No-Fault Case Law
S & M Supply Inc. v State Farm Mut. Auto. Ins. Co. (2005 NYSlipOp 50747(U))
May 19, 2005
The main issue in this case was whether plaintiff was entitled to summary judgment to recover first-party no-fault benefits for medical supplies furnished to its assignor. Plaintiff established a prima facie entitlement to summary judgment by proving that it submitted a claim setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. Since the defendant failed to pay or deny the claim within the prescribed period, it was precluded from raising most defenses. However, defendant was not precluded from asserting the defense of insurance fraud, and demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage. As a result, plaintiff's motion for summary judgment was properly denied. In addition, the defendant was not entitled to summary judgment based upon the plaintiff's assignor's nonattendance at scheduled examinations under oath.
SZ Med. P.C. v Allstate Ins. Co. (2005 NYSlipOp 50746(U))
May 19, 2005
The court considered the circumstances surrounding a default judgment entered against the defendant in an action to recover first-party no-fault benefits for medical services rendered to the plaintiffs' assignors. The main issue decided was whether the lower court had improvidently exercised its discretion in granting the defendant's motion to vacate the default judgment. The holding was that the lower court did not improvidently exercise its discretion in granting the defendant's motion to vacate the default judgment, and therefore the order was affirmed without costs.
SZ Med. P.C. v Allstate Ins. Co. (2005 NYSlipOp 50745(U))
May 19, 2005
The relevant facts of the case were that the plaintiffs, SZ Medical P.C., Life Chiropractic P.C., and Somun Acupuncture P.C., were seeking to recover first-party no-fault benefits for medical services rendered to their assignor, Rochelle B. Commodore. The defendant, Allstate Insurance Company, had a default judgment entered against them. The main issue decided by the court was whether the lower court had properly granted the defendant's motion to vacate the default judgment. The holding of the court was that the decision to vacate a default judgment rests in the sound discretion of the court and will be upheld in the absence of an improvident exercise of that discretion. The court affirmed the lower court's decision to grant the defendant's motion to vacate the default judgment.
Gpm Chiropractic, P.C. v State Farm Mut. Ins. Co. (2005 NYSlipOp 50744(U))
May 19, 2005
The main facts considered by the court were that the plaintiff, GPM Chiropractic, P.C., was seeking to recover $1,301.26 in first-party no-fault benefits for medical services rendered to its assignor, Rafael Rodrigues, following a motor vehicle accident. The court found that the plaintiff had established a prima facie entitlement to summary judgment by proving that it submitted a claim and that payment of no-fault benefits was overdue, precluding the defendant from raising most defenses. However, the defendant was not precluded from asserting the defense that the alleged injuries did not arise out of a covered accident. The court ultimately held that the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage and that the plaintiff's motion for summary judgment should have been denied.
The main issues decided were whether the plaintiff was entitled to summary judgment for first-party no-fault benefits, and whether the defendant was entitled to summary judgment based on the plaintiff's assignor's nonattendance at scheduled examinations under oath.
The court's holding was that the plaintiff's motion for summary judgment should be denied, as defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage. The court also held that the defendant was not entitled to summary judgment based on the plaintiff's assignor's nonattendance at scheduled examinations under oath.
All-County Med. & Diagnostic P.C. v Progressive Cas. Ins. Co. (2005 NY Slip Op 25183)
May 13, 2005
The relevant facts considered in this case were a motion by the defendant to compel the plaintiff to respond to a demand for a bill of particulars and to produce a witness for examination before trial. The main issues were whether the plaintiff adequately responded to the defendant's bill of particulars and whether the plaintiff's treating physician must appear for an examination before trial. The court held that the responses to the demand for a bill of particulars were sufficient and denied the defendant's motion to strike the plaintiff's complaint for failure to respond. The court also held that, based on relevant case law, the insurance carrier is entitled to an examination before trial of a medical provider in a no-fault case, provided certain conditions are met by the carrier. The court denied the defendant's motion, as the issue of whether the defendant issued a timely denial and the basis for denial of the plaintiff's claim was not addressed by either party.
Precision Diagnostic Imaging, P.C. v Travelers Ins. Co. (2005 NY Slip Op 25180)
May 12, 2005
The court considered the claims brought by Precision Diagnostic Imaging, P.C. to recover $1,791.73 under the No-Fault Law for MRIs that it performed on its assignor, Olga Papirova, and the issues of whether the plaintiff had standing to assert the claim and whether the MRIs were medically necessary. The court granted defendant Travelers Insurance Company's motion for summary judgment on the grounds that it satisfactorily showed that the MRIs were not medically necessary. The court's function on a motion for summary judgment is issue finding, and the defendant had tendered evidence to establish a prima facie case, which shifted the burden to the plaintiff to produce evidentiary proof to establish the existence of material issues of fact. Defendant showed the MRIs were not medically necessary, and plaintiff had not submitted any documentation to establish that the services rendered were medically necessary. The court held that the failure of the medical facility to rebut the insurer's showing that the service provided was not medically necessary requires denial of reimbursement.
Summit Med. Servs., P.C. v American Intl. Ins. Co. (2005 NY Slip Op 50725(U))
May 9, 2005
The main issues in the case involved an action for recovery of No-Fault Insurance benefits for medical treatment provided on a specific date, and the plaintiff's motion to strike the defendant's Notice of Trial. The defendant had repeatedly failed to respond to the plaintiff's motions. In order for the plaintiff to be entitled to summary judgment in a No-Fault Insurance action, it had to make a prima facie showing that it submitted the appropriate claim forms and that they were received by the insurer. Partial payment had been made and the balance was denied on each claim within the time prescribed by statute. The court found that the denials were ineffectual under the rationale articulated in a previous case, and that the defendant had failed to produce any evidentiary proof of a triable issue of fact requiring a trial. As a result, the plaintiff's motion for summary judgment was granted, and judgment was entered in favor of the plaintiff.
A.B. Med. Servs. P.L.L.C. v New York Cent. Mut. Fire Ins. Co. (2005 NY Slip Op 50662(U))
April 29, 2005
The court considered a case in which medical providers were seeking to recover first party no-fault benefits from an insurance company for treatments provided to an insured patient. The insurance company denied payment for psychotherapy sessions and neurological testing performed on the patient, claiming that the services were not medically necessary. The main issues decided in the case were whether the diagnostic testing and psychotherapy sessions were medically necessary, as defined by the Insurance Law, and whether the insurance company properly denied payment. The court held that the insurance company did not sustain its burden of proof for the lack of medical necessity of the psychotherapy sessions and neurological testing provided to the patient, except for neurological testing redundantly billed on a specific date. As a result, the judgment was entered for the plaintiff in the reduced amount of $3,761.15, plus interest and attorneys' fees as provided by the Insurance Regulations, and the statutory costs and disbursements of the action.
A.B. Med. Servs. PLLC v GEICO Cas. Ins. Co. (2005 NYSlipOp 50650(U))
April 29, 2005
The court considered the claim by A.B. Medical Services PLLC for first-party no-fault benefits from GEICO Casualty Insurance Co. A.B. Medical Services PLLC submitted completed claim forms and established that payment of benefits was overdue. The main issue was whether GEICO provided proof to raise a triable issue of fact regarding the lack of medical necessity of the services rendered. The court held that GEICO failed to provide proof in admissible form to support their defense, and therefore, granted the motion for summary judgment in favor of A.B. Medical Services PLLC in the principal sum of $3,971.20. The court remanded the matter to the lower court for a calculation of statutory interest and an assessment of attorney's fees. The appeal by Somun Acupuncture P.C. and Square Synagogue Transportation Inc. was dismissed.
Careplus Med. Supply Inc. v Travelers Home & Mar. Ins. Co. (2005 NYSlipOp 50648(U))
April 29, 2005
The case involves an action to recover first-party no-fault benefits for medical equipment furnished to assignors. The plaintiff claimed that it submitted the statutory claim forms, setting forth the fact and amount of the losses sustained, and that payment of no-fault benefits was overdue. The court decided in favor of the plaintiff, holding that the plaintiff established a prima facie entitlement to summary judgment. However, the burden shifted to the defendant to create a triable issue of fact, and it failed to do so. The court noted that proof of mailing or an admission of receipt was lacking, and the defendant failed to create triable issues of fact as to the assignors' alleged failure to comply with the initial and follow-up verification requests. Therefore, the plaintiff's motion for summary judgment was granted, and the case was remanded to the lower court for the calculation of statutory interest and an assessment of attorney's fees.