No-Fault Case Law
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51275(U))
June 28, 2006
The relevant facts the court considered in this case were that the plaintiff was seeking first-party no-fault benefits for medical services rendered to its assignors, and the defendant, an insurance company, had moved for summary judgment dismissing the complaint based on allegations of fraud related to the accident. The main issue decided was whether the plaintiff had standing to bring the action and whether the defendant's untimely denial of the claims was justified. The holding of the court was that defendant's motion for summary judgment was denied, plaintiff's cross motion for summary judgment was granted, and the matter was remanded for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law. The court found that the defendant had waived any defenses based on the assignment of benefits forms and failed to demonstrate the existence of a triable issue of fact related to the lack of coverage.
Amol, Inc. v Travelers Ins. Co. (2006 NY Slip Op 51271(U))
June 28, 2006
The court considered the facts surrounding a dispute between Amol, Inc. and Travelers Ins. Co. regarding the denial of plaintiff's claim for first-party no-fault benefits. The main issue decided was whether defendant's denial of plaintiff's claim was untimely, and if defendant was precluded from raising its defense of lack of medical necessity. The court held that the denial of plaintiff's claim was not untimely, as the affidavit of plaintiff's owner failed to establish the date the claim was mailed to defendant. It was also established that defendant denied plaintiff's claim on the ground of lack of medical necessity, and since plaintiff failed to establish that the denial of claim form was untimely, defendant was not precluded from raising its defense. Therefore, the lower court's denial of plaintiff's cross motion for summary judgment was affirmed.
Mary Immaculate Hosp. v Countrywide Ins. Co. (2006 NY Slip Op 51222(U))
June 28, 2006
The relevant facts considered by the court in this case involved a dispute between Mary Immaculate Hospital and Countrywide Insurance Company over $55,105.27 in medical services provided to Thomas Matamoros. The main issue decided by the court was whether the insurance company was required to pay for the medical services or whether they could deny the claim based on an alleged exclusion in the insurance policy. The holding of the case was that the hospital was awarded summary judgment against the insurance company for the amount of $55,105.27, along with statutory interest, attorney's fees, costs, and disbursements, as the court found that the insurance company failed to provide evidence to establish entitlement to apply the alleged exclusion from coverage.
Proscan Radiology of Buffalo v Progressive Cas. Ins. Co. (2006 NY Slip Op 51242(U))
June 27, 2006
The case involved a commercial claim brought by Proscan Radiology of Buffalo, Proscan Imaging, Buffalo, & Dr. Gurmeet Dhillon against Progressive Casualty Insurance Company. It began in the small claims part of the City Court of Buffalo and was adjourned at the consent of both parties. The main issue decided was the amount of payment owed by Progressive Casualty Insurance Company to the claimants. The court considered the evidence presented by both parties and ultimately held that Progressive Casualty Insurance Company was required to make a payment of $2,297.74 to the claimants.
Boai Zhong Yi Acupuncture Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51202(U))
June 23, 2006
The court considered the fact that the plaintiff filed a motion for summary judgment to recover first-party no-fault benefits for health care services rendered to its assignor. The defendant had timely sent requests for verification, which it argued tolled the 30-day period within which it was obligated to pay or deny the claims. The main issue decided was whether the defendant had established the timely mailing of its verification requests. The holding of the court was that the defendant's opposition papers established the timely mailing of the verification requests, therefore tolling the 30-day period. As a result, the denials of claims were not untimely, and the plaintiff's motion for summary judgment was denied.
A.B. Med. Servs. PLLC v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 51347(U))
June 22, 2006
The relevant facts the court considered were whether the medical service providers were entitled to receive first-party no-fault benefits for the health care services rendered. The main issue decided was whether the providers had established a prima facie entitlement to summary judgment, shifting the burden to the insurance company to raise a triable issue of fact. The holding of the case was that the judgment was reversed, the order granting summary judgment was vacated, and the matter was remanded for further proceedings. The court held that a low impact study submitted by the insurance company constituted a proper basis for denial of the claims, and that the insurance company had demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, therefore the motion for summary judgment should not have been granted.
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51195(U))
June 22, 2006
The court considered that Ocean Diagnostic Imaging P.C. was seeking to recover assigned first-party no-fault benefits and that a default judgment was entered in their favor. State Farm Mutual Automobile Insurance Company then moved to vacate the default judgment, which was granted by the Civil Court of the City of New York, Kings County. The main issue decided was whether defendant State Farm Mutual Automobile Insurance Company had a reasonable excuse for its default and a meritorious defense to the action. The court held that upon review of the record, there was no basis to disturb the lower court's finding that the defendant had established both a reasonable excuse for its default and a meritorious defense to the action, and therefore affirmed the lower court's order granting defendant's motion to vacate the default judgment.
Health & Endurance Med. P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 51191(U))
June 22, 2006
The relevant facts the court considered in this case were that the plaintiff, a medical provider, sought to recover no-fault benefits for services rendered to its assignor. The plaintiff moved for summary judgment, but the defendant insurer argued that the plaintiff was not entitled to recover direct payment of assigned no-fault benefits because the services were not rendered by the plaintiff or its employees, but by a treating provider who was an independent contractor. The main issue decided by the court was whether the plaintiff, as a billing provider, was entitled to recover no-fault benefits for services rendered by an independent contractor treating provider. The court held that the plaintiff was not entitled to recover direct payment of assigned no-fault benefits from the defendant insurer, and therefore the plaintiff's motion for summary judgment was denied, while the defendant was awarded summary judgment and the complaint was dismissed.
Sea Side Med., P.C. v State Farm Mut. Auto Ins. Co. (2006 NY Slip Op 26246)
June 22, 2006
The court considered the fact that the defendant requested for additional verification for the claims, and made an additional request after not receiving the requested verification. The main issue decided in this case was whether the defendant's denials of claims, all of which were issued more than 30 days after the defendant received the claims, were timely, given the circumstances. The court held that under these circumstances, the denials were not timely as a matter of law. The court found that the defendant's initial requests for verification tolled the 30-day period in which it had to pay or deny the claims, but the toll was eviscerated when the defendant failed to send out a follow-up request for the additional verification within the 10-day period specified in 11 NYCRR 65-3.6(b). Therefore, the plaintiff was entitled to judgment in the amount sued for.
Robert Physical Therapy, P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 26240)
June 21, 2006
The case involved consolidated lawsuits for first-party no-fault benefits for physical therapy services. The court reviewed the stipulated facts and briefs submitted by the parties to decide whether a physical therapist can use a billing code found in the medicine fee schedule when the services do not appear in the physical medicine fee schedule. Additionally, the court considered whether a physical therapist may bill for range of motion and muscle testing when an evaluation and management are billed for on the same day. The court determined that physical therapists are allowed to use a code from the medicine section to bill for services not specifically listed in the physical medicine section and that a defense regarding range of motion and muscle testing raised an issue of fact rather than an issue of law. As a result, the court made findings and awarded judgment in favor of the plaintiff for the disputed amounts in the cases.