No-Fault Case Law

Ostia Med., PC v Government Empls. Ins. Co. (2003 NY Slip Op 51560(U))

The court considered the issue of whether an insurance carrier is entitled to an examination before trial (EBT) of a medical provider under the CPLR and UDCA in no-fault claims. It involved 48 cases where medical providers represented by the same law firm sought recovery of first-party benefits from Government Employees Insurance Company (GEICO) for injuries claim to have resulted from various motor vehicle accidents. The main issue decided by the court was whether the insurance carrier was entitled to an EBT of the medical provider. The court held that under certain conditions, an insurance carrier is entitled to an EBT of a medical provider in a no-fault case, where it has made a timely denial based on "medical necessity." However, in cases where the carrier failed to issue a timely denial, no further discovery, including an EBT of the medical provider, was permissible on any defense, except if the defense fell within limited exceptions. The plaintiff's decision to litigate rather than seek arbitration was mentioned, stating that the plaintiff must comply with the discovery procedures set forth in the CPLR and the UDCA.
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Damadian Mri In Garden City v Liberty Mut. Ins. Co. (2003 NY Slip Op 51702(U))

The relevant facts in this case were that the plaintiff was seeking first-party no-fault medical benefits for treatment rendered to its assignor. The main issue decided by the court was whether the plaintiff was entitled to summary judgment in the amount of $1,571.80, and whether the defendant was precluded from raising the defense of lack of medical necessity due to failure to timely deny the plaintiff's claim. The holding of the court was that the plaintiff's proof of its claim as submitted to the defendant was sufficient to establish its prima facie case for summary judgment. The court also held that the defendant, by failing to timely deny the plaintiff's no-fault claim within 30 days of receipt, was precluded from raising the defense of lack of medical necessity. Consequently, the plaintiff's cross-motion was granted, and the matter was remanded to the court for the calculation of statutory interest and an assessment of attorney's fees due on $1,571.80.
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Amaze Med. Supply v Eagle Ins. Co. (2003 NY Slip Op 51701(U))

The relevant facts in the case were that plaintiff Amaze Medical Supply Inc. a/a/o Johnny Bermudez filed a lawsuit for $1,895 in first-party no-fault benefits. After he submitted his claim, the insurance company, Eagle Insurance Company, denied the claim, arguing that the medical equipment was unnecessary and failed to seek verification of the "proof of the fact and amount of loss sustained." The court held that the claim form submitted by the plaintiff was sufficient to place the burden on the insurer to object in a timely manner with the necessary supporting allegations. Since the insurance company did not do so, they were precluded from asserting that the health benefits were medically unnecessary. Therefore, the court granted the plaintiff partial summary judgment in the sum of $1,695 and remanded the matter back to the lower court for further proceedings.
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Damadian Mri In Elmhurst v Liberty Mut. Ins. Co. (2003 NY Slip Op 51700(U))

The court decided on the case of Damadian MRI in Elmhurst v Liberty Mut. Ins. Co., and granted the plaintiff's motion for summary judgment in the principal sum of $879.73. The plaintiff moved for summary judgment in order to recover first-party no-fault benefits, which the defendant failed to either pay or deny within 30 days of receipt. The plaintiff argued that the completion of statutory forms was enough to establish medical necessity for the treatment received. The court agreed with the plaintiff, citing that a properly completed claim form was all that was necessary at the claim stage to establish the treatment's medical necessity. Therefore, the order was unanimously affirmed without costs.
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A.B. Med. Servs. v Eagle Ins. Co. (2003 NY Slip Op 23978)

The plaintiffs sued the defendant in an attempt to recover Uninsured Motorists (UM) benefits from their insurance company. The court concluded that the defendant followed the proper procedure in evaluating and denying the plaintiff's claim. Affirming the lower court's decision, the appellate court held that the plaintiff's failure to deny the defendant's fault for the accident entitled the defendant to summary judgment. The court reasoned that the guilty plea agreement that the plaintiff signed following the car accident did not explicitly say that the plaintiff's potential claims where he had been arrested and that he "intentionally caused the accident" would be covered.
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ABC Med. Mgt. v GEICO Gen. Ins. Co. (2003 NY Slip Op 23923)

The court considered the case of ABC Medical Management v GEICO General Insurance Company. On May 16, 1999, Velez, the individual represented by ABC as an assignee, consulted with Kenneth Pieratti, Doctor of Chiropractic following an automobile accident, and received treatment that included several medical supplies and equipment prescribed by Dr. Pieratti. The main issue in this case was to determine whether a plaintiff-assignee medical equipment supplier can recover no-fault first-party benefits where the prescription was written by a chiropractor rather than a physician. The court's holding, although not entirely free of doubt, went against the defendant's motion for summary judgement to dismiss the complaint, arguing that a chiropractor's prescription would infringe on Education Law § 6551 which prohibits chiropractors from prescribing such equipment. The court supported its findings with its observation that analogous arguments have been rejected by other courts, which maintains that chiropractors are allowed to utilize the equipment in question for treatment.
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Matter of State Farm Mut. Auto. Ins. Co. v Travelers Ins. Co. (2003 NY Slip Op 51693(U))

The court considered the issue of whether State Farm Mutual Automobile Insurance Company had failed to establish that the arbitrator's award for its compulsory arbitration of a no-fault claim was not based on the evidence and was arbitrary and capricious. The court also considered the issue of whether State Farm had failed to establish that the arbitrator exceeded his power or so imperfectly executed it regarding its uninsured motorist claim. The court held that State Farm failed to establish either of these claims and therefore, its petition to vacate the awards was properly denied. Additionally, the court did not address Travelers Insurance Company's cross petition to confirm the awards, as it had not been cross-appealed.
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Park Health Ctr. v Peerless Ins. Co. (2003 NY Slip Op 51687(U))

The main issues in the case were whether the plaintiff was entitled to recover for medical services provided to its assignor under the No-Fault Law, and whether the defendant's denial of the claims based on an affirmed peer review report submitted by its doctor was justified. The court considered the claim forms, denial of the claims, and the affirmed peer review report in making its decision. The court held that the plaintiff's prima facie showing was opposed by the affirmed medical report, which raised a triable issue of fact. It was determined that the defense of lack of medical necessity could be based on a sufficiently detailed peer review report, as implicitly provided by Insurance Regulation 11 NYCRR 65-3.8 (b) (4), and that the defendant's timely denial of the plaintiff's no-fault benefits claim was justified based on the file-based peer review. Therefore, the order denying the plaintiff's motion for summary judgment was affirmed.
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King’S Med. Supply v Allstate Ins. Co. (2003 NY Slip Op 51681(U))

The court considered a case in which a medical supply company was seeking first-party no-fault insurance benefits from an insurance company. The insurance company objected to the claim on the basis that the prices of the medical equipment provided exceeded the prevailing rates in the geographic location. The main issue decided was whether the regulation permitting reference to prevailing fees in the geographic location applied, or whether the 150 percent limitation on fees under the Insurance Department regulation was applicable. The court held that the 150 percent rule was an applicable fee schedule within the contemplation of the regulation, and that it represented a legislative determination to help contain the no-fault premium. Therefore, the court reversed the order denying the medical supply company's motion for summary judgment, granted the motion, and remanded the matter to the lower court for the calculation of statutory interest and an assessment of attorney's fees.
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King’S Med. Supply v Allstate Ins. Co. (2003 NY Slip Op 51680(U))

The court considered the fact that this was a case to recover first-party no-fault insurance benefits, where the defendant insurer objected to the plaintiff's claim for medical equipment on the grounds that the supplier's prices exceeded the prevailing rates for such equipment in its geographical location. The main issue decided was whether the defendant insurer's objection to the claim was valid and whether the plaintiff's motion for summary judgment should be granted. The court held that as the defendant preserved no other proper defense to the action, the plaintiff's motion for summary judgment should have been granted. The matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees.
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