No-Fault Case Law

The court considered the issue of whether there must be a connection between an independent medical examination (IME) that a claimant fails to attend and the treatment in question for the failure to attend the IME to serve as a basis for denying a no-fault claim and dismissing this action. Boulevard Multispec Medical, P.C. sues as assignee of Phillip Sansone to recover first-party no-fault benefits for a functional capacity evaluation performed on March 11, 2013 and chiropractic and physical therapy treatment provided to Sansone on March 1 and March 8, 2013. Defendant Tri-State timely denied all three claims on the grounds that the treatment was not medically necessary based upon the IME report. Prior to the dates of the treatment in question, Tri-State had requested Sansone appear for an IME to be performed by a psychiatrist. The main issue was centered around the connection between an IME that the claimant failed to attend and the treatment in question in order for the denial of the claim to be justified, and whether or not a lack of appearance at an IME by the injured party would provide a basis for the denial of the claim. The court held that there must be some relationship between the IME for which the injured party failed to appear and the treatment in question for the failure to attend the IME to serve as a basis for denying a no-fault claim. In this case, as there was no evidence that the treatment in question was related to the IME that Sansone failed to attend, the denial of the claim by Tri-State was denied.

The court considered the fact that Sunrise Acupuncture PC, seeking recovery of assigned first-party no-fault benefits, appealed from an order of the Civil Court of the City of New York, which granted defendant's motion for summary judgment dismissing the complaint. The main issue decided was whether the defendant's motion for summary judgment should be granted, and the court held that the action is not ripe for summary dismissal. The court found that triable issues remain with respect to the claims denied outright by defendant on the stated basis that the CPT codes billed under were "outside the scope of the provider's specialty," and that the defendant's failure to meet its evidentiary burden mandates the denial of its motion, regardless of the sufficiency of the opposing papers. Therefore, the court reversed the order, denied defendant's motion for summary judgment, and reinstated the complaint.

The case involved a dispute between a provider seeking to recover first-party no-fault benefits and an insurance company. The insurance company moved for summary judgment to dismiss the complaint, while the provider made a cross-motion for summary judgment. The Civil Court denied the insurance company's motion as untimely, but granted the provider's cross-motion, which was made several months after the deadline. The main issue was whether the Civil Court properly considered the provider's untimely cross-motion for summary judgment without a showing of good cause for the delay. The holding of the case was that the Civil Court should not have considered the provider's untimely cross-motion, as the deadline for summary judgment motions set by CPLR 3212(a) is strictly enforced, and the absence of an objection does not constitute good cause to consider an otherwise untimely motion. Therefore, the order was reversed, and the provider's cross-motion for summary judgment was denied.

The main issue in this case was whether the defendant, Allstate Insurance Company, had failed to establish the lack of medical necessity of the diagnostic testing giving rise to the plaintiff's claim for assigned first-party no-fault benefits. The trial court found in favor of the plaintiff, Webster Ave Medical Pavilion, PC, awarding it damages in the principal sum of $3,045.08. The Appellate Term, First Department affirmed the trial court's judgment, agreeing that the defendant had not met its evidentiary burden and failed to establish the lack of medical necessity. The court also noted that the defendant's medical expert's sparse and confusing opinion testimony, which reflected a lack of knowledge as to the assignor's medical condition at the time of testing, was insufficient. As a result, the judgment in favor of the plaintiff was upheld.

The relevant facts considered by the court were that the plaintiff, Clinton Place Medical, P.C., was seeking first-party no-fault benefits from defendant New York Central Mutual Fire Insurance Company. The defendant had denied the claim based on the assignor's failure to appear for independent medical examinations (IMEs), and had timely denied the claim forms. The main issues decided by the court were whether the defendant had met the conditions for its liability on the policy by timely mailing IME scheduling letters and denying claim forms, and whether the failure to appear for IMEs by the assignor would preclude the defendant's liability if the claims had been timely denied. The holding of the court was that the defendant's motion for summary judgment dismissing the plaintiff's first through fourth causes of action was granted, as defendant had met the conditions precedent to its liability. However, the branches of defendant's motion seeking summary judgment dismissing the fifth through ninth causes of action were properly denied, as it had not been established that these claims had been timely denied.

The relevant facts the court considered in this case were that Clinton Place Medical, P.C. was seeking to recover no-fault benefits from New York Central Mutual Fire Insurance Company. The insurance company had scheduled independent medical examinations (IMEs) for the plaintiff's assignor but the assignor failed to appear for the IMEs. The insurance company subsequently denied the claim forms, some of which were timely and some were not. The main issue decided was whether the insurance company was liable for the claims at issue, considering the failure of the assignor to appear for the IMEs and the timing of the denial of the claims. The holding of the case was that the branches of the insurance company's motion seeking summary judgment dismissing the first, second, and fifth through eighth causes of action were granted, while the motion seeking to dismiss the third and fourth causes of action was denied.

The relevant facts that the court considered in this case were that Clinton Place Medical, P.C. was seeking to recover first-party no-fault benefits that were assigned to them by Daniel Canela. The main issue decided was whether the denial of the claim was timely after Canela failed to appear for scheduled independent medical examinations. The court held that there was a question of fact as to whether the denial was timely, and that such a defense is subject to preclusion if the denial of claim form was untimely. Therefore, the court affirmed the denial of the defendant's cross motion for summary judgment and held that the only issue for trial was the mailing of the denial.

The court considered the facts of an action by a provider to recover assigned first-party no-fault benefits, where defendant's motion for summary judgment dismissing the complaint was granted. The main issue decided was whether the defendant had timely mailed verification requests and follow-up verification requests, and whether the plaintiff had provided the verification requested prior to commencing the action. The holding of the court was that the defendant had demonstrated they had not received all the verification requested, and the plaintiff did not show that such verification had been provided to the defendant prior to commencing the action, making the plaintiff's action premature. Therefore, the Civil Court properly granted the defendant's motion for summary judgment dismissing the complaint.

The relevant facts considered by the court in this case were that the plaintiff, Eagle Surgical Supply, Inc., appealed an order from the Civil Court dismissing their complaint. The defendant, Allstate Fire & Casualty Insurance Company, had filed a motion for summary judgment based on the plaintiff's failure to appear for scheduled examinations under oath. However, the defendant did not provide evidence to establish when they had received the plaintiff's claim forms, which would have tolled the 30-day period within which the defendant was required to pay or deny the claims. The main issue decided by the court was whether the defendant had demonstrated that it was not precluded from raising its defense that the plaintiff failed to appear for scheduled EUOs. The court held that the defendant had failed to provide evidence to establish that it had tolled the 30-day period required to pay or deny the claims, and as a result, the defendant's motion for summary judgment should have been denied. Therefore, the judgment was reversed, the order was vacated, and the defendant's motion for summary judgment was denied.

The main issue in this case was whether the defendant's defense of lack of medical necessity was valid in a lawsuit by a medical supply provider to recover assigned first-party no-fault benefits. After a nonjury trial, the Civil Court found that the defendant's doctor's testimony had demonstrated that the supplies in question were not medically necessary and that the plaintiff had failed to rebut this showing. On appeal, the plaintiff objected to the admission of the peer review reports, but the court affirmed the judgment, stating that defendant properly established the lack of medical necessity at trial through the testimony of its expert witness. The court held that the peer review reports were not admissible to prove lack of medical necessity, but in this case, the defendant's expert witness's testimony based on his independent review of the medical records was sufficient to demonstrate the lack of medical necessity.