No-Fault Case Law

The relevant facts the court considered in this case were that Leica Supply, Inc. was seeking to recover first-party no-fault benefits, and defendant, American Transit Insurance Co., had denied the claim form on the basis that it had been untimely submitted. Defendant had submitted an affidavit by its claims examiner to establish the timely mailing of the denial of claim form and that plaintiff had submitted its claims more than 45 days after the services were rendered. The main issue decided by the court was whether defendant's denial of claim form was valid and whether plaintiff had provided a reasonable justification for the late submission of the claim. The holding of the court was that defendant's denial of claim form was valid, and plaintiff had not provided a reasonable justification for the late submission, therefore defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the case brought by Jersey Rehab PA, P.C., where the defendant, IDS Property Casualty Insurance Company, sought summary judgment to dismiss no-fault benefit claims that had been filed by the plaintiff on behalf of Owen G. Webb after an auto accident. The main issue decided was whether the defendant could properly claim that Mr. Webb breached a condition precedent to coverage by failing to attend an independent medical examination (IME) when the notices sent by the insurer did not comply with mandatory notice requirements as outlined in the no-fault regulations. The holding of the case was that the defendant's IME notices were deemed ineffective and insufficient to give proper notice to Mr. Webb of his right to reimbursement for lost earnings and transportation expenses. As a result, the motion for summary judgement was granted only to the extent of dismissing some of the causes of action, and denied in all other respects.

The main issues decided by the court in this case were related to the termination of an insurance policy and its impact on medical claims. The court considered the facts related to the termination of an insurance policy ab initio, based on fraudulent procurement, which resulted in the denial of medical claims by the defendant insurer. Another issue involved a sister-state dismissal order from Virginia and the enforceability of the order in New York. The court also reviewed whether the denials and termination of the policy were done in accordance with proper mailing procedures by the defendant insurer. The holding of the court was that the termination of the insurance policy was void as a matter of law and the sister-state dismissal order from Virginia was enforceable. The court granted the defendant's motion for summary judgment and dismissed the complaint with prejudice, while also stating that the plaintiff could pursue claims against the assignor for payment of medical services provided.

The relevant facts considered by the court in Utica Acupuncture, P.C. v Interboro Ins. Co. were that the defendant-insurer sought to dismiss the plaintiff's no-fault claims for acupuncture services rendered during specific periods in 2009. The main issue decided by the court was whether the plaintiff had provided enough evidence to raise a triable issue of fact regarding the receipt of verification requests and the medical necessity of the acupuncture treatments. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint was granted in its entirety. The court found that the plaintiff failed to raise a triable issue of fact regarding the receipt of verification requests and the medical necessity of the acupuncture treatments, and therefore, the defendant was entitled to judgment dismissing the plaintiff's claims.

The court considered the defendant-insurer's motion for summary judgment to dismiss the complaint or compel discovery. The main issue decided was whether the plaintiff had raised a material issue requiring a trial of its claim for assigned no-fault first-party benefits, as the defendant had shown that the assignor's treated medical condition was not causally related to the underlying motor vehicle accident. The holding of the court was that the defendant's motion for summary judgment dismissing the complaint was granted, as the plaintiff had failed to raise a material issue requiring a trial of its claim for assigned no-fault first-party benefits. The court found that the plaintiff's principal, an orthopedist who performed the surgical procedure giving rise to the no-fault action, had provided an insufficient affidavit that failed to set forth a factual basis for his conclusion on the critical causation issue, and had not addressed or rebutted the contrary findings made by defendant's medical experts.

The court considered the appeal of a motion for summary judgment from the Civil Court of the City of New York, Bronx County, which sought to dismiss a complaint brought by Amherst Medical Supply, LLC. The complaint was filed against New York Central Mutual Fire Insurance Company, seeking recovery of assigned first-party no-fault benefits. The main issue decided was whether the peer review report and accompanying affidavit submitted by the defendant's chiropractor provided sufficient factual basis or medical rationale for his conclusion that the medical supplies in question were not medically necessary. The holding of the court was that the action was not ripe for summary dismissal, as the defendant's submission failed to meet its prima facie burden of eliminating all triable issues as to medical necessity. The court affirmed the order entered by the Civil Court and held that plaintiff's submission of an affidavit prepared by the assignor's treating chiropractor was sufficient to raise a triable issue as to medical necessity.

The main issue decided in this case was whether a no-fault provider had established a prima facie case to recover assigned first-party no-fault benefits. The court considered the submission of claim forms, proof of the fact and amount of loss, and whether the defendant had failed to pay or deny the claim within the requisite 30-day period. The holding of the court was that the plaintiff had established a prima facie case, as they had submitted the claim forms and proved the fact and amount of loss sustained. Additionally, the court determined that the defendant's proffered defense of lack of medical necessity was without merit as a matter of law, and that the defendant failed to raise a triable issue of fact in opposition to the motion. As a result, the court reversed the order, granted the plaintiff's motion for summary judgment, and remitted the matter to the Civil Court for a calculation of statutory interest and an assessment of attorney's fees.

The relevant facts the court considered in this case were that a healthcare provider, Physical Performance Testing of NY, was seeking to recover assigned first-party no-fault benefits from New York Central Mutual Insurance Company. However, Mutual moved for summary judgment, arguing that Physical was unlicensed and therefore ineligible for reimbursement of the benefits. The main issue decided by the court was whether a healthcare provider is eligible for reimbursement of first-party no-fault benefits if they fail to meet New York State or local licensing requirements. The holding of the court was that a provider of healthcare services is not eligible for reimbursement if they fail to meet licensing requirements, and in this case, Physical failed to raise a triable issue of fact with respect to its claims because the services were not performed by a medical professional corporation or a licensed health provider. Therefore, the court affirmed the orders and dismissed Physical's complaints.

The relevant facts of this case are that after a motor vehicle accident, Kocourek sought treatment at Sound Shore Medical Center and assigned her no-fault benefits to the center. The medical center submitted a UB-04 form to New York Central, her insurance company, indicating that $13,053.02 in services were provided to Kocourek. In response, New York Central requested further verification and treatment information from Sound Shore. Then, Sound Shore submitted an N-F 5 form requesting $4,834.95 for the treatment, as well as an assignment of benefits form, which New York Central rejected. The main issue the court decided was whether the UB-04 form was the same as the N-F 5 form, which would trigger the 30-day period in which an insurer must pay or deny a claim. The court held that the UB-04 form sent by Sound Shore is not the "functional equivalent" of an N-F 5 form, reversing the Appellate Term's decision. The court also determined that New York Central's time to respond to Sound Shore's claim was not tolled, and therefore, Sound Shore's claim was not premature. Consequently, Sound Shore established its entitlement to judgment, and New York Central failed to raise a triable issue of fact and was required to pay the claim to Sound Shore. Ultimately, the court reversed the Appellate Term's decision and reinstated the District Court's order.

The case involved a dispute between W.H.O. Acupuncture, P.C., an assignee of individuals who were injured, and American Transit Insurance Company, regarding the payment of first-party no-fault benefits. American Transit Insurance Company argued that the injured individuals may be eligible for workers' compensation benefits, and therefore they moved for summary judgment dismissing the complaint. The Civil Court denied the defendant's motion and granted the plaintiff's cross motion for summary judgment. However, the Appellate Court reversed the decision, stating that the issue of the injured individuals' eligibility for workers' compensation benefits must be resolved by the Workers' Compensation Board. Therefore, both the defendant's motion and the plaintiff's cross motion were remitted to the Civil Court for a new determination after the final resolution of the application to the Workers' Compensation Board to determine the parties' rights under the Workers' Compensation Law. If the plaintiff fails to file proof with the Civil Court within 90 days of the date of this decision, the court is instructed to grant the defendant's motion for summary judgment and deny the plaintiff's cross motion unless the plaintiff shows good cause why the complaint should not be dismissed.