No-Fault Case Law

The court considered the facts of Merrick Medical, P.C., as Assignee of Glenda Chin, bringing a action to recover assigned first-party no-fault benefits from A Central Insurance Company. A worker's compensation fee schedule was used to deny part of the claim, and the remaining claims were denied on the grounds of lack of medical necessity. The court ruled in favor of A Central Insurance Company and held that the remaining issues for trial were the reduction of plaintiff's claims in accordance with the workers' compensation fee schedule and medical necessity. The court ultimately granted A Central Insurance Company's motion for summary judgment to dismiss the complaint.

The court considered the failure of the plaintiff to appear for duly scheduled examinations under oath (EUOs) and the untimely denial of claims by the defendant. The main issue was whether the defendant was entitled to summary judgment dismissing the complaint based on the failure to appear for EUOs, and whether the plaintiff was entitled to summary judgment based on the untimely denial of claims. The holding was that the defendant failed to demonstrate it was entitled to summary judgment based on the failure to appear for EUOs, as the initial EUO request was sent more than 30 days after the defendant had received the claims at issue. The court also held that the plaintiff's cross motion for summary judgment should have been denied, as the proof submitted failed to establish that the claims had not been timely denied or that the defendant had issued timely denial of claim forms that were conclusory, vague, or without merit as a matter of law. Therefore, the order was modified to provide that the plaintiff's cross motion for summary judgment was denied.

The court considered a case in which Oriental Health Acupuncture, P.C., sought to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. The main issue decided was whether the amounts sought to be recovered were in excess of the workers' compensation fee schedule. The court held that the order granting the defendant's motion for summary judgment to dismiss the complaint and denying the plaintiff's cross motion for summary judgment was affirmed, with costs of $25. The court referred to a similar case, BQE Acupuncture, P.C., as Assignee of Carrington, Earnel v State Farm Mut. Auto. Ins. Co., in its reasoning for the decision.

The court considered the allegations of a provider seeking to recover assigned first-party no-fault benefits, and the defendant insurance company's motion for summary judgment to dismiss the complaint. The main issue decided was whether the amounts sought to be recovered by the plaintiff were in excess of the workers' compensation fee schedule, and whether the fee reductions made by the defendant in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors were proper. The court held that the insurer could use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which a licensed acupuncturist is entitled to receive for such acupuncture services, and consequently affirmed the order granting the defendant's motion for summary judgment and denying the plaintiff's cross-motion for summary judgment.

The court considered an appeal from an order denying the defendant's motion for summary judgment in a case involving a provider seeking to recover assigned first-party no-fault benefits. The main issue was whether the defendant was entitled to summary judgment dismissing the complaint which sought to recover upon the unpaid portion of the plaintiff's claims. The court held that the order, insofar as appealed from, was reversed and the defendant's cross motion for summary judgment dismissing so much of the complaint as sought to recover upon the unpaid portion of plaintiff's claims was granted. The holding was based on the reasons stated in a similar case, Natural Therapy Acupuncture, P.C., as Assignee of Boodoo, Anselm Kevin v GEICO Ins. Co., decided herewith.

The relevant facts that the court considered in the case of Natural Therapy Acupuncture, P.C. v GEICO Ins. Co. involved a provider seeking to recover first-party no-fault benefits that had been assigned to them. The main issue decided was whether the provider was entitled to recover the unpaid portion of their claims. The court held that the branch of the defendant's cross motion seeking summary judgment dismissing the unpaid portion of the plaintiff's claims was granted. This decision was based on the court's reasoning in a similar case, Natural Therapy Acupuncture, P.C., as Assignee of Boodoo, Anselm Kevin v GEICO Ins. Co., which was decided alongside this case. The decision was unanimous, with Justices Pesce, Aliotta, and Elliot concurring.

The court considered the fact that the plaintiff, Compas Medical, P.C., was seeking to recover first-party no-fault benefits as an assignee. The main issue was whether the plaintiff's assignor had failed to appear for duly scheduled examinations under oath (EUOs). The court held that the EUO scheduling letters had been timely mailed and that the plaintiff's assignor had indeed failed to appear for the scheduled EUOs. The court also found that the defendant had mailed the EUO scheduling letters to the address provided by the plaintiff. As a result, the court affirmed the order which denied the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment dismissing the complaint.

The court considered an appeal from an order of the Civil Court of the City of New York involving a case in which Natural Therapy Acupuncture, P.C. was seeking to recover assigned first-party no-fault benefits from GEICO Ins. Co. The main issue decided was whether the branch of the defendant's cross motion seeking summary judgment dismissing the complaint, insofar as it sought to recover upon the unpaid portion of plaintiff's claims, should be granted. The holding of the court was that the order of the Civil Court, insofar as it was appealed from, was reversed, and the branch of the defendant's cross motion seeking summary judgment dismissing so much of the complaint as sought to recover upon the unpaid portion of the plaintiff's claims was granted. The decision was made on August 2, 2019, and was decided by the Appellate Term, Second Department.

The court considered the appellant's motion for summary judgment dismissing the complaint on the grounds that the plaintiff had failed to appear for scheduled examinations under oath (EUOs). The court also considered the plaintiff's cross motion for summary judgment. The main issue decided was whether the appellant had issued timely EUO notices and whether the plaintiff had failed to appear for scheduled EUOs. The court held that the follow-up requests for verification from the appellant were actually delay letters, as they did not specify the time and place the EUOs would take place, and therefore the appellant failed to establish that it had issued timely EUO notices with respect to the claims underlying the first and second causes of action. However, the court found that the proper EUO scheduling letters had been timely mailed with respect to the third cause of action, and the appellant's time to pay or deny this claim was tolled, and therefore the branch of the appellant's motion seeking summary judgment dismissing the third cause of action should have been granted. The court also held that the plaintiff's cross motion for summary judgment should have been denied as the proof submitted by plaintiff failed to establish that the claims underlying the first and second causes of action had not been timely denied, and that the appellant had issued timely denial of claim forms that were conclusory, vague or without merit as a matter of law. Therefore, the judgment was reversed, and the branch of the defendant's motion seeking summary judgment dismissing the third cause of action was granted, and the plaintiff's cross motion was denied.

The court considered a case in which Natural Therapy Acupuncture, as assignee of Boodoo, Anselm Kevin, sought to recover unpaid first-party no-fault benefits from GEICO Ins. Co. Plaintiff moved for summary judgment, while defendant cross-moved for summary judgment to dismiss the complaint on the basis that it had fully paid for the services at issue rendered prior to April 1, 2013. The main issue decided was whether defendant demonstrated that it had timely denied the claims at issue and properly used the workers' compensation fee schedule to determine the amount plaintiff was entitled to receive for the services in question. The holding of the court was that the branch of defendant's cross motion seeking summary judgment to dismiss the unpaid portion of plaintiff's claims should have been granted, reversing the lower court's decision.