No-Fault Case Law

The relevant facts the court considered in this case were that the plaintiff, a medical provider, sought to recover no-fault benefits for services rendered to its assignor. The plaintiff moved for summary judgment, but the defendant insurer argued that the plaintiff was not entitled to recover direct payment of assigned no-fault benefits because the services were not rendered by the plaintiff or its employees, but by a treating provider who was an independent contractor. The main issue decided by the court was whether the plaintiff, as a billing provider, was entitled to recover no-fault benefits for services rendered by an independent contractor treating provider. The court held that the plaintiff was not entitled to recover direct payment of assigned no-fault benefits from the defendant insurer, and therefore the plaintiff's motion for summary judgment was denied, while the defendant was awarded summary judgment and the complaint was dismissed.

The court considered the fact that the defendant requested for additional verification for the claims, and made an additional request after not receiving the requested verification. The main issue decided in this case was whether the defendant's denials of claims, all of which were issued more than 30 days after the defendant received the claims, were timely, given the circumstances. The court held that under these circumstances, the denials were not timely as a matter of law. The court found that the defendant's initial requests for verification tolled the 30-day period in which it had to pay or deny the claims, but the toll was eviscerated when the defendant failed to send out a follow-up request for the additional verification within the 10-day period specified in 11 NYCRR 65-3.6(b). Therefore, the plaintiff was entitled to judgment in the amount sued for.

The case involved consolidated lawsuits for first-party no-fault benefits for physical therapy services. The court reviewed the stipulated facts and briefs submitted by the parties to decide whether a physical therapist can use a billing code found in the medicine fee schedule when the services do not appear in the physical medicine fee schedule. Additionally, the court considered whether a physical therapist may bill for range of motion and muscle testing when an evaluation and management are billed for on the same day. The court determined that physical therapists are allowed to use a code from the medicine section to bill for services not specifically listed in the physical medicine section and that a defense regarding range of motion and muscle testing raised an issue of fact rather than an issue of law. As a result, the court made findings and awarded judgment in favor of the plaintiff for the disputed amounts in the cases.

In this case, Vista Surgical Supplies, Inc. sought to recover first-party no-fault benefits for medical supplies furnished to its assignor, Santiago Robinson. The main issue decided was whether the provider had established a prima facie entitlement to summary judgment by proof that it submitted the statutory claim forms and that payment of no-fault benefits was overdue. The court denied the defendant's cross motion for summary judgment and granted partial summary judgment to the appellant in the sum of $2,133 with further proceedings required to calculate interest and attorney's fees. The court found that while plaintiff established a prima facie case, they failed to establish their entitlement to summary judgment for a specific claim. Additionally, the court ruled that the timely denials of the claims precluded defenses to the action, and warranted the granting of summary judgment in favor of the plaintiff.

In this case, Montgomery Medical, P.C. filed a lawsuit against State Farm Insurance Company for failing to pay or deny claims for acupuncture services rendered to Dian Pringle following a motor vehicle accident. The main issue was whether the defendant failed to timely deny the claims, the medical necessity of the services, and the possible fraudulent incorporation of the medical provider. The court held that the defendant's denials of the claims were not timely and, therefore, it was precluded from offering evidence on the lack of medical necessity or concurrent care. Additionally, the court held that the defendant's objections to the proof of claim forms were precluded due to the failure to include them in a timely denial. However, the court ruled that questions about the fraudulent incorporation raised issues of fact which precluded summary judgment to the plaintiff. Therefore, both the plaintiff's motion and defendant's cross-motion for summary judgment were denied, and the plaintiff's motion seeking an order precluding defendant from offering any evidence was granted only with regard to information demanded in its discovery notices not previously provided by defendant, or already in plaintiff's possession.

The relevant facts the court considered involved an action to recover no-fault medical payments brought by the plaintiffs against the defendant. The plaintiffs appealed an order from the Supreme Court of Nassau County which granted the defendant's cross motion for summary judgment dismissing the third cause of action and awarded interest on the fourth cause of action until the date of the determination. The main issues decided were whether the plaintiffs were entitled to judgment as a matter of law on the second cause of action, as well as the appropriate time frame for awarding interest on the fourth cause of action. The holding of the case was that the plaintiffs were entitled to summary judgment on the second cause of action, as they submitted evidence that the defendant failed to pay the entire claim or issue a Denial of Claim Form in a timely manner. Additionally, the court held that the defendant was required to pay interest at a rate of 2% per month on the claim for the period commencing 30 days after the claim was presented until the date it was paid.

The Court of Appeals considered the case of Matter of New York Central Mutual Fire Insurance Company v. Aguirre, in which the key facts were that Jorge Aguirre and Rosa and Amanda Alzate were injured in a car accident involving a hit-and-run driver. New York Central Mutual issued an automobile insurance policy to the owner of the car, and the claimants sought underinsured motorist arbitration as a result of their injuries. The main issue decided was whether New York Central Mutual timely disclaimed liability or denied coverage within the meaning of Insurance Law § 3420 (d). The court held that the insurer's 48-day delay in notifying the insured of denial of coverage was unreasonable as a matter of law, and the delay in mailing proof-of-claim forms was not a reasonable basis for disclaiming coverage. Therefore, the order of the Appellate Division was reversed, with costs, and the petition to stay arbitration was dismissed.

Main Issues: Issue was whether plaintiff's motion to preclude the testimony of defendant's peer review expert on the ground that he did not prepare the peer review reports upon which defendant relied in denying the claims was valid. Decision: The court held that there was no basis to preclude the testimony of defendant's peer review expert, Dr. Gastaldi, as he was limited to testifying to the facts and opinions contained in the peer review reports, and the defendant preserved its right to defend the claims at trial on the ground of lack of medical necessity. The court also found that defendant complied with the rules pertaining to expert disclosure, and Dr. Gastaldi's testimony did not go beyond the facts and opinions contained in Dr. Cole's reports. No witnesses were called by the plaintiff to rebut his testimony. Consequently, the court ordered that judgment be entered in favor of the defendant, dismissing the complaint.

The court considered the fact that the plaintiff, Colonia Medical, P.C., was seeking to recover first-party no-fault benefits for medical services rendered to the assignor, Sherman Fraser. The main issue was whether the defendant, Travelers Insurance Company, had timely denied the plaintiff's claims based on the assignor's failure to attend independent medical examinations. The court held that the defendant failed to establish that it timely denied the plaintiff's claims, as it did not show that the statutory time period within which it had to pay or deny the claims was tolled by timely verification and follow-up requests. Therefore, the court reversed the order, granted the plaintiff's motion for summary judgment, and remanded the matter to the court below for the calculation of statutory interest and an assessment of attorney's fees.

The Appellate Term considered an appeal from an order of the District Court of Nassau County that denied the plaintiff's motion for summary judgment. The main issue was whether the defendant's timely denial of first-party no-fault benefits on the ground of lack of medical necessity was sufficiently supported by a factual basis and medical rationale. The court held that the peer review conclusions underlying the denial were not supported by a sufficient factual foundation and were therefore insufficient to support a defense of lack of medical necessity. As a result, summary judgment was granted in favor of the plaintiff and the case was remanded for the calculation of statutory interest and assessment of attorney's fees.