No-Fault Case Law

The court considered the circumstances of a dispute between a healthcare provider and an insurance company over the payment of no-fault benefits. The provider had filed a motion to strike the insurance company's demand for a trial de novo after the insurer had participated in mandatory arbitration, but the motion was denied by the District Court. The main issue decided was whether the insurance company's limited participation in the arbitration constituted a default, barring them from demanding a trial de novo. The holding of the court was that the insurance company had not defaulted, as their attorney had appeared at the arbitration, participated in the hearing, and submitted evidence, which, if admissible, would have tended to rebut the provider's case. Therefore, the District Court had properly denied the provider's motion to strike the insurance company's demand for a trial de novo.

The Supreme Court, Nassau County ruled in favor of the plaintiff and against the defendant in the medical payment case. The defendant failed to appear or answer the complaint, resulting in a judgment against them. The defendant appealed and argued that they had a reasonable excuse for their delay and that they had a potentially meritorious defense to the action. The Supreme Court denied the defendant's motion to vacate the judgment and compel the acceptance of their answer. The Appellate Division reversed the decision, holding that the defendant had a reasonable excuse for their brief delay and demonstrated a potentially meritorious defense to the action. Therefore, the defendant's motion was granted, and the judgment was vacated.

The main issue decided in this case was whether defendant was entitled to summary judgment dismissing the claims of plaintiff Spring Medical, P.C. for assigned first-party no-fault benefits. The court held that defendant made a prima facie showing of entitlement to judgment as a matter of law dismissing Spring Medical, P.C.'s claims, as the fees charged by Spring for the medical services exceeded the relevant rates set forth in the fee schedule. Defendant's motion for summary judgment dismissing the claim of plaintiff Right Aid Diagnostic Medicine, P.C. based on lack of medical necessity was properly denied, as defendant did not demonstrate as a matter of law that it timely denied the claim within the statutory 30-day period or that the 30-day period was tolled by a proper verification request. Therefore, the court modified the order to grant defendant summary judgment dismissing the claims of plaintiff Spring Medical, P.C., and affirmed the order as modified.

The Supreme Court granted a New York hospital's motion for summary judgment, ordering GMAC Ins. Co. to pay no-fault benefits at the request of plaintiff, New York and Presbyterian Hospital. The hospital had demonstrated that billing documents were sent and received by GMAC, and payment was overdue. GMAC was unable to raise a triable issue of fact showing timely denial of the claim, as they could not show copy of the bill received on the date claimed. Moreover, GMAC was precluded from asserting a residency misrepresentation defense as a result of untimely claim denial. GMAC was also not able to argue that North Carolina law applied to the case, as they had not raised this argument in court. Therefore, the order was affirmed, and GMAC was held liable to pay the benefits requested.

The case involved an action to recover first party no-fault medical payments under an insurance contract. The defendant appealed from an order which had modified a judgment in favor of the plaintiff and against the defendant. The issue was whether the defendant insurer's submission of follow-up verification requests to the plaintiff medical provider 30 days after its initial verification requests was premature. The court decided that the follow-up requests were not premature and did not fully comply with the defendant's verification requests, thus the 30-day period within which the defendant was required to pay or deny the claim did not commence to run. As a result, the action was commenced prematurely. The court held that the plaintiff's motion for summary judgment should have been denied and the defendant's cross motion for summary judgment dismissing the complaint should have been granted, without prejudice to the commencement of a new action.

The court considered the defendant's appeal from an order of the Appellate Term, Second, Eleventh, and Thirteenth Judicial Districts, which affirmed a lower order denying the defendant's motion for summary judgment. The main issue in the case was whether the defendant insurer's submission of follow-up verification requests to the plaintiff medical provider on the 30th day after the initial verification requests was premature or "without effect." The court held that under the circumstances of the case, the defendant insurer's submission of follow-up verification requests was not premature or "without effect" and therefore the defendant's motion for summary judgment dismissing the complaint should have been granted. The court reversed the lower orders and granted the defendant's motion for summary judgment without prejudice to the commencement of a new action by the plaintiff.

The relevant facts that the court considered were around a medical center seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company had requested verification documents from the medical center, which they failed to provide. The main issues decided were whether the insurance company had sent the verification requests in a timely manner and whether the medical center had failed to respond to them. The holding of the court was that the insurance company's initial and follow-up verification requests were found to be timely, and the medical center had failed to respond to them, thus the insurance company's motion for summary judgment was granted, and the medical center's cross motion for summary judgment was denied.

The main issue in this case was whether the plaintiff, 62-41 Woodhaven Medical, P.C., should be compelled to produce copies of its corporate tax returns and tax records regarding its professional employees. The defendant had argued that the plaintiff was ineligible to recover no-fault benefits because it failed to meet applicable state and local licensing requirements. The court found that the defendant's cross motion papers were sufficient to establish that special circumstances exist which warrant the disclosure of the plaintiff's corporate tax returns and its professional employees' tax records. As a result, the court affirmed the order, without costs, granting the branch of defendant's cross motion seeking to compel plaintiff to produce these documents. The complaint would be dismissed in the event plaintiff failed to produce these documents.

The facts of the case involve a plaintiff insurer who commenced a lawsuit against the defendant, a provider of medical equipment, seeking to recover $2,846.18 in no-fault benefits. The defendant had been paid as an assignee of a patient for whom the benefits had been paid. The plaintiff determined through investigation that the patient was never supplied with the equipment for which the defendant had billed and been reimbursed. The plaintiff moved for leave to enter a default judgment after the defendant failed to appear or answer the complaint. The main legal issue was whether the insurer was precluded from seeking to recover the amounts paid on the claim based on a theory of unjust enrichment since the insurer had paid the no-fault benefits within the 30-day claim determination period. The holding of the case was that the plaintiff was not barred from bringing the action to recover the amount it paid to the defendant because the defendant had secured the payment through fraudulent means. Thus, the District Court should have granted the plaintiff's motion for leave to enter a default judgment.

The court considered whether the assignors of the plaintiff failed to attend independent medical examinations (IMEs) for psychological services rendered to them. The main issue was whether the insurance policy's mandatory personal injury protection endorsement required that IMEs of eligible injured persons be conducted only by physicians to the exclusion of other health care providers, even when the health services were provided by nonphysicians. The court decided that the requirement for an EIP to submit to medical examinations should not be strictly limited to examinations by physicians and could properly have been conducted by the psychologist retained by the defendant. Therefore, the Civil Court's order granting the defendant's motion for summary judgment dismissing the complaint was affirmed.