No-Fault Case Law

A provider petitioned to vacate a master arbitration award that upheld the insurer's denial of $3,577.64 for electrodiagnostic testing and $64.65 for physical therapy, although the arbitrator found the denial untimely. The arbitrator rested on a finding that the provider was part of an entity organized to defraud insurers and used template reports, without describing the evidence. The court held that the award could not stand on medical necessity because an untimely denial precludes that defense, and that ignoring preclusion in arbitration violates the public policy of the no-fault law. The insurer's fraud finding rested on inadmissible information and no competent evidence that the services billed were not rendered. The court vacated the master arbitration award and awarded judgment to the petitioner.

The court considered a motion for summary judgment in a case involving a claim for first-party no-fault benefits for medical supplies provided to an assignor. The plaintiff established a prima facie case for summary judgment by demonstrating that it submitted claims and that payment of the benefits was overdue. In response, the defendant submitted peer reviews that raised a triable issue as to the medical necessity of the equipment. The main issue decided in the case was whether the plaintiff was entitled to summary judgment for the recovery of first-party no-fault benefits. The court held that the order denying the plaintiff's motion for summary judgment was affirmed without costs, indicating that there was a genuine issue as to the medical necessity of the equipment, and therefore summary judgment was not appropriate.

The court considered a billing dispute between a psychiatric services provider and an insurance company. The main issue in the case was whether the services provided were medically necessary. The court decided that based on the testimony of the expert witnesses and the evidence presented, the comprehensive intake interview was never performed, and therefore the payment for certain services was denied. The court found that a comprehensive intake interview was necessary to determine the medical necessity and appropriateness of the various tests performed, which was not done in this case. Based on this, the court denied payment for the psychological testing and for the explanation and interpretation of results to the primary physician. However, the court did award payment for the review of records for medical diagnosis, as the insurance company had failed to prove that it was not medically necessary. Therefore, judgment was entered in favor of the plaintiff for the amount of $67.24, along with statutory interest and attorney's fees and costs.

A medical supply provider sued for first-party no-fault benefits and the insurer cross-moved for summary judgment, claiming a timely verification request for letters of medical necessity and fraud. The billing manager's affidavit stating the date and address of mailing the letters was sufficient proof of mailing. The insurer also argued the claim was fraudulent because the assignor said he never received the supplies. The majority held that an untimely denial precludes the defense that a provider's claim was fraudulent, because only defenses based on staged accidents and similar lack of an insured incident survive preclusion. It reversed and granted the provider summary judgment of $1,628.98, remanding for interest and attorney's fees. One justice dissented.

The plaintiff providers sought first-party no-fault benefits for services to their assignor and appealed from the denial of summary judgment. The Appellate Term found that the plaintiffs established a prima facie case by showing that claims were submitted and payment was overdue. In opposition, the insurer submitted peer reviews that set out a factual basis and medical rationale sufficient to raise a triable issue on the medical necessity of the treatment. The court affirmed the denial of summary judgment. One justice concurred in the result only.

The case revolves around an action taken by Hospital for Joint Diseases to recover unpaid no-fault benefits. The Supreme Court decided on an order that granted the defendant's cross motion for summary judgment dismissing the first and second causes of action and denied the plaintiff's motion for summary judgment. The Appellate Division of the Supreme Court ordered that this decision be modified. They decided that the Supreme Court erred in concluding that the plaintiff lacked standing to bring the action absent proof of a valid assignment from each claimant. They also found that the defendant failed to raise a triable issue of fact as to whether the insured's 2002 medical expenses were for injuries for which expenses for treatment had not been submitted within one year of his accident. The holding of the case was that the Supreme Court's order was modified to deny the defendant's motion for summary judgment, reinstate the first and second causes of action, and grant the plaintiff's motion for summary judgment on the first cause of action. Both parties were denied summary judgment on the second cause of action.

The court considered the case of A.B. Medical Services PLLC, D.A.V. Chiropractic P.C., and Lvov Acupuncture P.C. suing Allstate Insurance Company for $6,523.32 in first-party no-fault benefits for medical services rendered to their assignor. The health care providers moved for partial summary judgment in the sum of $6,326.52, which was comprised of various claims for each provider. The main issue decided was whether the health care providers were entitled to the requested sum, and the court held that the providers were entitled to partial summary judgment in the aggregate amount of $6,334.98. The court found that the providers established a prima facie entitlement to partial summary judgment by showing that they submitted claims setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. The burden then shifted to the defendant to show a triable issue of fact, but the defendant failed to establish by competent evidence that its denial of claim forms were timely mailed within the requisite 30-day period to pay or deny the claims. Therefore, the court granted the provider's motion for partial summary judgment and remanded the case for a calculation of statutory interest and an assessment of attorney's fees on the aggregate sum of $6,334.98.

The relevant facts were that the plaintiff, Great Wall Acupuncture, P.C., sought to recover $789.10 in first-party No-Fault benefits from defendant GEICO General Insurance Co. for acupuncture treatment provided to June Jackson. The defendant had reimbursed only $380.90 for the treatment, arguing that the fee billed exceeded the permissible charges for similar procedures under existing fee schedules. The main issue was whether acupuncture performed by a licensed acupuncturist should be reimbursed at a rate higher than what was considered permissible for chiropractors. The court held that plaintiff's motion for summary judgment was denied, as they failed to establish that a licensed acupuncturist should receive higher fees, and the fact that a licensed acupuncturist's services are similar to that of a chiropractor was not resolved. The only remaining issue for trial was whether the defendant had properly reduced the amount billed.

The court considered that defendant insurer had moved for summary judgment dismissing the complaint. The main issue was whether the record established, as a matter of law, that the plaintiff failed to submit proof of his claims for medical expenses and lost wages within the applicable time limitations. The court held that the Supreme Court erred in granting the defendant insurer's motion for summary judgment dismissing the complaint. The record did not establish, as a matter of law, that plaintiff failed to submit proof of his claims for medical expenses and lost wages within the applicable time limitations. The existing record also did not establish the defense of seeking a double recovery as a matter of law. Finally, the plaintiff was not precluded from asserting the claims at bar based on an assignment of benefits executed more than six years prior to the accident.

A provider sued the Motor Vehicle Accident Indemnification Corporation for first-party no-fault benefits for services to its assignor, and the Civil Court granted MVAIC's cross motion without prejudice. The Appellate Term noted that Insurance Law article 52 provides no-fault benefits to qualified persons injured by uninsured vehicles and that claimants must comply with article 52 requirements. Although MVAIC's denial was untimely, that was immaterial because the denial rested on lack of coverage. The record showed that the assignor never filed a timely notice of claim or sought leave to file late, so he was not a covered person and a condition precedent was unmet. The court modified to dismiss the action with prejudice and denied the plaintiff's motion as academic.