion for summary judgment filed by the defendant in relation to a complaint brought by the plaintiff to recover first-party no-fault benefits. The main issue in this case was whether the medical supplies provided by the plaintiff to its assignor were medically necessary. The court held that the defendant's submissions established prima facie that the medical supplies were not medically necessary, and the plaintiff failed to present evidence to raise a triable issue of fact in opposition. Additionally, the court found that the medical report relied upon by the plaintiff was not properly sworn and should not have been considered. Therefore, the court granted the defendant's motion for summary judgment and dismissed the complaint.

Providers sued American Transit Insurance Company for first-party no-fault benefits and were granted summary judgment in Civil Court, New York County. The Appellate Term, First Department, agreed that the providers made a prima facie showing by proving that the statutory billing forms were mailed to and received by the insurer on January 22, 2001, and that payment was overdue. The insurer failed to raise a triable issue in opposition. The court held that the providers were entitled to statutory interest from 30 days after the claims were presented, and remanded to Civil Court to calculate interest, taking into account any tolling under Insurance Law 5106(a). The order was otherwise affirmed.

The main issues at hand was a no-fault action where the defendant moved for summary judgment to dismiss the case based on the opinions of its peer review doctor, who found that three MRIs were not medically necessary. The plaintiff argued that it needed to obtain copies of the medical records in order to make a proper opposition to the motion. The court found that the plaintiff needed to have access to the underlying medical records and that it may lead to relevant evidence. The plaintiff, being a diagnostic facility, lacked personal knowledge of the facts which established the medical necessity of the MRIs and therefore was entitled to the benefit of the law which stated that facts essential to justify opposition were exclusively within the knowledge and control of the nonparty treating physicians and the defendant's peer review doctor. So, the court had the discretion to deny the defendant's motion for summary judgment or order a continuance to allow the plaintiff to pursue disclosure of the underlying medical records.

The relevant facts of the case involved a dispute between Darlington Medical Diagnostics, P.C. and Praetorian Insurance Company regarding the payment of no-fault benefits. The main issue decided by the court was whether the insurer was obligated to pay or deny a claim for no-fault benefits before receiving verification of the information requested. The court held that the insurer is not obligated to do so and that it had established its prima facie entitlement to summary judgment dismissing the claim as premature, as the plaintiff failed to respond to the insurer's verification requests. The court also found that the plaintiff's denial of receipt of the initial verification letter was insufficient to raise a triable issue, and therefore granted the insurer's motion for summary judgment and dismissed the complaint.