No-Fault Case Law

The relevant facts in this case involved Liberty Mutual Insurance Company seeking de novo adjudication of defendant Bayside Pain & Rehabilitation Medicine's assigned first-party no-fault benefits claim, which had resulted in an arbitration award in favor of the provider. The complaint sought a determination that defendant was not entitled to recover assigned first-party no-fault benefits under plaintiff insurer's policy. The main issue decided was whether the District Court of Nassau County had subject matter jurisdiction to adjudicate this particular type of declaratory judgment action. The holding of the case was that the District Court lacked subject matter jurisdiction, and thus its order was considered a nullity, resulting in the dismissal of the appeal and vacating of the District Court's order from July 12, 2011.

The court considered an appeal from an order denying the defendant's motion for summary judgment. The case involved a provider seeking to recover assigned first-party no-fault benefits upon 15 claims, and the appeal was based on disputed claims of lack of medical necessity and timely requests for verification. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint based on the lack of medical necessity for the claims and untimely responses to verification requests. The holding of the court was that the defendant was entitled to summary judgment dismissing the claims seeking to recover $2,516.58, $967.52, and $832.92, as there was a lack of medical necessity and no timely responses to verification requests for those claims. Additionally, the court found that the defendant failed to establish, as a matter of law, that the fee charged exceeded the amount set forth in the workers' compensation fee schedule.

The court considered the issue of whether the defendant, Geico Ins. Co., was entitled to summary judgment dismissing the complaint of Right Aid Diagnostic Medicine, P.C. as Assignee of Delmy-Carolina Castro to recover assigned first-party no-fault benefits. The defendant had timely denied the claims on the basis of a lack of medical necessity and submitted two affirmed peer review reports in support of this determination. The court held that as the defendant's showing that the services were not medically necessary was not rebutted by the plaintiff, the defendant's cross motion for summary judgment dismissing the complaint should have been granted. Therefore, the court found in favor of the defendant and reversed the lower court's decision, granting the defendant's cross motion for summary judgment dismissing the complaint.

The court was deciding whether the case was properly dismissed based on the statute of limitations. The action was commenced by service of a summons in 2003. However, the time in which to sue ended if a claim asserted in the complaint is not interposed after the summons is served upon the defendant. The dismissal was not warranted because the Civil Court conditionally permitted the filing of the summons with the proof of service nunc pro tunc. Consequently, the six-year statute of limitations had not expired prior to the commencement of the action in April 2003. Therefore, the defendant's motion to dismiss the complaint was denied.

The relevant facts in this case included the defendant insurer's failure to pay first-party no-fault benefits and the plaintiff's claim for recovery of those benefits. The main issue decided was whether the defendant's requests for verification through an examination under oath (EUO) were effective to toll its time to pay or deny the claims at issue. The court held that the action was not ripe for summary disposition because the defendant failed to establish that its EUO requests were effective. The court also found that triable issues were raised as to whether the defendant properly followed up on its request for verification. Therefore, the court affirmed the order denying the defendant's motion for summary judgment.

The court considered a case that involved an action to recover damages for breach of contract and other causes of action. The plaintiff appealed a lower court order that granted multiple motions to dismiss the complaint. The court ultimately decided that the cause of action for fraud could not lie where based on the same allegations as a cause of action alleging breach of contract. They found that the fraud cause of action against the defendant State Farm Mutual Automobile Insurance Company was based on the same allegations as the breach of contract cause of action and properly granted the motion to dismiss. The court also found that the fraud cause of action against the remaining defendants should be dismissed, as the allegations were either bare and conclusory or did not rise to the level of fraud. However, the court erred in granting the motion to dismiss the first cause of action, which alleged breach of contract. The Supreme Court should have denied that branch of State Farm's motion. Additionally, the court properly granted the motion to dismiss the second cause of action, which sought consequential damages for breach of the no-fault insurance benefits policy.

The main issue in the case was whether an insurance company was justified in denying a healthcare provider's claim for first-party no-fault benefits on the grounds of insufficient verification being provided. The court had to consider whether the provider had failed to provide all the requested verification in a timely manner, and therefore whether the insurance company was within its rights to deny the claim. The court ultimately held that the insurance company was justified in denying the claim, as the provider had not demonstrated that they had provided all of the requested verification prior to the commencement of the action, and therefore the 30-day period within which the insurance company was required to pay or deny the claims had not begun to run. The court reversed the judgment, vacated the previous order, denied the provider's motion for summary judgment, and granted the insurance company's cross motion for summary judgment dismissing the complaint.

The relevant facts considered by the court in this case were that Eagle Surgical Supply, Inc. was seeking to recover first-party no-fault benefits as the assignee of a patient, Tristan Joris, and had brought a lawsuit against GEICO Insurance Co. The main issue decided was whether the supplies provided by Eagle Surgical Supply were medically necessary. The court found in favor of GEICO, stating that the supplies in question were not medically necessary, and dismissed the complaint. Eagle Surgical Supply appealed, arguing that the peer review report and underlying medical records should not have been admitted into evidence. The Appellate Term upheld the original judgment, stating that the lack of medical necessity had been properly established at trial through the testimony of GEICO's expert witness, and that Eagle Surgical Supply's objections lacked merit. Therefore, the judgment in favor of GEICO Insurance Co. was affirmed.

The court considered a case in which a provider sought to recover assigned first-party no-fault benefits from an insurance company. The insurance company denied the provider's claims, alleging that there was a "material misrepresentation" because the provider had billed for a heating pad that had not been provided to the assignor. The main issue decided was whether the provider was barred from receiving benefits not only for the heating pad but also for the remaining supplies for which they sought to recover. The holding of the court was that the insurance company failed to establish that the claim forms sought payment for medical supplies that were not actually provided, and that billing for a heating pad that was not delivered did not void the insurance policy. Therefore, the court affirmed the denial of the insurance company's motion to dismiss the claims for the remaining supplies.

The court considered the fact that after the plaintiff presented its case in a trial to recover first-party no-fault benefits, the defendant offered no defense but relied on the record. Despite the claim forms not containing language about an assignment of benefits, the defendant did not object to the completeness of the forms or seek verification of the existence of a valid assignment. The main issue decided was whether the plaintiff had established a prima facie case and whether the defendant waived any defense based on the absence of an assignment of benefits. The court held that the defendant waived any defense based on the absence of an assignment of benefits and that it was the defendant's burden to show a meritorious defense, therefore it reversed the previous judgment and remitted the matter to the Civil Court for the entry of a judgment in favor of the plaintiff in the principal sum of $2,063.10, plus statutory interest and attorney's fees.