No-Fault Case Law

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.

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.

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.

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.

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.