No-Fault Case Law
Metro Pain Specialist, P.C. v State Farm Mut. Auto. Ins. Co. PIP/BI Claims (2020 NY Slip Op 51381(U))
November 13, 2020
The relevant facts considered by the court were that Metro Pain Specialist, P.C. was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. The main issue decided was whether the amount of available coverage had been exhausted, and the court granted the defendant's motion for summary judgment dismissing the complaint and denied the plaintiff's cross motion for summary judgment. The holding of the case was that the defendant's payment log was properly considered by the court, and therefore, the order granting the defendant's motion for summary judgment and dismissing the complaint was affirmed.
ARIS Diagnostic Med., PLLC v Ameriprise Ins. Co. (2020 NY Slip Op 51380(U))
November 13, 2020
The court considered the appeal of an order from the Civil Court of New York, Kings County, which granted the plaintiff's cross motion for summary judgment in a case to recover assigned first-party no-fault benefits. Upon review of the record, the court found that the defendant demonstrated the existence of issues of fact as to whether a misrepresentation had been made to the defendant in connection with the insurance policy and, if such a misrepresentation was made, whether it was material. The main issue decided was whether there were issues of fact regarding the misrepresentation in connection with the insurance policy and if it was material. The holding of the court was that the defendant demonstrated the existence of issues of fact and for this reason, the order granting the plaintiff's cross motion for summary judgment was reversed and the motion was denied.
Gentlecare Ambulatory Anesthesia Servs.; Lyonel F. Paul M.D. v Hereford Ins. Co. (2020 NY Slip Op 51379(U))
November 13, 2020
The court considered an appeal from an order denying the defendant's motion for summary judgment dismissing the complaint and granting the plaintiff's cross motion for summary judgment. The main issue in the case was whether the defendant had established that there was no coverage for no-fault benefits since they had not issued an automobile insurance policy which would cover the underlying accident. The court held that the lack of coverage defense may be raised without regard to the propriety or timeliness of an insurer's denial of claim form. The papers submitted by the defendant in support of its motion were sufficient to establish that the policy being sued upon was a workers' compensation insurance policy which did not cover the plaintiff's claim to receive reimbursement of assigned first-party no-fault benefits. Therefore, the court reversed the judgment, vacated the order, granted the defendant's motion for summary judgment dismissing the complaint, and denied the plaintiff's cross motion.
A.C. Med., P.C. v Ameriprise Ins. Co. (2020 NY Slip Op 51378(U))
November 13, 2020
The relevant facts the court considered in A.C. Med., P.C. v Ameriprise Ins. Co. were that the defendant had sent letters scheduling an examination under oath (EUO) which were timely mailed, but the plaintiffs failed to appear on the scheduled dates. The claims submitted by A.C. Medical, P.C. (ACM) were timely denied on that ground. However, with regards to the claims submitted by Vital Chiropractic, P.C. (Vital), the defendant failed to establish, as a matter of law, that the claims were timely denied after Vital had failed to appear at both an initial and a follow-up EUO. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint. The holding of the case was that the order denying defendant's motion for summary judgment was modified to grant summary judgment dismissing so much of the complaint as sought to recover upon claims submitted by plaintiff A.C. Medical, P.C.
21st Century Pharm., Inc. v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 51377(U))
November 13, 2020
The court considered the fact that the defendant had appealed from an order of the Civil Court that denied their cross motion for summary judgment dismissing the complaint. The main issue decided was whether the plaintiff's assignor had failed to appear for duly scheduled independent medical examinations (IMEs), and whether this failure constituted a failure to comply with a condition precedent to coverage. The court held that the defendant had sufficiently established that the IME scheduling letters had been timely mailed and that the assignor had failed to appear for the IMEs. Therefore, the defendant had demonstrated that the plaintiff had failed to comply with a condition precedent to coverage. As a result, the defendant was entitled to summary judgment dismissing the complaint.
A.C. Med., P.C. v Ameriprise Ins. Co. (2020 NY Slip Op 51376(U))
November 13, 2020
The main issue in this case was whether the defendant had timely denied the plaintiff's claims after the plaintiff had failed to appear for duly scheduled examinations under oath (EUOs). The court considered the fact that the defendant had contended that its initial EUO scheduling letter tolled the time to pay or deny all of the claims at issue and that the toll was maintained by timely follow-up scheduling letters. However, the court found that the defendant's motion failed to establish, as a matter of law, that the defendant had timely denied the plaintiff's claims after the plaintiff had failed to appear at both an initial and a follow-up EUO. The holding of the court was that the order denying the defendant's motion for summary judgment was affirmed.
Avalon Radiology, P.C. v Global Liberty Ins. (2020 NY Slip Op 51374(U))
November 13, 2020
The main issue in this case was whether defendant's denial of claim forms were timely. The Civil Court concluded that the denials could not be timely because they were based upon the assignor's failure to appear for independent medical examinations (IMEs) and were mailed more than 30 days after that failure to appear. However, the Appellate Term held that the Civil Court's holding was erroneous, and that an insurer need not deny a claim while it is waiting for requested verification even if it already has a basis to deny it. As no testimony was taken from defendant's witness, the matter was remitted to the Civil Court for a new trial. Therefore, the order denying defendant's motion to set aside the decision of the Civil Court and the judgment entered pursuant thereto was reversed, and the matter was remitted to the Civil Court for a new trial.
Advanced Recovery Equip. & Supplies, LLC v Global Liberty Ins. Co. (2020 NY Slip Op 51373(U))
November 13, 2020
The court in this case considered the defendant's motion for summary judgment to dismiss the complaint on the grounds of lack of medical necessity for the supplies at issue, untimely submission of claims, and exceeding the workers' compensation fee schedule amounts. The court also considered the plaintiff's cross-motion for summary judgment. The main issue decided was whether there were triable issues of fact as to the medical necessity of the supplies and timely submission of claims, and whether the trial should be limited to the issue of the fee schedule. The holding was that the defendant was not entitled to summary judgment dismissing the complaint, and there was no basis for the court to find that the claims had been timely and properly mailed or to limit the trial to the issue of the fee schedule. Therefore, the implicit CPLR 3212 (g) finding in plaintiff's favor and the limitation of the trial to the fee schedule were vacated.
JPF Med. Servs., P.C. v Hereford Ins. Co. (2020 NY Slip Op 51372(U))
November 13, 2020
The main issue in this case was whether or not the defendant was entitled to summary judgment dismissing the complaint on the ground that the plaintiff had failed to provide requested verification in a first-party no-fault benefits action. The defendant had demonstrated that they had timely mailed initial and follow-up requests for verification and that they had not received the requested verification, and had timely denied the plaintiff's claims on that ground. However, the affidavit submitted by the plaintiff in opposition to the defendant's motion was sufficient to give rise to a presumption that the requested verification had been mailed to, and received by, the defendant. As a result, the court found that there was a triable issue of fact as to whether the plaintiff provided the requested verification. Therefore, the judgment was reversed and the order granting the plaintiff's cross-motion for summary judgment was vacated, and the plaintiff's cross-motion for summary judgment was denied.
Master Cheng Acupuncture, P.C. v Global Liberty Ins. of N.Y. (2020 NY Slip Op 51371(U))
November 13, 2020
The main issue in the case was whether or not the defendant, Global Liberty Ins. of NY, had properly paid the claims for services rendered by Master Cheng Acupuncture, P.C. According to defendant's proof, they had paid the claims in accordance with the worker's compensation fee schedule. The court agreed with the defendant's argument and found that there was no triable issue of fact with respect to this branch of defendant's motion. However, the court did find a triable issue of fact regarding the medical necessity of the services rendered on May 23, 2014. Therefore, the court modified the order to provide that the branch of defendant's motion seeking summary judgment dismissing the unpaid portion of plaintiff's claims for services rendered from April 17, 2014, through May 12, 2014, is granted.