No-Fault Case Law

The court considered the facts of an insurance claim dispute in which the plaintiff, LMK Psychological Services, P.C., had provided psychological treatment following automobile accidents. The plaintiffs moved for summary judgment as the insurance company, Liberty Mutual Insurance Company, had failed to timely deny coverage or verify the insurance claims. The court granted summary judgment partially and in favor of the plaintiffs, stating that the insurance company did not deny or seek verification of the claims timely. The court found that plaintiffs had provided proper prima facie proof of the claims and benefits. The court also did not find any evidence of fraudulent activity, thus affirming the order for summary judgment in favor of the plaintiffs and denying the defendant's cross-motion.

The court considered the facts surrounding plaintiff's claim involving psychological testing and psychotherapy services provided to a woman injured in a motor vehicle accident, whereby the vehicle was insured by the defendant, Liberty Mutual Insurance Company. The main issue decided was whether the defendant's assertion of a fraud defense, alleging that the plaintiff submitted fraudulent bills, was precluded by its untimely denial. The holding of the case was that the defendant's untimely denial precluded it from asserting the fraud defense, and accordingly, the plaintiff was entitled to a judgment in its favor. The Court determined that the defendant's fraud defense did not implicate the coverage and required a timely denial, thus the defense was precluded. Subsequent to this determination, the order was reversed, and the case was remitted to the City Court for further proceedings.

The relevant facts the court considered in this case include Long Island Radiology, on behalf of itself and all other entities and individuals that are assignees of claims for the payment of radiology no-fault benefits similarly situated, bringing a motion for summary judgment on the issue of whether no-fault insurers may raise lack of medical necessity as a basis to deny claims for reimbursement to radiologists seeking payment for MRI tests provided to no-fault patients pursuant to prescriptions. Long Island Radiology had received assignments of no-fault benefits from injured persons and submitted claims directly to the defendants, who denied numerous claims for payment on the ground of an alleged "lack of medical necessity." The main issue decided was whether "lack of medical necessity" is a valid defense that insurers may raise in the context of the no-fault statute and regulations when denying claims for reimbursement for radiology tests performed on the basis of prescriptions from treating physicians. The court held that "lack of medical necessity" is a defense available to insurers in no-fault cases, but it cannot be raised against radiologists when a prescription for a radiology test has been provided by a treating physician or licensed medical provider in a no-fault case. The court denied the defendants' motion for summary judgment and granted Long Island Radiology's cross-motion for summary judgment. The court also denied Long Island Radiology's motion for class certification.

The legal case of Lexington Acupuncture, P.C. v State Farm Ins. Co. presented the issue of whether the plaintiff was entitled to recover first-party no-fault benefits for health care services rendered to its assignor. The court considered the fact that the plaintiff had submitted the claims and demonstrated that payment of the benefits was overdue, thus establishing a prima facie entitlement to summary judgment. However, the defendant insurer subsequently conducted a preclaim independent medical examination that led to a determination that the assignor no longer needed acupuncture and denied each claim based on a report of lack of medical necessity. The main legal issues included the admissibility of the report in the denial of the plaintiff's motion for summary judgment, as well as the plaintiff's eligibility for reimbursement of no-fault benefits and whether it was fraudulently incorporated. The court held that the plaintiff's motion for summary judgment was premature pending the completion of discovery, granted the defendant's cross motion to compel the plaintiff to respond to the discovery demands seeking information regarding the ownership, control, and licensing of the plaintiff corporation, and reversed the original order.

The court considered the facts of the case, which involved an action to recover first-party no-fault benefits for medical supplies provided to a patient. The plaintiff submitted claims for payment of medical supplies but the defendant denied all the claims based on excessive billing and the results of an investigation that revealed the injuries were not related to a motor vehicle accident. The main issues decided were whether the plaintiff was entitled to summary judgment and whether there was a triable issue of fact regarding the lack of coverage and excessive billing. The holding of the case was that the defendant had demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage and excessive billing. Therefore, the plaintiff's motion for summary judgment was properly denied and the court directed the plaintiff to produce an individual for deposition with personal knowledge of its billing and distribution procedures.

The court considered the submission of a claim and the amount of loss sustained by a plaintiff in a case to recover assigned no-fault benefits. It also reviewed the denial of the claims by the defendant based on peer review reports, the use of an explanation of benefits form in place of a denial of claim form, and the lack of submission of a denial of claim form by the defendant. The main issue decided was whether the plaintiff properly established its entitlement to summary judgment and whether the denial of the claims by the defendant was valid. The holding was that the plaintiff established its entitlement to summary judgment and the defendant was precluded from raising any defense as to one of the claims due to the lack of submission of a denial of claim form. The decision was modified by granting partial summary judgment in favor of the plaintiff and the matter was remanded for further proceedings.

The court considered whether State Farm Insurance Company was obligated to pay or deny claims from Montgomery Medical, P.C. in a timely manner as required by regulations governing the payment of no-fault benefits. The main issues decided were the timeliness of State Farm's response to the claims, the preclusion of defendant's evidence due to lack of timely denial, the issue of fraudulent incorporation of the medical provider, and whether the evidence supported concurrent care. The holding of the case was that both the plaintiff's motion and the defendant's cross-motion for summary judgment were denied. The court found that the defendant's subsequent denial of claim forms were untimely, precluding them from proving lack of medical necessity of the services, as well as raised questions about the fraudulent incorporation of the medical provider.

The main issue in this case was whether the health care provider was entitled to recover first-party no-fault benefits for medical services rendered to its assignors. The court considered the submission of required no-fault claim forms by the plaintiff and timely denial of the claims by the defendant based on the fact that the alleged automobile accidents were not covered and the procedures were not listed in the fee schedule for the provider. The court also considered whether the defendant demonstrated that the services were not covered based on the fact that the procedures were not listed in the fee schedule and were used more than what is normally expected per visit. The holding of the case was in favor of the plaintiff, with the court ruling that the plaintiff was entitled to recovery for the expenses, as the procedures were in fact listed in the schedule and the defendant failed to maintain its defense. The judgment was to be entered in favor of the plaintiff in the amount of $1,453.32, plus statutory interest and reasonable attorney fees.

The court considered the facts of an action to recover assigned first-party no-fault benefits, in which the defendant moved to strike the complaint, or alternatively, to preclude the plaintiff from offering testimony at trial or compel plaintiff to respond to its demand for a bill of particulars and demand for discovery and inspection. The plaintiff also cross-moved for summary judgment, which the defendant opposed. The main issue decided was whether the plaintiff had established its prima facie entitlement to summary judgment, and whether the defendant's motion should be granted on default. The court held that the plaintiff failed to establish its entitlement to summary judgment as the claim forms indicated that the named treating providers were independent contractors, and plaintiff did not cure this defect by providing evidence that the providers were employed by the plaintiff on the date the services were rendered. Additionally, the defendant's motion was granted on default and therefore no appeal lies therefrom. The court dismissed the appeal from the portion of the order that conditionally granted the defendant's motion and awarded costs.

The court considered the fact that First Help Acupuncture P.C. was seeking to recover no-fault benefits from State Farm Ins. Co. The main issue decided was whether the defendant demonstrated the existence of a triable issue of fact as to whether the plaintiff was a fraudulently licensed medical corporation. The court held that the defendant's submissions raised an issue of fact as to whether the plaintiff was a fraudulently incorporated medical corporation, and as a result, the plaintiff's motion for summary judgment was denied. This was based on the nonwaivable defense that a provider is fraudulently licensed and hence ineligible for reimbursement of no-fault benefits under 11 NYCRR 65-3.16 (a) (12).