No-Fault Case Law

The court considered the denial of Plaintiff’s claims for no-fault benefits for physical therapy services provided to Santo Fernandez in January and February 2011. GEICO based its denial on the results of independent medical examinations (IMEs) conducted by three different doctors. Plaintiff's case was limited to the defense of lack of medical necessity, and the trial was based solely on the testimony of Dr. Jacquelin Emmanuel, the first doctor who conducted the IME. Plaintiff presented no witnesses in rebuttal, but submitted medical records for the court’s consideration. The main issue decided was whether plaintiff met its burden of proving the medical necessity of post-IME physical therapy treatments. The court decided that defendant’s proof satisfied its burden under the law, but plaintiff satisfied its burden through submission of medical records containing findings and opinions of the treating doctor, Dr. Demetrius. The court held in favor of the plaintiff.

The relevant facts considered by the court were that the defendant had timely issued examination under oath (EUO) scheduling letters and that the plaintiff had failed to appear for the scheduled EUOs. The main issue decided was whether the failure to appear for the EUOs could be grounds for timely denial of the claims at issue. The court held that the defendant had established that the time to pay or deny the plaintiff's claim had been tolled by the timely issuance of EUO scheduling letters, and that the plaintiff's failure to appear for the EUOs was a valid reason for the timely denial of the claims. Therefore, the court reversed the order and granted the defendant's cross motion for summary judgment dismissing the complaint.

The court considered the fact that the defendant had established that a declaratory judgment had been entered on default in a Supreme Court, New York County, action, which provided that the named defendants, including the plaintiff, "are not entitled to recover assigned first-party no-fault benefits stemming from the accident at issue." The main issue decided was whether the plaintiff was entitled to recover assigned first-party no-fault benefits arising from the same accident at issue in the Supreme Court case. The holding of the case was that the defendant's motion to dismiss the complaint pursuant to CPLR 3211 (a) (5) and CPLR 3212 was properly granted, and the order was affirmed.

The court considered the timely mailing of the denial of claim form and conflicting medical expert opinions in the case of Advanced Orthopedics, PLLC v New York Cent. Mut. Fire Ins. Co. The main issue was whether there was a lack of medical necessity for the services provided, and whether the defendant's motion for summary judgment should be denied based on this conflicting evidence. The court held that the conflicting medical expert opinions were sufficient to demonstrate the existence of a triable issue of fact, so the defendant's motion for summary judgment was properly denied.

The court considered the specific details of a no-fault insurance claim brought by LMS Acupuncture, P.C. against Geico Insurance Company. The main issue decided was whether or not plaintiff was entitled to summary judgment on their claims for recovery of no-fault benefits, including a specific claim for $80.02 for services rendered on August 2, 2010. The court held that plaintiff was entitled to summary judgment for the $80.02 claim as defendant failed to raise any other issues with regards to that specific claim. However, defendant demonstrated that it had fully paid plaintiff for the remaining services in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. Therefore, the court granted defendant's cross motion for summary judgment to dismiss all other claims made by plaintiff. The court affirmed the lower court's decision with modification, granting summary judgment to plaintiff for the $80.02 claim, but dismissing all other claims made by plaintiff.

The relevant facts considered in this case include that Ema Acupuncture, P.C. sought to recover assigned first-party no-fault benefits and moved for summary judgement. They were seeking to recover payment for acupuncture services rendered to Oralia Hernandez. Geico Insurance company cross-moved for summary judgement, arguing that they had properly used the workers' compensation fee schedule to reimburse Ema Acupuncture, P.C. for the services rendered, which was applicable to chiropractors who render the same services as acupuncturists. The main issue decided by the court was whether the fee schedule for chiropractors was the appropriate basis for reimbursing an acupuncturist. The holding of the case was that Ema Acupuncture, P.C. was entitled to summary judgment for the initial acupuncture visit on January 6, 2009 as billed under fee schedule treatment code 99205. However, Geico Insurance Company was granted summary judgement dismissing the remaining claims, as they had demonstrated that they had fully paid Ema Acupuncture, P.C. for those services in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors.

The relevant facts 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 main issue decided was whether the defendant had timely mailed proper independent medical examination scheduling letters to the plaintiff. The holding of the case was that the requirement to mail the scheduling letters to the plaintiff was not necessary, and the defendant was entitled to summary judgment dismissing plaintiff's first, second, and fifth causes of action. Additionally, the defendant failed to show that it had denied the underlying claims or otherwise raised a triable issue of fact, so there was no basis to disturb the judgment entered upon plaintiff's third, fourth, sixth, and seventh causes of action.

The court considered the provider's appeal from the granting of the defendant's motion for summary judgment in a case involving first-party no-fault benefits. The main issue was whether the defendant had the right to deny the plaintiff's claims either pursuant to the workers' compensation fee schedule or on the ground of lack of medical necessity. The holding of the court was that the defendant's motion for summary judgment was granted with respect to the unpaid portion of the claim for dates of service August 3, 2007 through August 25, 2007. The court found that the defendant had paid a portion of the claim, but had denied the remainder on the ground that the amount billed by the plaintiff exceeded the fees allowed by the workers' compensation fee schedule. Additionally, the court determined that the plaintiff had failed to raise a triable issue of fact regarding the unpaid portion of the claim for those specific dates, however, they did submit sufficient evidence to raise a triable issue of fact as to the medical necessity of the services rendered for other claims.

The court considered an order from the Civil Court of the City of New York, Queens County, which granted the defendant's motion for summary judgment dismissing the complaint. The main issue decided was whether the affidavits submitted by the defendant demonstrated that the denial of claim form had been timely mailed. The holding of the case was that the judgment was affirmed, with $25 costs. The court found that the plaintiff improperly raised the argument that the defendant's employees did not possess sufficient personal knowledge to demonstrate that the denial of claim form had been timely mailed. The court also found that the argument that one of the affidavits submitted by the defendant did not comply with CPLR 2309 (c) was waived.

The main issue in this case was the denial of plaintiff's motion for leave to enter a default judgment based on defendant's failure to appear in the action or answer the complaint. The court considered the fact that plaintiff's moving papers failed to establish that the defendant failed to pay or deny the claim within the requisite 30-day period, as well as the fact that plaintiff did not establish that the defendant issued a timely denial of claim that was conclusory, vague, or without merit as a matter of law. The court ultimately affirmed the denial of plaintiff's motion, finding that the plaintiff had not established its prima facie case. The holding of the case was that the order denying plaintiff's motion for leave to enter a default judgment was affirmed.