No-Fault Case Law
Restoration Sports & Spine v Geico Ins. Co. (2014 NY Slip Op 51729(U))
December 5, 2014
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.
Surgicare Surgical v National Interstate Ins. Co. (2014 NY Slip Op 24362)
November 17, 2014
In this case, Surgecare Surgical sought reimbursement for services provided in New Jersey after a car accident. The question before the court was whether an insurance company complied with New York's no-fault law by reimbursing health services provider for out-of-state services in accordance with the no-fault fee schedule of that state. The main issue to decide was whether the "prevailing fee in the geographic location of the provider" meant the fee schedule of another state could be used. The court ruled that the insurance company acted properly when it limited payment for the health services performed by the plaintiff to the amount in New Jersey's fee schedule.
Greater Forest Hills Physical Therapy, PC v State Farm Mut. Auto. Ins. Co. (2014 NY Slip Op 51594(U))
November 10, 2014
The court considered whether a medical provider is required to submit claims for no-fault benefits to an insurance carrier when the carrier has disclaimed coverage based on a medical review. The main issue was whether the medical provider was obligated to submit proof of claim forms to the insurance carrier after the carrier denied all further coverage for no-fault benefits based on an independent medical examination. The court held that the medical provider was not obligated to submit timely claim forms for no-fault benefits after the insurance carrier denied coverage. The court based its decision on a previous holding of the Second Department, which stated that an insurance carrier cannot insist upon adherence to the terms of its policy after it has repudiated liability on the claim by sending a letter disclaiming coverage. Therefore, the court denied the motion for summary judgment and allowed the plaintiff to proceed with its no-fault claim for services rendered.
NJ/NY Pain Mgt. v Allstate Ins. Co. (2014 NY Slip Op 51569(U))
November 3, 2014
The court considered the evidence presented by the plaintiffs that the necessary billing documents were mailed to and received by the defendant-insurer, and that payment of the no-fault benefits was overdue. The main issue decided was whether the plaintiffs were entitled to judgment as a matter of law based on the evidence presented. The court held that the plaintiffs had established prima facie their entitlement to judgment as a matter of law, and that the defendant failed to raise a triable issue. Therefore, the court affirmed the order granting the plaintiffs' cross motion for summary judgment on the complaint.
Clarke v Scottsdale Ins. Co. (2014 NY Slip Op 51586(U))
October 29, 2014
The main issue in this case was whether the out-of-state affidavit submitted by the defendant's claims analyst in support of the motion for summary judgment was admissible due to the absence of a certificate of conformity. Plaintiff objected to the form of the affidavit, but the court held that the absence of a certificate of conformity was not a fatal defect and could be corrected nunc pro tunc or disregarded. However, the affidavit was found to be inadmissible for a different reason, as the notary public did not affirm that the claims analyst had appeared before her and established her identity. Therefore, the court affirmed the denial of defendant's motion for summary judgment. The holding of the court was that the affidavit of defendant's claims analyst was not in proper admissible form and there was no basis to disturb the denial of the motion.
Urban Well Acupuncture, P.C. v American Commerce Ins. Co. (2014 NY Slip Op 51520(U))
October 22, 2014
The court considered the plaintiff's appeal from the Civil Court's order granting the defendant's motion for summary judgment dismissing the complaint in a first-party no-fault benefits action. The main issue decided was whether the defendant had failed to establish that the denial of claim form was actually mailed to the plaintiff, and whether the affidavit submitted by the defendant insurer to establish proof of mailing was sufficient. The court held that the action was not ripe for summary dismissal because the defendant had failed to establish that the denial of claim form was in fact mailed to the plaintiff, and the affidavit submitted by the defendant insurer to establish proof of mailing was insufficient. As a result, the court reversed the order, denied the motion, and reinstated the complaint.
Karina K. Acupuncture P.C. v State-Wide Ins. Co. (2014 NY Slip Op 51518(U))
October 22, 2014
The court considered that defendant timely denied a portion of plaintiff's first-party no-fault claim for acupuncture services, citing that the fees charged by the plaintiff exceeded the amount permitted by the applicable workers' compensation fee schedule. The affidavits and documentary evidence submitted by the defendant established prima facie that the denial was proper. Plaintiff failed to raise a triable issue regarding the efficacy of the denial form issued by the defendant or the calculation of the fee. Therefore, the court upheld defendant's motion for summary judgment dismissing the $1,182.53 claim. However, the defendant failed to establish entitlement to summary dismissal of plaintiff's remaining claim of $1,259.53, as the motion papers did not address the validity of this claim. As a result, the court reinstated plaintiff's claim for first-party no-fault benefits in the sum of $1,259.53.
Mount Sinai Hosp. v Auto One Ins. Co. (2014 NYSlipOp 06954)
October 15, 2014
The main issue of this legal case was to determine whether the healthcare provider was entitled to no-fault benefits, when the automobile insurance company claimed the health care provider did not respond to a verification request within 30 days. The healthcare provider argued that the insurance company requested verification of items they were not authorized to release. The court held that as long as the healthcare provider responded to the verification request with respect to the records in its possession, it may be entitled to no-fault benefits. Furthermore, there were significant issues of fact concerning the propriety of the insurance company's verification requests, such as whether the items requested actually existed or were in the possession of the healthcare provider. Therefore, the case was remanded because there were outstanding factual issues to be resolved.
Matter of Emerald Claims Mgt. for Ullico Cas. Ins. Co. v A. Cent. Ins. Co. (2014 NYSlipOp 06892)
October 14, 2014
The relevant facts in the case include an insured driver being in an accident and another driver's insurance company refusing to pay. The main issue before the court was whether the insurer was obligated to pay despite their claim of noncooperation from the driver. The appellate division upheld the original judgment against the insurance company. The court held that the arbitration awards would be upheld if there was evidence to support them, which there was in this case. This was based on the interpretation of the Insurance Law and the insurer's direct right to recover loss transfer reimbursement from the adverse insurer, even if the adverse insurer had disclaimed coverage.
Prestige Med. P.C. v Travelers Home & Mar. Ins. Co. (2014 NY Slip Op 24317)
October 5, 2014
The court considered the issue of whether an insurance company is required to schedule an examination before trial (EUO) of a medical provider within 15 business days after completing the assignment's EUO. The case raised tensions between treating the EUO as a condition precedent to coverage and as part of the verification procedures. The insurance company failed to issue a scheduling letter to the provider for an EUO within the required 15 business days, but later issued a denial based on the provider's failure to appear for the EUO. The court ultimately held that the insurance company forfeited its right to issue an untimely denial as permitted by a prior decision and the time in which to issue the denial was reduced by the insurance company's untimely request for an additional EUO. The insurance company's motion for summary judgment was granted, and the plaintiff's cross motion for summary judgment was denied.