No-Fault Case Law
Metropolitan Med. Supplies, LLC v GEICO Ins. Co. (2012 NY Slip Op 51490(U))
August 6, 2012
The main facts considered by the court were that Metropolitan Medical Supplies, LLC, was seeking to recover $686.44 for the first cause of action and $1,409.24 for the second cause of action for first-party no-fault benefits that had been denied by GEICO Insurance Co. The trial was limited to the issue of the medical necessity of the billed-for supplies, and defendant's expert witness was allowed to testify for the first cause of action but was precluded from testifying for the second cause of action. Defendant's expert should have been allowed to testify for the second cause of action and therefore a new trial was ordered for that claim. The decision was reversed and the case was remitted to the Civil Court for entry of a new judgment in favor of the plaintiff for the first cause of action and for a new trial on the second cause of action.
Rainbow Supply of NY, Inc. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51489(U))
August 6, 2012
The relevant facts the court considered were that Rainbow Supply of NY, Inc. was seeking to recover assigned first-party no-fault benefits from Clarendon National Ins. Co. The main issue decided was whether Clarendon had timely denied the claim at issue, and whether they were precluded from raising as a defense the failure of Rainbow Supply's assignor to appear for an independent medical examination. The court held that the affidavit submitted by Clarendon in support of its motion for summary judgment failed to establish that they had timely denied the claim, and thus the denial of Clarendon's motion for summary judgment dismissing the complaint was affirmed.
Perfect Point Acupuncture, P.C. v Auto One Ins. Co. (2012 NY Slip Op 51486(U))
August 6, 2012
The relevant facts the court considered in this case include the plaintiff, Perfect Point Acupuncture, P.C., seeking to recover assigned first-party no-fault benefits and the defendant, Auto One Insurance Company, denying the claims based on the plaintiff's assignor's failure to appear for independent medical examinations (IMEs). The main issue decided by the court was whether the defendant had properly established that the letters scheduling the IMEs had been mailed to the plaintiff's assignor, and therefore, whether the assignor had failed to comply with a condition precedent to the insurer's liability on the policy. The holding of the case was that the defendant did not sufficiently establish that the letters scheduling the IMEs had been mailed to the plaintiff's assignor, and therefore, the defendant's cross motion for summary judgment dismissing the complaint was denied. The court also affirmed that the plaintiff's motion for summary judgment was properly denied.
Ocean Diagnostic Imaging, P.C. v Chubb Indem. Ins. Co. (2012 NY Slip Op 51485(U))
August 6, 2012
The main issue in this case was whether Ocean Diagnostic Imaging, P.C., as the assignee of AIKELI BOLES, had the legal authority to bring the action to recover assigned first-party no-fault benefits, given that the sole officer, director, and shareholder of the plaintiff had died before the commencement of the action. The court considered relevant facts such as the death of Stephen A. Zinn, M.D., and the lack of evidence demonstrating that the commencement of the action was authorized by someone with the authority to do so. The court ultimately held that as the record did not demonstrate that the commencement of the action was authorized by someone with the authority to do so, the branch of defendant's motion seeking to dismiss the complaint was granted, and the order of the Civil Court was reversed.
Searay Med., P.C. v Praetorian Ins. Co. (2012 NY Slip Op 51383(U))
July 26, 2012
The court considered the facts that the defendant-insurer had timely and properly mailed notices for independent medical examinations to the plaintiff's assignor, and the assignor failed to appear for the examinations. The main issue decided was whether the defendant-insurer was entitled to summary judgment dismissing the action for first-party no-fault benefits. The court held that the defendant-insurer made a prima facie showing of entitlement to summary judgment by establishing proper mailing of the notices for the examinations and the assignor's failure to appear. The court found that the plaintiff did not raise a triable issue in opposition to the defendant's showing, and therefore granted the defendant's motion for summary judgment and dismissed the complaint.
Gaba Med., P.C. v Progressive Specialty Ins. Co. (2012 NY Slip Op 51448(U))
July 25, 2012
The relevant facts the court considered were the denial of first-party no-fault benefits to Gaba Medical, P.C., as well as the reduction of claims and unilateral determination of the appropriate CPT code by Progressive Specialty Ins. Co. The main issues decided were whether the denial and reduction of plaintiff's claims were proper and whether the unilateral determination of the appropriate CPT code was valid. The holding of the case was that the appellate court reversed the lower court's decision and granted plaintiff's motion for summary judgment, remitting the matter to the Civil Court for the calculation of statutory interest and assessment of attorney's fees. The court found that defendant did not raise a triable issue of fact in opposition to plaintiff's motion, and that the reduction of the claim by defendant without sufficient documentation was not warranted.
Five Boro Psychological Servs., P.C. v GEICO Gen. Ins. Co. (2012 NY Slip Op 51447(U))
July 25, 2012
The relevant facts considered by the court in this case were related to a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The main issue decided was whether the insurance company had timely denied the claim and whether there was a lack of medical necessity for the billed-for services. The holding of the court was that the denial of claim forms had been timely mailed by the insurance company, and that the insurance company's showing of lack of medical necessity was unrebutted by the provider. As a result, the court affirmed the order granting the insurance company's cross motion for summary judgment dismissing the complaint.
Hillside Surgicare Diagnostic & Treatment Ctr., LLC v Utica Mut. Ins. Co. (2012 NY Slip Op 51371(U))
July 24, 2012
The court considered the fact that the defendant-insurer made a prima facie showing of entitlement to judgment as a matter of law by submitting an orthopedist's peer review report, which detailed a factual basis and medical rationale for concluding that the medical services in question lacked medical necessity. The main issue decided was whether the defendant-insurer was entitled to summary judgment dismissing the complaint, and the court held that the defendant-insurer was entitled to summary judgment. The court found that the plaintiff's opposing submission, consisting solely of an attorney's affirmation together with unsworn, and thus inadmissible, medical reports was insufficient to withstand summary judgment. Therefore, the court reversed the order denying the defendant's motion for summary judgment, granted the motion, and dismissed the complaint.
Alrof, Inc. v Praetorian Ins. Co. (2012 NY Slip Op 51445(U))
July 18, 2012
In this case, Alrof, Inc. sued Praetorian Ins. Co. to recover assigned first-party no-fault benefits. The main issue was whether the medical supplies provided to the plaintiff's assignor were medically necessary. Both parties established their prima facie cases, and the Civil Court concluded that the only issue for trial was the medical necessity of the supplies. Defendant submitted peer review reports that stated there was a lack of medical necessity for the supplies, and plaintiff's affirmation from a doctor failed to rebut these conclusions. The court reversed the order and granted the branch of defendant's cross motion seeking summary judgment, dismissing the second through fifth causes of action, as it was determined that there was a lack of medical necessity for the supplies provided.
Patchogue Physical Therapy, P.C. v Clarendon Natl. Ins. Co. (2012 NY Slip Op 51444(U))
July 18, 2012
The court considered the evidence presented by the defendant, which included an affirmed peer review report stating that the services rendered were not medically necessary. The main issue decided was whether the plaintiff had rebutted the defendant's showing that the services were not medically necessary. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted, as the plaintiff had not challenged the finding that the defendant was otherwise entitled to judgment. Therefore, the order denying the defendant's motion for summary judgment was reversed.