No-Fault Case Law
Matter of Countrywide Ins. Co. v DHD Med., P.C. (2011 NY Slip Op 05864)
July 7, 2011
The court considered whether a medical services provider, DHD Medical, P.C., was fraudulently incorporated and therefore ineligible for reimbursement of no-fault insurance benefits, and precluded from demanding arbitration. The main issue was whether the defense of fraudulent incorporation was for the arbitrator and not the courts. The court held that the defense of fraudulent incorporation is for the arbitrator and not the courts, and has been the subject of numerous arbitration proceedings. Therefore, the court affirmed the order denying the petition to stay arbitration of claims for no-fault insurance benefits and granting respondent's cross motion to dismiss the proceeding.
Corona Hgts. Med., P.C. v Lancer Ins. Co. (2011 NY Slip Op 51293(U))
July 5, 2011
The court considered the fact that the plaintiff had failed to appear at scheduled examinations under oath (EUOs) as required by the defendant insurance company. The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint on the ground of the plaintiff's failure to appear for EUOs. The court held that the defendant was entitled to summary judgment dismissing the claims in question because the appearance of an eligible injured person's assignee at an EUO upon a proper request is a condition precedent to the assignee's right to recover under the policy. Therefore, the order granting the defendant's motion for summary judgment was affirmed.
Ave T MPC Corp. v Auto One Ins. Co. (2011 NY Slip Op 51292(U))
July 5, 2011
The court considered the appeal of Ave T MPC Corp. as Assignee of Juliana Kogan, in a case against Auto One Insurance Company. The main issue decided was whether the provider had established its entitlement to summary judgment for first-party no-fault benefits. The court held that a no-fault provider needs to prove the submission of a claim form, the fact and amount of loss, and either that the defendant failed to pay or deny the claim within 30 days, or that the defendant issued a timely denial of claim that was conclusory, vague, or without merit as a matter of law. In this case, the plaintiff demonstrated that the claims were not paid, but failed to demonstrate that the defendant had failed to deny the claim or issued a legally insufficient denial of claim form. As a result, the court affirmed the order denying the plaintiff's motion for summary judgment.
Manhattan Med. Imaging, P.C. v New York Cent. Mut. Fire Ins. Co. (2011 NY Slip Op 51230(U))
June 30, 2011
The relevant facts considered by the court were that the defendant denied a provider's claim for first-party no-fault benefits on the ground of lack of medical necessity and also denied a claim on the basis that the assignor had failed to appear for scheduled independent medical examinations. The main issue decided was whether the peer review reports submitted by the defendant were admissible and if the defendant had timely denied the claims on the grounds provided. The court held that the defendant had established its prima facie entitlement to summary judgment upon the claims of lack of medical necessity and that the defendant had timely denied the claim based on the assignor's failure to appear for scheduled IMEs. Therefore, the order of the Civil Court denying the defendant's motion for summary judgment was reversed, and the defendant's motion for summary judgment dismissing the complaint was granted.
East Coast Acupuncture, P.C. v Clarendon Natl. Ins. Co. (2011 NY Slip Op 51229(U))
June 30, 2011
The relevant facts considered by the court in this case include a dispute over payments for acupuncture services rendered by the plaintiff to its assignor. The defendant had partially paid for some sessions at a reduced rate and denied payment for others due to the assignor's failure to attend scheduled independent medical examinations (IMEs). The main issue decided was whether the defendant was entitled to summary judgment dismissing the complaint based on the assignor's failure to attend IMEs and the reduced reimbursement for sessions. The holding of the court was that the defendant was entitled to summary judgment dismissing the complaint with regard to the claims for which it had denied reimbursement based on the assignor's failure to attend IMEs, but it was not entitled to summary judgment for unpaid portions of the remaining bills based on a different reason. The order from the Civil Court was modified to reflect these conclusions.
Kuzma v Protective Ins. Co. (2011 NY Slip Op 51348(U))
June 29, 2011
The relevant facts considered by the court in Kuzma v Protective Ins. Co. involved the plaintiff's claim for disability benefits under an insurance policy after being injured in a motor vehicle accident while working as a driver for Fed Ex. The defendant, Protective Insurance Company, denied the plaintiff's claim for benefits. The main issues decided by the court were whether the defendant's motion for summary judgment should be granted and whether the contractual statute of limitations in the insurance policy was unconscionable. The court held that the defendant's motion for summary judgment was denied, as the contractual statute of limitations in the insurance policy was procedurally and substantively unconscionable and would not be enforced. The court also denied the defendant's motion to dismiss the complaint for failure to state a cause of action.
Lifex Med. Care, P.C. v Safeco Natl. Ins. Co. (2011 NY Slip Op 51221(U))
June 28, 2011
The main issues that the court considered in this case were whether the provider was entitled to recover assigned first-party no-fault benefits and whether the insurance company's denial of certain claims was without merit as a matter of law. The court held that while the provider demonstrated that the insurance company had not paid their claims, they failed to show that the basis for the denial of several specific claims was conclusory, vague, or without merit. As a result, the court denied the provider's motion for summary judgment. Additionally, the court declined to grant the insurance company's cross motion for summary judgment dismissing the complaint due to insufficient evidence submitted in admissible form. The court reversed the judgment, vacated the part of the order that granted the provider's motion for summary judgment, and denied the provider's motion. The court left undisturbed the implicit denial of the insurance company's cross motion for summary judgment.
Providence Wash. Ins. Co. v Munoz (2011 NY Slip Op 05684)
June 28, 2011
The relevant facts of the case involved two related subrogation actions to recover insurance benefits paid by the plaintiff's insured in actions Nos. 1 and 3 and a related action to recover damages for personal injuries (action No. 2). Providence Washington Insurance Company appealed from an order denying its motion to dismiss a counterclaim and granted the cross motion of the defendants for an award of costs and an attorney's fee against it. The court decided that the counterclaim against Providence "cannot effect an affirmative recovery," and therefore should have been dismissed. The court also decided that the defendants failed to demonstrate that Providence's conduct was frivolous and granted an attorney's fee against it. The holding of the case was that the order was therefore reversed, granting that branch of Providence's motion to dismiss the counterclaim, and denied the defendants' cross motion for an award of costs and a fee against Providence.
Mount Sinai Hosp. v Country Wide Ins. Co. (2011 NY Slip Op 05680)
June 28, 2011
The main issue in the case was whether the plaintiffs were entitled to recover no-fault insurance medical payments under two insurance policies. The court considered whether the defendant insurer failed to pay or deny the claims within the requisite 30-day period, as required by Insurance Law § 5106 and 11 NYCRR 65-3.8[a][1]. The holding of the case was that the Supreme Court should have denied the plaintiffs' motion for summary judgment on the complaint due to the presence of triable issues of fact raised by the defendant in opposition to the motion. The court also declared that the Supreme Court properly denied the defendant's cross motion for summary judgment, and that there was no reasonable justification offered by the defendant to renew its cross motion for summary judgment.
Mount Sinai Hosp. v Government Empls. Ins. Co. (2011 NY Slip Op 05679)
June 28, 2011
The relevant facts considered by the court were that Mount Sinai Hospital and New York Presbyterian Hospital sued Government Employees Insurance Company for no-fault medical payments. The main issue in the case was whether the hospitals had demonstrated that the necessary billing forms had been mailed to and received by the defendant and that the defendant had failed to either pay or deny the claim within the requisite 30-day period. The holding of the court was that the defendant raised a triable issue of fact as to whether it issued a denial of claim form dated April 2, 2008, to the hospital, so the Supreme Court should have denied the hospital's motion for summary judgment on its fourth cause of action.