No-Fault Case Law
PDG Psychological P.C. v State Farm Mut. Ins. Co. (2005 NY Slip Op 50150(U))
February 10, 2005
The relevant facts considered by the court include the insurance company denying payment for psychological services billed by the plaintiff, on grounds of failure to provide verification and examination under oath. The insurance company also alleged a consistent pattern of fraud in billing for psychological services. However, the plaintiff denied receiving any verification requests and the insurance company failed to provide proof of mailing such requests. The main issues decided by the court include the insurance company's failure to adhere to statutory time requirements, as well as the lack of evidence demonstrating fraud with respect to the specific claim at hand. The court held that the plaintiff is entitled to summary judgment in the amount of $1200.92 plus interest, attorney's fees, and costs, as the insurance company failed to provide proper verification requests and did not demonstrate any fraud with respect to the specific claim.
Boai Zhong Yi Acupuncture Servs. PC v General Assur. Ins Co. (2005 NY Slip Op 50329(U))
February 9, 2005
The main issue in this case was whether the defendant insurance company timely denied claims submitted by the plaintiff for first party No-Fault benefits. The court considered the fact that the insurance company received the claims but failed to deny them within thirty days as required by law. The court held that the insurance company's denials were untimely and that the basis for denial, which was the failure of the assignor to appear for Independent Medical Examinations (IMEs), was not a permissible reason to deny the claims. Therefore, the court granted summary judgment in favor of the plaintiff, awarding them $1,559.33 plus statutory interest and attorney's fees.
Ocean Diagnostic Imaging P.C. v American Protection Ins. Co. (2005 NY Slip Op 50273(U))
February 9, 2005
The court considered a case in which a medical service provider, Ocean Diagnostic Imaging P.C., sought to recover payment from American Protection Insurance Company for medical services it provided to an individual, Mohammed Rahman. American Protection had denied the claim based on a physician peer review conducted by Dr. Daniel G. Kassan, M.D., which stated that the MRIs were inappropriate and unnecessary. However, the court held that the peer review conducted was not admissible as it was not affirmed or sworn to by the physician. As a result, the court granted summary judgment in favor of Ocean Diagnostic Imaging P.C., and ordered American Protection to pay the plaintiff the sum of $1,758.40 with statutory interest, along with statutory attorney's fees and applicable costs and disbursements.
563 Grand Med., P.C. v Allstate Ins. Co. (2005 NY Slip Op 50127(U))
February 8, 2005
The court considered the standing of the medical provider, 563 Grand Medical, P.C., to receive no-fault benefits under New York's No-Fault Insurance Law. The main issue decided was whether the medical provider had the necessary licensing to perform acupuncture services, as the sole owner of the corporation was a licensed physician but not licensed or certified to practice acupuncture. The court held that the medical provider did not have standing to bill for acupuncture services under the No-Fault Law because it was not licensed or certified to perform acupuncture, as required by New York law. The court affirmed the award of the arbitrator and Master Arbitrator, and found it unnecessary to address other grounds that may be used to vacate such awards.
T&G Med. Supplies, Inc. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 50636(U))
February 4, 2005
In this case, T&G Medical Supplies, Inc. sued State Farm Mutual Automobile Insurance Co. to recover insurance benefits for nerve stimulating electrodes used in the treatment of an individual injured in a motor vehicle collision. The main issues decided by the court were whether the assignment of coverage for the medical supplies was valid and whether the insurance claim submitted by T&G Medical Supplies, Inc. was complete. The court held that the assignment of benefits to T&G Medical Supplies, Inc. was ineffective, as it did not include essential information and the insured patient did not receive the supplies. Additionally, the court found that T&G Medical Supplies, Inc. lacked standing to sue as the insured patient did not incur any obligation to pay for the supplies, and the assignment did not accomplish the statutory purpose of New York's "No-Fault" Insurance Law. As a result, the court granted State Farm Mutual Automobile Insurance Co.'s motion for summary judgment and dismissed the action.
A.B. Med. Servs. PLLC v New York Cent. Mut. Fire Ins. Co. (2005 NY Slip Op 50115(U))
February 2, 2005
The relevant facts considered by the court in this case include the motion for summary judgment filed by A.B. Medical Services PLLC, Lvov Acupuncture P.C., and Somun Acupuncture P.C., as well as the lack of opposition papers received from the defendant. The main issue decided by the court was whether the moving plaintiffs were entitled to summary judgment, based on the fact that they submitted statutory proof of claim forms to the defendant, and the payment of no-fault benefits was overdue. The holding of the court was that the order denying the motion for summary judgment was unanimously reversed, and the motion by the plaintiffs for summary judgment was granted. The court also noted that the defendant could seek appropriate relief if it had served and filed opposing papers, but since it did not appear that the court received opposition papers, the motion for summary judgment should have been granted.
A.B. Med. Servs. PLLC v American Mfrs. Mut. Ins. Co. (2005 NY Slip Op 50114(U))
February 2, 2005
The relevant facts in the case included a timely denial of claims submitted by A.B. Medical Services PLLC by American Manufacturers Mutual Insurance Company (American). American's denials were based on a peer review that concluded there was no medical necessity for the procedures performed, due to the reviewer lacking sufficient information to make such a determination. However, the court found that the reviewer's lack of information alone did not demonstrate the existence of a triable issue of fact, as American failed to seek the necessary information through verification procedures. Therefore, the court held that American was precluded from asserting the defense of lack of medical necessity, and granted summary judgment in favor of A.B. Medical Services PLLC. The main issue decided was whether American's defense of lack of medical necessity was valid, and the court held that it was not, granting summary judgment in favor of A.B. Medical Services PLLC.
Triboro Chiropractic v New York Cent. Mut. Fire Ins. Co. (2005 NY Slip Op 50110(U))
February 2, 2005
The court considered an action to recover $8,205.98 in assigned first-party no-fault benefits, in which defendant's denials of plaintiff's claims for $151.28, $67.40, and $180.00 in no-fault benefits were found to be untimely. The main issue was whether the defendant's failure to attend independent medical examinations (IMEs) prior to the submission of statutory claim forms precluded the defendant from defending its denials. The holding of the court was that while the failure of the plaintiff's assignor to attend the IMEs did not afford the insurer a defense to the action, it did rebut the presumption of medical necessity that attaches to the claim forms. The court modified the order to grant the plaintiff partial summary judgment in the sum of $398.68 and remanded the matter for the calculation of statutory interest and attorney's fees thereon.
SZ Med. P.C. v State-Wide Ins. Co. (2005 NY Slip Op 50103(U))
February 2, 2005
The court considered the evidence submitted by the plaintiffs, including claim forms and medical reports, in a case to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiffs had established a prima facie entitlement to summary judgment by proving that payment of the benefits was overdue. The court held that in order to establish that payment on the claims was overdue, the plaintiffs had to demonstrate that the 30 calendar days had elapsed from the time the insurer received proof of the claim. Since there was no evidence as to when the claim forms were submitted to the defendant and the defendant's letters did not specify which claims were received, the court found that the plaintiffs were unable to establish whether payments on any of the claims were overdue. Therefore, the plaintiffs' motion for summary judgment was properly denied.
A & S Med. P.C. v Allstate Ins. Co. (2005 NY Slip Op 00505)
February 1, 2005
The main issue in A & S Medical P.C. v Allstate Insurance Company was whether a no-fault insurer was able to defend against a claim for services provided after a certain date based on an earlier blanket denial issued to the insured. Plaintiff submitted a claim to defendant for orthopedic services it had provided, and defendant had previously denied all further orthopedic benefits. However, defendant rejected a portion of the claim more than 30 days later. The Court held that the No-Fault Law and regulations required the insurer to respond to the claim within the statutory 30-day time limit, and that it was not sufficient for the insurer to rely silently on an earlier denial issued to the insured. The Appellate Division ultimately affirmed the lower court's decision, granting summary judgment in favor of the plaintiff.