No-Fault Case Law
Maiga Prods. Corp. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51682(U))
November 23, 2018
The main issue in this case was whether the defendant, State Farm Mutual Automobile Insurance Co., was entitled to summary judgment dismissing the complaint brought by Maiga Products Corp. as Assignee of Dorsinvil, Mireille, to recover assigned first-party no-fault benefits. State Farm argued that Maiga had failed to appear for duly scheduled examinations under oath (EUOs). The court found that State Farm had established the timely and proper mailing of the EUO scheduling letters and the denial of claim forms, as well as Maiga's failure to appear for the EUOs. The court also found that the only remaining issue for trial was "the nexus between where the bill is received and where the verification and denial is processed and mailed from Ballston Spa, when the bill was received in Atlanta, Georgia. The holding of the court was that State Farm was entitled to summary judgment dismissing the complaint, reversing the order of the Civil Court and granting State Farm's motion.
Maiga Prods. Corp. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51681(U))
November 23, 2018
The main issue in this case was whether an insurer was entitled to summary judgment dismissing a complaint on the basis that a provider failed to appear for examinations under oath (EUOs). The insurer argued that it had twice demanded an EUO from the provider, and that the provider had twice failed to appear, thus justifying their timely denial of the claims. The Civil Court found that the insurer had established the timely and proper mailing of the EUO scheduling letters and the denial of claim forms, as well as the provider's failure to appear for the EUOs. However, the provider challenged this finding and argued that the insurer's practices and procedures regarding the receipt of its mail were irrelevant. The Appellate Term ultimately reversed the order, granting the insurer's motion for summary judgment dismissing the complaint.
Big Apple Med. Supply, Inc. v Nationwide Affinity Ins. Co. of Am. (2018 NY Slip Op 51659(U))
November 21, 2018
The court considered a motion by the defendant to grant summary judgment and dismiss the complaint based on the plaintiff's failure to respond within 120 days to the initial request for verification. The main issue was whether the defendant could prove by admissible evidence that it did not receive the requested verification within the allotted 120-day period. The court held that defendant's conclusory denial of receipt was insufficient to make a prima facie showing of entitlement to summary judgment. Additionally, the court found that the defendant failed to produce an original "certificate of conformity" for two affidavits, rendering the affidavits inadmissible as a matter of law. As a result, the defendant failed to establish their entitlement to summary judgment by admissible evidence, and the motion for summary judgment was denied.
UGP Acupuncture, P.C. v 21st Century Ins. Co. (2018 NY Slip Op 51657(U))
November 16, 2018
The court considered the fact that UGP Acupuncture, P.C., as the assignee of Nicole Santana, was seeking to recover first-party no-fault benefits from 21st Century Insurance Company, but their amounts were in excess of the workers' compensation fee schedule. The main issue decided was whether the fee reductions made by the defendant were proper, as they were done in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The holding of the case was that the insurer may 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. The court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.
Restoration Chiropractic, P.C. v 21st Century Ins. Co. (2018 NY Slip Op 51656(U))
November 16, 2018
The court considered a case where Restoration Chiropractic, P.C. was seeking to recover no-fault benefits from 21st Century Insurance Company, as an assignee of Lopez, Candice. The main issue decided was whether the denial of plaintiff's motion for summary judgment and the granting of defendant's cross motion for summary judgment dismissing the complaint was proper, based on the fact that plaintiff's assignor had failed to appear for scheduled examinations under oath (EUOs). The court held that the proof submitted by the defendant was sufficient to establish the proper mailing of the EUO scheduling letters and that the remaining contentions raised by the plaintiff were either without merit or not considered because they were raised for the first time on appeal. Therefore, the court affirmed the order, with costs of $25.
LMS Acupuncture, P.C. v State Farm Mut. Auto. Ins. Co. (2018 NY Slip Op 51655(U))
November 16, 2018
The court considered a motion for summary judgment dismissing the complaint in an action by a provider to recover assigned first-party no-fault benefits. The main issue was whether the defendant demonstrated that the plaintiff had failed to appear for examinations under oath (EUOs) and if the defendant was required to set forth objective reasons for requesting the EUOs to establish its entitlement to summary judgment. The court held that the proof submitted by the defendant was sufficient to demonstrate that the plaintiff had failed to appear for the EUOs, and that the defendant was not required to set forth objective reasons for requesting the EUOs to establish its entitlement to summary judgment. Therefore, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.
Pavlova v Allstate Ins. Co. (2018 NY Slip Op 51654(U))
November 16, 2018
The court considered the denial of plaintiff's claim for services billed under CPT code 20999 by the defendant insurance company in this case regarding first-party no-fault benefits. The main issue of the case was whether there was sufficient evidence to demonstrate that the plaintiff's claim for services had not been timely denied, and whether the insurer had issued a timely denial of claim. The court held that the plaintiff had not demonstrated prima facie that the claim for the services at issue had not been timely denied, and that the insurer was required to request additional verification of proof of claim for services billed under CPT code 20999, which it had not done. As a result, the court modified the order to deny the branch of defendant's cross motion seeking summary judgment dismissing so much of the complaint as sought to recover for services billed under CPT code 20999.
Gentlecare Ambulatory Anesthesia Services; Lyonel F. Paul, M.D. v GEICO Ins. Co. (2018 NY Slip Op 51653(U))
November 16, 2018
The court in this case considered whether a provider was entitled to recover assigned first-party no-fault benefits from an insurance company. The main issue was whether the provider had failed to appear for duly scheduled examinations under oath (EUOs) as required by the insurance company. The court found that the insurance company had provided sufficient proof to establish that the EUO scheduling letters and denial of claim form had been timely mailed and that the provider had failed to appear for the EUOs. The court also held that the insurance company was not required to set forth objective reasons for requesting EUOs in order to establish its entitlement to summary judgment. The court ultimately affirmed the lower court's decision to deny the provider's motion for summary judgment and grant the insurance company's cross motion for summary judgment dismissing the complaint.
Parisien v 21st Century Ins. Co. (2018 NY Slip Op 51652(U))
November 16, 2018
The court considered a case in which a medical provider, acting as the assignee of a patient, was seeking to recover first-party no-fault benefits from an insurance company. The main issue in this case was whether the insurance company had properly denied the claim forms on the ground of a lack of medical necessity, and whether the denial had been timely mailed. The court ultimately held that the denial of the claim forms had been timely mailed, and therefore affirmed the lower court's decision to deny the provider's motion for summary judgment and to grant the insurance company's cross motion for summary judgment dismissing the complaint.
All Healthy Style Med., P.C. v Ameriprise Ins. Co. (2018 NY Slip Op 51651(U))
November 16, 2018
The Court considered an order of the Civil Court of the City of New York, Kings County, which granted the defendant's motion for summary judgment, thus dismissing the complaint. The main issue decided was whether the plaintiff's assignor had made a material misrepresentation as to his place of residence when procuring the insurance policy in question. The holding of the case was that the order was reversed, and the defendant's motion for summary judgment dismissing the complaint was denied. The Court based its decision on a similar case, Liliya Veksler, LCSW, P.C. v Ameriprise Ins. Co., and concluded that the defendant's motion should be denied.