No-Fault Case Law
Six Star Supply, Inc. v Praetorian Ins. Co. (2013 NY Slip Op 50755(U))
May 6, 2013
The relevant facts for this legal case are that the plaintiff, Six Star Supply, Inc., initiated an action to recover assigned first-party no-fault benefits in October 2009, and the defendant, Praetorian Ins. Co., defaulted. More than a year later, the plaintiff moved for leave to enter a default judgment against the defendant, and the defendant cross-moved to dismiss the complaint pursuant to CPLR 3215 (c). The main issue decided by the court was whether the plaintiff offered a reasonable excuse for the delay in moving for leave to enter a default judgment, and whether the plaintiff demonstrated that the complaint was meritorious. The holding of the case was that as the plaintiff failed to offer any excuse for its delay in moving for leave to enter a default judgment, the court found that dismissal of the complaint was required pursuant to CPLR 3215 (c). Therefore, the court reversed the order, denied plaintiff's motion, and granted the defendant's cross motion.
Five Boro Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 50753(U))
May 6, 2013
The court considered the denial of the plaintiff's motion for summary judgment and the granting of the defendant's cross motion for summary judgment in a case involving a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided was whether the examination under oath scheduling letters and denial of claim form had been timely mailed, and whether the plaintiff had failed to appear at the scheduled examinations under oath. The court found that the affidavits submitted by the defendant established that the scheduling letters and denial of claim form had been timely mailed, and that the plaintiff had failed to appear at the scheduled examinations under oath, which was a condition precedent to the insurer's liability on the policy. The judgment was affirmed in favor of the defendant insurance company.
Jamaica Dedicated Med. Care, P.C. v GEICO Gen. Ins. Co. (2013 NY Slip Op 50752(U))
May 6, 2013
The main issue in this case was whether the Civil Court was correct in denying the plaintiff's motion for summary judgement and granting the defendant's cross motion for summary judgement in a lawsuit by a provider to recover assigned first-party no-fault benefits. The Court found that the affidavit of the defendant's claims examiner, submitted in support of its cross motion, failed to address certain of the plaintiff's claims and failed to substantiate the fee schedule defense which was the stated basis for one denial. The court reversed the judgment, vacated the part of the order that granted the defendant's cross motion for summary judgement, and denied the defendant's cross motion. Therefore, the decision was in favor of the plaintiff, and the judgment was reversed and the defendant's cross motion was denied.
Infinity Health Prods., Ltd. v Redland Ins. Co. (2013 NY Slip Op 50751(U))
May 6, 2013
The relevant facts the court considered in this case were that the defendant had mailed independent medical examination (IME) scheduling letters to the plaintiff's assignor, but to the wrong address. The main issue decided was whether the defendant had properly scheduled the IMEs and whether the assignor had failed to appear. The holding of the case was that the defendant failed to demonstrate that the IMEs had been properly scheduled, as the zip code on the mailing logs did not match the zip code provided by the plaintiff's assignor. Therefore, the court affirmed the order granting the plaintiff's motion for summary judgment and denying the defendant's cross motion for summary judgment.
Quality Psychological Servs., P.C. v Travelers Home & Mar. Ins. Co. (2013 NY Slip Op 50750(U))
May 6, 2013
The court considered the case of Quality Psychological Services, P.C. as the assignee of Phillip Williamson, who was seeking to recover assigned first-party no-fault benefits from Travelers Home & Marine Insurance Company. The main issue decided was whether the defendant had failed to prove that the plaintiff's assignor had not appeared for independent medical examinations (IMEs). The court held that the affidavit executed by the operations manager of SIGNET Medical Services, P.C. was not sufficient to raise a triable issue of fact as to whether plaintiff's assignor had appeared for the scheduled IMEs. The court found that the defendant failed to demonstrate that the plaintiff's assignor actually failed to comply with a condition precedent to coverage by failing to appear for duly scheduled IMEs, and therefore affirmed the order granting the plaintiff's motion for summary judgment.
Kew Garden Imaging v State Farm Mut. Auto. Ins. Co. (2013 NY Slip Op 50748(U))
May 6, 2013
In the case of Kew Garden Imaging v. State Farm Mutual Automobile Ins. Co., the main issue was whether the services at issue were medically necessary. The trial court precluded the defendant's medical witnesses from testifying on the ground that they could not testify as to the contents of the medical records they had reviewed in preparing their peer reviews. The Appellate Term, Second Department, held that the defendant's doctors should have been permitted to testify and that a new trial was required. The court also noted that the trial involved a claim for $60.70, to which the defendant had apparently raised a workers' compensation fee schedule defense. The entire case was remitted for a new trial and the judgment of the trial court was reversed.
Leica Supply, Inc. v American Tr. Ins. Co. (2013 NY Slip Op 50711(U))
April 30, 2013
The relevant facts the court considered in this case were that Leica Supply, Inc. was seeking to recover first-party no-fault benefits, and defendant, American Transit Insurance Co., had denied the claim form on the basis that it had been untimely submitted. Defendant had submitted an affidavit by its claims examiner to establish the timely mailing of the denial of claim form and that plaintiff had submitted its claims more than 45 days after the services were rendered. The main issue decided by the court was whether defendant's denial of claim form was valid and whether plaintiff had provided a reasonable justification for the late submission of the claim. The holding of the court was that defendant's denial of claim form was valid, and plaintiff had not provided a reasonable justification for the late submission, therefore defendant's motion for summary judgment dismissing the complaint was granted.
Jersey Rehab PA, P.C. v IDS Prop. Cas. Ins. Co. (2013 NY Slip Op 50652(U))
April 26, 2013
The court considered the case brought by Jersey Rehab PA, P.C., where the defendant, IDS Property Casualty Insurance Company, sought summary judgment to dismiss no-fault benefit claims that had been filed by the plaintiff on behalf of Owen G. Webb after an auto accident. The main issue decided was whether the defendant could properly claim that Mr. Webb breached a condition precedent to coverage by failing to attend an independent medical examination (IME) when the notices sent by the insurer did not comply with mandatory notice requirements as outlined in the no-fault regulations. The holding of the case was that the defendant's IME notices were deemed ineffective and insufficient to give proper notice to Mr. Webb of his right to reimbursement for lost earnings and transportation expenses. As a result, the motion for summary judgement was granted only to the extent of dismissing some of the causes of action, and denied in all other respects.
Stracar Med. Servs. v Nationwide Mut. Ins. Co. (2013 NY Slip Op 50633(U))
April 22, 2013
The main issues decided by the court in this case were related to the termination of an insurance policy and its impact on medical claims. The court considered the facts related to the termination of an insurance policy ab initio, based on fraudulent procurement, which resulted in the denial of medical claims by the defendant insurer. Another issue involved a sister-state dismissal order from Virginia and the enforceability of the order in New York. The court also reviewed whether the denials and termination of the policy were done in accordance with proper mailing procedures by the defendant insurer. The holding of the court was that the termination of the insurance policy was void as a matter of law and the sister-state dismissal order from Virginia was enforceable. The court granted the defendant's motion for summary judgment and dismissed the complaint with prejudice, while also stating that the plaintiff could pursue claims against the assignor for payment of medical services provided.
Utica Acupuncture, P.C. v Interboro Ins. Co. (2013 NY Slip Op 50643(U))
April 18, 2013
The relevant facts considered by the court in Utica Acupuncture, P.C. v Interboro Ins. Co. were that the defendant-insurer sought to dismiss the plaintiff's no-fault claims for acupuncture services rendered during specific periods in 2009. The main issue decided by the court was whether the plaintiff had provided enough evidence to raise a triable issue of fact regarding the receipt of verification requests and the medical necessity of the acupuncture treatments. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint was granted in its entirety. The court found that the plaintiff failed to raise a triable issue of fact regarding the receipt of verification requests and the medical necessity of the acupuncture treatments, and therefore, the defendant was entitled to judgment dismissing the plaintiff's claims.