No-Fault Case Law

The relevant facts the court considered were that Island Chiropractic Testing, P.C. was seeking to recover first-party no-fault benefits from Praetorian Ins. Co. as the assignee of Shawn Killingbeck. Praetorian Ins. Co. argued that the action was premature because Island Chiropractic Testing, P.C. had not provided verification as requested, while Island Chiropractic Testing, P.C. argued the opposite. The main issue decided was whether the action to recover payment for first-party no-fault benefits was premature when the provider had failed to respond to a request for verification. The holding of the case was that there was a triable issue of fact as to whether Island Chiropractic Testing, P.C. adequately responded to the verification requests, and therefore the court denied the motion for summary judgment in favor of Island Chiropractic Testing, P.C. and modified the order accordingly.

The relevant facts the court considered in the case were that the plaintiff, Right Solution Medical Supply, Inc., sued Praetorian Ins. Company to recover assigned first-party no-fault benefits. Plaintiff moved for summary judgment and defendant cross-moved for summary judgment dismissing the complaint. The main issue decided was whether defendant's cross motion for summary judgment dismissing the complaint should have been granted and whether the branch of plaintiff's motion seeking summary judgment on the fourth cause of action should have been denied. The holding of the case was that the judgment awarding plaintiff the principal sum of $2,357.95 was reversed and the branch of plaintiff's motion seeking summary judgment on the fourth cause of action was denied. The order denying defendant's cross motion and granting plaintiff's motion on the fourth cause of action was affirmed.

The main issue in this case was whether the insurance company had properly scheduled examinations under oath (EUOs) and provided timely denial of claim forms in order to deny the provider's claim for first-party no-fault benefits. The court considered the evidence presented by the defendant that they had timely mailed the EUO scheduling letters and denial of claim forms, and also submitted certified transcripts of the scheduled EUOs that showed the plaintiff's assignor had failed to appear. The court held that the defendant had established its entitlement to judgment as a matter of law, and that the plaintiff had failed to raise a triable issue of fact in opposition. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint was granted, and the plaintiff's cross motion for summary judgment was denied.

The court considered the defendant's motion for summary judgment dismissing the plaintiff's no-fault claim for $355 stemming from acupuncture services rendered. Defendant failed to demonstrate prima facie that its denials were properly mailed. The affidavit submitted by the defendant's claims administrator failed to adequately describe their mailing procedures and did not remedy these deficiencies in their reply papers. Additionally, the report of defendant's peer review acupuncturist did not set forth sufficient facts or medical rationale for the conclusion that further acupuncture treatment was not medically necessary. The main issue decided was whether the defendant's motion for summary judgment should have been denied, and the court held that the plaintiff's claim for first-party no-fault benefits in the amount of $355 should be reinstated. Therefore, the defendant's motion for summary judgment was reversed, and the plaintiff's claim was reinstated.

The main issue in the case was whether the defendant insurer had established, prima facie, that it did not timely receive the plaintiff provider's no-fault claim. The court considered the affidavit of a claims representative who stated there was no record of the claim in their office's files, but had no personal knowledge of the procedures for handling claims sent to the insurer's Oklahoma City office. The plaintiff, in opposition, produced a stamped mailing certificate to support the assertion that it timely mailed the claim to the designated Oklahoma City address. The court held that the action seeking recovery of first-party no-fault benefits was not ripe for summary dismissal and reversed the lower court's decision, denying the defendant's motion for summary judgment and reinstating the complaint.

The case involved a dispute over whether State Farm was obligated to pay claim by Avanguard Medical Group for providing health services to Patria Martell, for injuries sustained in a car accident, which was denied on the basis of improper fee schedule billing. Avanguard is an office-based surgical facility not licensed under Article 28 of the New York State Public Health Law and State Farm's policy included payment of No-Fault benefits. Avanguard billed State Farm $2,550.00 for services provided to Martell, but State Farm denied the claim and argued that Avanguard improperly billed pursuant to a fee schedule reserved exclusively for facilities licensed under Article 28. The court held that State Farm's denial of the claim was proper because Avanguard, as an office-based surgical facility, is not authorized to bill pursuant to the fee schedule reserved for facilities licensed under Article 28, and therefore, the complaint was dismissed. The court reasoned that there was no fee schedule for office-based surgical facilities and thus, Avanguard was not entitled to recover a facility fee.

The court considered the fact that the plaintiff had failed to appear for scheduled examinations under oath (EUOs), as required by the insurance company in order to recover assigned first-party no-fault benefits. The main issue decided was whether the insurance company was justified in denying the claim based on the plaintiff's failure to appear for the scheduled EUOs. The holding of the case was that the insurance company's affidavits established that the EUO scheduling letters had been timely mailed, and the plaintiff had failed to appear at the scheduled EUOs, therefore the denial of the claim was justified. The judgment of the Civil Court granting the insurance company's motion for summary judgment and dismissing the complaint was affirmed.

The court considered whether the defendant had timely sent letters scheduling examinations under oath and whether the defendant had timely denied the plaintiff's claims. The main issues decided were whether the plaintiff had satisfied its prima facie burden and whether the defendant had presented any evidence at trial. The holding was that since the parties stipulated to plaintiff's prima facie case and the defendant failed to present any evidence, there was no basis to reverse the judgment, and the court affirmed the judgment in favor of the plaintiff.

The case involves a dispute over no-fault benefits under a policy of automobile insurance. The plaintiff, a hospital, sought reimbursement for medical services provided to a patient injured in a car accident, and argued that the defendant, the patient's insurance company, issued a defective denial of claim form. The main issues were whether the defendant's NF-10 denial of claim form was sufficient and timely, and whether nonprejudicial mistakes or omissions in the form were fatal. The court held that the defendant's NF-10 denial of claim form was timely and sufficient, and that the plaintiff did not meet its burden of establishing entitlement to judgment as a matter of law, so the court reversed the judgment in favor of the plaintiff and denied the motion for summary judgment.

The court considered the fact that the plaintiffs commenced an action to recover assigned first-party no-fault benefits in September 2008, and the defendant served a 90-day notice pursuant to CPLR 3216 (b) (3) on June 25, 2011. The plaintiffs did not file a notice of trial, move to vacate the 90-day notice, or move to extend the 90 days. The main issue decided was whether the plaintiffs demonstrated a justifiable excuse for their delay and a meritorious cause of action to avoid dismissal pursuant to CPLR 3216. The holding of the court was that the plaintiffs' attorney's statement that bills had been submitted to the defendant and had not been paid within 30 days of their submission was insufficient to demonstrate the merit of plaintiffs' case, and the plaintiff did not commence the action upon a verified complaint. Therefore, the court reversed the order and granted the defendant's motion to dismiss the complaint pursuant to CPLR 3216.