No-Fault Case Law
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.
VS Sunrise Med., P.C. v Global Liberty Ins. (2020 NY Slip Op 51370(U))
November 13, 2020
The relevant fact considered by the court in this case was whether the defendant had received the claim forms underlying the plaintiff's second and third causes of action. The main issue decided in this case was whether the defendant had received the claim forms at issue. The holding of the court was that the defendant had submitted sufficient proof to demonstrate, prima facie, that it had not received the claim forms, but the affidavit of the plaintiff's billing administrator raised an issue of fact as to whether those claim forms had been mailed to the defendant. Therefore, the court held that there was an issue of fact as to whether the defendant had received the claims at issue, and consequently denied the branches of the plaintiff's motion seeking summary judgment upon the second and third causes of action.
Island Life Chiropractic Pain Care, PLLC v Ameriprise Ins. (2020 NY Slip Op 51369(U))
November 13, 2020
The court considered the facts that the defendant, Ameriprise Insurance, had timely mailed initial and follow-up letters scheduling an examination under oath, which the plaintiff's assignor had failed to appear for. The defendant had also timely denied the claims on that ground. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint for failure to appear for the examination under oath. The holding of the court was that the defendant's motion for summary judgment was granted, and the plaintiff's cross motion for summary judgment was denied. Therefore, the complaint was dismissed.
Silver Lotus Acupuncture, P.C. v Global Liberty Ins. Co. of N.Y. (2020 NY Slip Op 51368(U))
November 13, 2020
The court considered the fact that the plaintiff, Silver Lotus Acupuncture, P.C., was seeking to recover assigned first-party no-fault benefits, but the defendant, Global Liberty Ins. Co. of NY, had moved for summary judgment dismissing the complaint on the grounds that the plaintiff's assignor had failed to appear for independent medical examinations (IMEs). The court determined that the record was sufficient to establish the proper mailing of the IME scheduling letters to the plaintiff's assignor and that the assignor had indeed failed to appear for the scheduled IMEs. The main issue decided was whether the plaintiff had satisfied the requirements for the assigned first-party no-fault benefits, and the holding was that the defendant's motion for summary judgment was granted because the plaintiff's assignor had failed to appear for the scheduled IMEs. The court affirmed the order, with costs, and the decision was entered on November 13, 2020.