No-Fault Case Law

The court considered the motion for summary judgment made by the defendant, who sought to dismiss the complaint brought by the plaintiff, a provider seeking to recover assigned first-party no-fault benefits. The main issue decided was whether there was a lack of medical necessity for the chiropractic services rendered, and if there was an issue of fact as to the medical necessity of the services. The court held that both the plaintiff and the defendant had established their prima facie cases, and that the sole issue for trial was the medical necessity of the services rendered to the plaintiff's assignor. The court affirmed the order, denying the defendant's motion for summary judgment.

The relevant facts of the case involved plaintiff, a medical provider, submitting a claim for no-fault benefits to the defendant, an insurance company, through their attorneys. The defendant then mailed verification requests directly to the plaintiff, but failed to send copies of the letters to the plaintiff's attorneys, as requested. The main issue decided was whether the defendant's failure to send verification requests to the plaintiff's attorneys, as explicitly requested, was legally consequential, and whether the failure to send the requests to the attorneys warranted dismissing the claim. The holding of the case was that the defendant's mistake in not sending verification requests to the plaintiff's attorneys was not legally consequential, and the court ruled in favor of the defendant's cross motion for summary judgment, dismissing the claim as premature.

The court considered the fact that the defendant had appealed from an order of the Civil Court of the City of New York, Bronx County, which denied its motion for summary judgment dismissing the complaint. The main issue decided was whether the plaintiff had submitted timely proof of its claim for first-party no-fault benefits. The court held that in opposition to the defendant's showing of entitlement to judgment as a matter of law, the plaintiff had failed to raise a triable issue of fact. The conclusory affidavit of the plaintiff's employee and the certified mail receipt were insufficient to raise an issue of fact, especially given that the receipt contained two different postmarks and a file number that did not correspond to the plaintiff's claim. The court also noted that the plaintiff had submitted no proof of "reasonable justification" for the failure to provide timely notice of the claim. Therefore, the court reversed the order, granted the defendant's motion, and dismissed the complaint.

The court considered the fact that the defendant had timely mailed a request and follow-up request for verification, and that the requested verification had not been provided by the plaintiff. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should be granted on the grounds that the action was premature. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted, as the plaintiff did not rebut the defendant's prima facie showing that the initial request and follow-up request for verification were timely mailed and that the plaintiff failed to respond to the requests. The court also found that the denial attached to the plaintiff's opposition was a general denial, not a specific denial, and therefore granted the defendant's motion for summary judgment.

The court considered the fact that Alev Medical Supply, Inc. filed a lawsuit against American Transit Insurance Company to recover assigned first-party no-fault benefits. The District Court had previously ordered Alev to file proof within 90 days that its assignor had filed an application with the Workers' Compensation Board. Alev failed to comply with this order, and as a result, American Transit Insurance Company moved for summary judgment dismissing the complaint. Alev did not demonstrate in opposition to the motion that its assignor had made such an application, and did not show good cause why the complaint should not be dismissed. The main issue decided was whether Alev had complied with the prior court order, and the holding of the case was that the District Court properly granted American Transit Insurance Company's motion for summary judgment dismissing the complaint.

The relevant facts the court considered in this case were that Lenox Hill Radiology, P.C. was seeking to recover assigned first-party no-fault benefits from Redland Insurance Company. Redland Insurance Company moved for summary judgment to dismiss the complaint, arguing that the denial of claim had been issued in duplicate. The main issue decided was whether the denial of claim had been issued in duplicate. The holding of the case was that the appellate court reversed the lower court's decision, stating that the affidavit submitted by the defendant established that the denial of claim had been issued in duplicate. Therefore, defendant's motion for summary judgment dismissing the complaint was granted.

The court considered a provider's claim to recover assigned first-party no-fault benefits, and the defendant insurance company moved for summary judgment to dismiss the complaint. In support of its motion, the insurance company submitted affirmed peer review reports and an independent medical examination report, which determined that there was a lack of medical necessity for the services rendered. The Civil Court denied the defendant's motion, stating that the matter shall proceed to trial on the issue of medical necessity. However, the appellate court reversed the decision, ruling in favor of the defendant, as the plaintiff failed to rebut the conclusions set forth in the defendant's reports. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted.

Issues: The main issue in this case was whether the defendant's refusal to pay the full $25,000 SUM coverage limits amounted to a breach of the implied covenant of good faith and fair dealing. Facts: Sarah Orman was involved in a car accident while making a left turn, and her car was struck in the rear by another vehicle. At the time of the accident, the other driver had an automobile insurance policy with limits of $25,000 per person and $50,000 per accident, and Orman had a policy with SUM coverage with the same limits. Geico, her insurance company, advised her to settle the case and even granted permission to settle a bodily injury claim with the adverse tort carrier. However, Orman requested the full $25,000 SUM coverage limits, which Geico refused to pay. Geico also requested medical authorizations and MRI films to properly evaluate the claim. Holding: The court granted Orman's motion to dismiss Geico's affirmative defenses and denied Geico's cross-motion to dismiss the claim for breach of the implied covenant of good faith and fair dealing, holding that the plaintiff was justified in understanding a promise of the full $25,000 SUM coverage limits was included in the contract. Since the insured must also meet the serious injury requirement before entitlement to supplementary benefits, the serious injury defense put forth by Geico did not constitute bad faith. Geico's refusal and negligence to pay Orman was not made in good faith, and thus, the court held that there was a valid cause of action for breach of the implied covenant of good faith and fair dealing.

The court considered the evidentiary proof submitted by the defendant-insurer, which established that its initial and follow-up verification letters were timely and properly mailed to the plaintiff medical provider's attorney. The main issue decided was whether the defendant was entitled to summary judgment dismissing the claim as premature, as the plaintiff failed to respond to the verification requests. The court held that the defendant was entitled to summary judgment dismissing the claim, as the plaintiff's attorney's denial of receipt of the verification letters was insufficient to raise a triable issue. The court also rejected the plaintiff's claim that 11 NYCRR 65-3.6(b) required the defendant to issue a delay letter to both the plaintiff and its attorney.

The court considered the defendant insurer's motion for summary judgment to dismiss the complaint and the plaintiff's cross motion for summary judgment. The main issue decided was whether the defendant insurer's verification requests were valid and if the plaintiff failed to respond to those requests. The court held that the defendant established its entitlement to summary judgment because the plaintiff failed to respond to the verification requests, and therefore, the underlying first-party no-fault claims were premature. The court also found that the defendant's requests for verification, made after the 15-day period but before the 30-day claim denial window expired, did not render the requests invalid, but only reduced the 30-day time period for payment or denial of the claim. Therefore, the court reversed the order, denied the plaintiff's cross motion, and granted the defendant's motion for summary judgment.