No-Fault Case Law

The court considered the issue of whether an insurer had timely denied payment for no-fault benefits for medical services. The main issue decided was whether the insurer had fully paid the provider for the services billed, and whether there was evidence to warrant the dismissal of a claim for an initial acupuncture visit. The holding of the case was that the insurer had timely denied payment on the ground that the unpaid portion exceeded the amount permitted by the workers' compensation fee schedule, and had fully paid the provider for the services billed. The court granted summary judgment in the sum of $114 for the initial acupuncture visit on October 26, 2005, and granted summary judgment to the insurer dismissing the remaining claims for acupuncture services from October 26, 2005 through January 19, 2006.

The relevant facts in this case involved a provider seeking to recover assigned first-party no-fault benefits from an insurer. The provider appealed from an order denying its motion for summary judgment, arguing that the insurer did not pay its claims within 30 days. The main issue decided was whether the provider had established its entitlement to judgment as a matter of law. The court found that although the provider had shown that the insurer did not pay its claims, it failed to demonstrate that the claims were not denied within 30 days or that the basis for the denials was conclusory, vague, or had no merit as a matter of law. The court affirmed the order denying the provider's motion for summary judgment, but on different grounds, and without costs.

The court considered the appeal of a provider seeking to recover assigned first-party no-fault benefits that had been denied by the insurance company. The insurance company had partially paid and partially denied the claim for services rendered from September 6 through September 29, 2005, on the basis that the unpaid portion exceeded the amount permitted by the workers' compensation fee schedule. The insurance company demonstrated that it had fully paid the provider for the billed-for services in accordance with the workers' compensation fee schedule. The main issue decided was whether the insurance company was entitled to summary judgment upon the claim, and the court held that the insurance company was not entitled to summary judgment upon the claim for services rendered from September 6 through September 29, 2005.

The court considered the fact that in an action by a provider to recover assigned first-party no-fault benefits, the plaintiff had moved for summary judgment and the defendant failed to submit written opposition. The Civil Court granted the plaintiff's motion, and the defendant subsequently moved to vacate the order, which was denied by the court. The issue decided was whether an order granting a motion is appealable if the opposing party fails to submit written opposition, even if the party orally argued the motion. The holding of the case was that where a party fails to submit written opposition to a motion, an order granting the motion is considered to have been entered on default and is not appealable, even if the party orally argued the motion. Therefore, the appeal from the judgment entered pursuant to the default order was dismissed. The defendant's remedy, if so advised, was to move to reargue the denied order or to file a notice of appeal therefrom.

The relevant facts considered by the court were that the plaintiff was seeking to recover first-party no-fault benefits as an assignee of Johnie Daniels. The main issue decided in the case was whether there was a lack of medical necessity for the services rendered to the plaintiff's assignor. The court ultimately held in favor of the defendant, granting their cross motion for summary judgement dismissing the complaint. This decision was based on the fact that the defendant submitted an affirmed peer review report and an affirmed independent medical examination (IME) report, both of which provided a factual basis and medical rationale for the determination of a lack of medical necessity. Additionally, the plaintiff's affidavit from a doctor failed to meaningfully refer to the conclusions set forth in the peer review report or the IME report. Therefore, the defendant was entitled to summary judgement dismissing the complaint.

The relevant facts of this case involve a provider seeking to recover assigned first-party no-fault benefits and the defendant insurance company's assertion that there was a lack of medical necessity for the supplies provided to the plaintiff's assignor. The main issue decided in this case was whether or not the defendant's cross motion for summary judgment dismissing the complaint should be granted. The court held that the defendant's cross motion for summary judgment dismissing the complaint should be granted based on the lack of medical necessity for the supplies provided to the plaintiff's assignor, as supported by sworn peer review reports from a chiropractor and the failure of the plaintiff to meaningfully address or rebut these conclusions. As a result, the order of the Civil Court implicitly denying the cross motion for summary judgment dismissing the complaint was reversed.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, which denied defendant's cross motion for summary judgment. The main issue in the case was whether plaintiff's assignor was eligible for workers' compensation benefits and if such benefits were available after a car accident. The court held that the defendant had provided sufficient evidence which gave rise to a triable issue as to whether the plaintiff's assignor had been acting as an employee at the time of the accident, and that therefore workers' compensation benefits might be available. The case was remitted to the Civil Court for a new determination after final resolution of a prompt application to the Workers' Compensation Board to determine the parties' rights under the Workers' Compensation Law. The Civil Court was directed to grant defendant's cross motion for summary judgment dismissing the complaint unless plaintiff showed good cause why it should not be dismissed.

In the case of W.H.O. Acupuncture, P.C. v National Cont. Ins. Co., the provider, W.H.O. Acupuncture, P.C., appealed from an order granting the insurer's motion for summary judgment and denying the provider's cross motion for summary judgment. The judgment was entered dismissing the complaint for first-party no-fault benefits. The court found that the insurer had fully paid the provider for some of the acupuncture services rendered, and the provider failed to raise a triable issue of fact in response. Therefore, the court held that the insurer properly granted summary judgment dismissing the complaint for those services. Additionally, the insurer denied payment for other acupuncture services based on a sworn independent medical examination report establishing a prima facie showing of lack of medical necessity. The court affirmed the judgment, as the issue of medical necessity was not properly raised on appeal. The main issues decided in this case were whether the insurer properly denied payment for specific acupuncture services based on lack of medical necessity and whether the provider had raised a triable issue of fact in response to the insurer's motion for summary judgment. The holding of the court was that the insurer had established lack of medical necessity for certain services and had fully paid the provider for other services, and the provider had failed to raise a triable issue of fact in response. Therefore, the judgment dismissing the complaint was affirmed.

The main issue in this case was whether the defendant, GEICO Ins. Co., had timely denied the plaintiff's claim on the ground of lack of medical necessity. The court considered the affidavit of the defendant's claims examiner and an affirmed peer review report which concluded that there was no medical necessity for the services rendered. The record did not contain an affidavit from a health care practitioner on behalf of the plaintiff to rebut the conclusion set forth in the peer review report. Ultimately, the court reversed the judgment, vacated the order, denied the plaintiff's motion for summary judgment, and granted the defendant's cross motion for summary judgment dismissing the complaint. Consequently, the plaintiff's claim for assigned first-party no-fault benefits was denied.

The court considered an appeal from an order denying the defendant's motion for summary judgment in a case involving a provider seeking to recover first-party no-fault benefits. The main issue was whether the defendant was entitled to summary judgment dismissing the complaint due to lack of written notice of the accident, as required by the insurance policy. The court held that compliance with the notice requirement of the policy is a condition precedent to coverage, and since the plaintiff failed to demonstrate the existence of a triable issue of fact, the defendant was entitled to summary judgment dismissing the complaint. Therefore, the order was reversed, and the defendant's motion was granted.