No-Fault Case Law
Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 50347(U))
February 28, 2014
The relevant facts considered by the court were that a provider was seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company argued that the action was premature because the provider had failed to provide requested documentary verification. The insurance company demonstrated that it had timely requested verification from the provider and that the provider had not responded to these requests. The main issue decided by the court was whether the action by the provider to recover benefits was premature due to the lack of response to verification requests. The holding of the case was that the court reversed the prior determination, denying the provider's motion for summary judgment and granting the insurance company's cross motion for summary judgment dismissing the complaint. Therefore, the complaint was deemed to be premature due to the lack of response to verification requests.
American Chiropractic Care, P.C. v Praetorian Ins. Co. (2014 NY Slip Op 50346(U))
February 28, 2014
The main issue in this case was whether the defendant, Praetorian Insurance Company, was entitled to summary judgment dismissing the complaint brought by the plaintiff, American Chiropractic Care, P.C., seeking to recover assigned first-party no-fault benefits. The defendant had timely mailed denial of claim forms based on lack of medical necessity and provided a sworn peer review report by their chiropractor to support their determination. The court found that the defendant had established its prima facie entitlement to summary judgment. However, the plaintiff submitted a sworn letter of medical necessity by its treating chiropractor, which created a question of fact as to medical necessity. As a result, the court affirmed the order denying the defendant's motion for summary judgment, without costs.
Eagle Surgical Supply, Inc. v Allstate Ins. Co. (2014 NY Slip Op 50343(U))
February 28, 2014
The court considered the fact that in this action by a provider to recover assigned first-party no-fault benefits, a nonjury trial was held, at which plaintiff's witness was the sole witness. Plaintiff attempted to move into evidence certain documents, including an NF-10 denial of claim form and a mailing log, but the court refused to admit those documents. After the trial, the complaint was dismissed on the ground that plaintiff had failed to establish a prima facie case.
The main issue decided was whether plaintiff should have been allowed to use the denial of claim form as an admission by the defendant that the claim form had been received.
The holding of the case was that the matter was remitted to the Civil Court for the entry of judgment in favor of plaintiff in the principal sum of $918.75, plus statutory interest and attorney's fees due pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder, as plaintiff proved that defendant had not paid the claim and as defendant consented to the admission into evidence of plaintiff's claim form.
Great Health Care Chiropractic, P.C. v Lancer Ins. Co. (2014 NY Slip Op 50340(U))
February 28, 2014
The main issues decided in this case were whether the plaintiff's assignor was eligible for workers' compensation benefits and if those benefits might be available. The court held both motions for summary judgment in abeyance until an application could be made to the Workers' Compensation Board to determine the parties' rights under the Workers' Compensation Law. The court determined that there was sufficient evidence to support the contention that the plaintiff's assignor may have been acting in the course of his employment at the time of the accident, and thus workers' compensation benefits might be available. The court also found that defendant's failure to submit certificates of conformity was not a fatal error. Therefore, the order of the Civil Court was affirmed.
Stracar Med. Servs. v New York Cent. Mut. Ins. Co. (2014 NY Slip Op 50263(U))
February 27, 2014
The relevant facts considered by the court in this case were that the defendant insurance company denied payment for first-party no-fault benefits to the plaintiff, Stracar Medical Services, for the medical treatment of Inma Villa. The main issue decided by the court was whether the insurance company was entitled to summary judgment dismissing the complaint based on the assignor's failure to appear at scheduled independent medical examinations (IMEs). The holding of the court was that the insurance company demonstrated its entitlement to summary judgment by submitting evidence that the notices scheduling the IMEs were timely and properly mailed, and that the assignor failed to appear at the scheduled IMEs. The court found that the plaintiff did not raise a triable issue with respect to the assignor's nonappearance or the mailing and reasonableness of the notices, and therefore the defendant's motion for summary judgment dismissing the complaint was granted in full.
Westchester Med. Ctr. v A Cent. Ins. Co. (2014 NY Slip Op 01319)
February 26, 2014
The case involved an action to recover no-fault benefits under a policy of automobile insurance. The plaintiff appealed from an order denying its motion for summary judgment on the complaint, which was based on the defendant's alleged failure to timely pay or deny the no-fault claim within 30 days. The issue was whether the defendant raised a triable issue of fact regarding its timely denial of the plaintiff's claim. In opposition to the plaintiff's showing of entitlement to judgment as a matter of law, the defendant raised a triable issue of fact as to whether it mailed a proper NF-10 denial of claim form to the plaintiff. The court held that the defendant satisfied its burden by raising a triable issue and affirmed the order denying the plaintiff's motion for summary judgment on the complaint.
Wyckoff Hgts. Med. Ctr. v Government Empls. Ins. Co. (2014 NY Slip Op 01166)
February 19, 2014
The case involves Wyckoff Heights Medical Center as the assignee of Aida Ruiz and Government Employees Insurance Company in an action to recover no-fault benefits under an automobile insurance policy. The Supreme Court, Nassau County granted Wyckoff Height Medical Center's motion for summary judgment on the first cause of action, but the defendant appealed. While the plaintiff showed evidence that the prescribed billing forms were sent to and received by the defendant, the defendant raised a triable issue of fact as to whether it timely and properly denied the claim. The defendant submitted evidence showing that it had mailed a denial of claim form within the required 30-day period, and although there were minor errors on the form, they were not considered fatal. The Supreme Court reversed the original order, denying the plaintiff's motion and holding that the defendant's denial of the claim was not ineffective despite the issues raised by the plaintiff.
Professional Health Imaging, P.C. v Old Republic Ins. Co. (2014 NY Slip Op 50200(U))
February 18, 2014
The court considered the facts surrounding a federal court's dismissal of a personal injury claim by the plaintiff's assignor, Barbara Harvey, against Ryder Truck Rental, Inc. Defendant, Old Republic Insurance Company, argued that the federal court's ruling collaterally estopped the plaintiff from seeking no-fault benefits for services provided to Ms. Harvey after the accident. However, the court noted that the federal court never ruled definitively on whether the Ryder truck was involved in the accident, and the decision granted summary judgment to Ryder based on a lack of evidence. The court also considered previous appellate term decisions regarding collateral estoppel claims by no-fault insurers in cases where the provider had not been given an opportunity to be heard. The holding of the case was that plaintiff was not collaterally estopped from pursuing its independent no-fault claim against the defendant insurer, and defendant's motion was denied.
Flatlands Med., P.C. v AAA Ins. (2014 NY Slip Op 24048)
February 14, 2014
The court addressed a case concerning an action to recover assigned first-party no-fault benefits from an out-of-state insurer for medical services that were provided to an assignor in New York. The defendant filed a cross-motion to dismiss the complaint on the grounds that it had not been properly served, and that the court lacked jurisdiction. Despite an error in the certificate of conformity for the defendant's affidavit, the court considered the evidence in the affidavit. The court ultimately found that the defendant had demonstrated prima facie evidence that it was not authorized to conduct insurance business in New York, and therefore, jurisdiction could not be obtained. The plaintiff did not provide enough evidence to show that jurisdiction was acquired over the defendant, and thus, the court held in favor of the defendant on grounds different from those stated by the Civil Court, dismissing the complaint.
Comprehensive Psychiatric Care, P.C. v Clarendon Natl. Ins. Co. (2014 NY Slip Op 50184(U))
February 11, 2014
The court considered the timeliness of a cross motion to dismiss the complaint pursuant to CPLR 3211 (a) (5) in a case involving an action to recover first-party no-fault benefits. The defendant in the case appealed from an order of the Civil Court that rejected its cross motion as untimely, despite the fact that it had been served in a timely manner according to a so-ordered stipulation. The main issue decided was whether the Civil Court erred in failing to consider the defendant's cross motion, and the holding of the case was that the order was reversed and the matter was remitted to the Civil Court for a determination of the merits of the defendant's cross motion to dismiss the complaint pursuant to CPLR 3211 (a) (5).