No-Fault Case Law

Facts: The case arises from an incident wherein plaintiff's assignor allegedly sustained personal injuries and received treatment from plaintiff health services provider. Before this lawsuit was commenced, defendants initiated and won a default judgment in a declaratory judgment action in Kings County Supreme Court. This judgment declared that the defendant had no coverage requirement for any lawsuit claiming no-fault benefits related to the incident. Issues: The main issue is whether the declaratory judgment order, issued on a default, applies as collateral estoppel in other actions seeking to litigate the same issue. Decision: The court held that the doctrine of collateral estoppel does not apply if there has been a default judgment in the previous action. They argued for a case-specific evaluation rather than a rigid rule approach to determine whether the issue had been "actually litigated." This conclusion prevented the defendant from using the declaratory judgment order as a basis for dismissal of this lawsuit.

The main issue of the case was whether the defendant-insurer was entitled to summary judgment dismissing the complaint, which asserted claims to recover assigned first-party no-fault benefits. The court considered the affirmed peer review report of a physician, which demonstrated that the medical supplies provided to the assignor were not medically necessary, as the assignor was already receiving physical and chiropractic therapy for his injuries, which the physician concluded was sufficient. The court held that the defendant made a prima facie showing of entitlement to judgment as a matter of law, and that the plaintiff failed to submit any evidence regarding the medical necessity of the supplies, therefore failing to raise a triable issue. As a result, the court reversed the order, granting the defendant's motion for summary judgment and dismissing the complaint.

The relevant facts of the case is that Lenox Hill Radiology, P.C. sought to recover payment for first-party no-fault benefits for four MRIs it performed, and the insurance company, Tri-State Consumer Insurance Company, argued the claims were premature because the radiology center failed to respond to a request for verification. At trial, the insurance company presented the testimony of an experienced claims examiner, Jennifer Piccolo, who testified to the company's mailing procedures. The court reversed the original judgment in favor of the radiology center, agreeing with the insurance company's argument that the claims were premature and dismissing the case. However, a dissenting opinion was raised, arguing that the burden was on the insurer to establish proper and timely mailing of verification requests, and the testimony presented did not thoroughly establish this. The dissent argued that a change is needed in no-fault litigation to ensure more substantive, timely results.

The main issue in this case was the medical necessity of medical supplies being claimed under first-party no-fault benefits. The court considered the peer review reports submitted by the defendant, which stated that there was a lack of medical necessity for the supplies in question. The plaintiff, as the assignee of the patient, failed to demonstrate that it needed certain documents to raise a triable issue of fact regarding medical necessity. Additionally, the plaintiff failed to rebut the defendant's showing that there was a lack of medical necessity for the supplies. Due to this, the court held that the defendant was entitled to summary judgment dismissing the complaint.

The court considered the fact that the plaintiff was injured while driving a vehicle insured by the defendant and that the defendant initially paid for her chiropractic treatment but ceased doing so after an independent medical examination found no further treatment necessary. The main issue decided was whether the plaintiff had the right to bring the present action to recover benefits, and the court held that the defendant waived their right to assert that the plaintiff lacked standing as an affirmative defense. Therefore, the order granting the defendant's motion for summary judgment dismissing the complaint was reversed, and the motion was denied.

The relevant facts in the case were that the plaintiffs filed a lawsuit seeking to recover first-party no-fault benefits for medical services rendered. The defendant, an insurance company, argued that the plaintiffs were ineligible for reimbursement of these benefits because they were operated in violation of state licensing requirements. After a nonjury trial, the court found in favor of the plaintiffs and awarded them the principal sum of $4,223.17, ruling that the defendant had failed to establish, by clear and convincing evidence, that the plaintiffs were ineligible for reimbursement. The defendant appealed, arguing that it only needed to establish its defense by a preponderance of the evidence, but the court found that the evidence at trial was insufficient to establish the violation of state licensing requirements. Additionally, the court determined that interest on the claims began to accrue from 30 days after the claims were submitted to the insurer for payment, and that the awarding of compound interest was not in error. The court ultimately affirmed the judgment in favor of the plaintiffs.

The relevant facts in this legal case involve an action for first-party no-fault benefits, in which the defendant insurance company failed to pay or deny a claim within the prescribed 30-day time period. The plaintiff moved for summary judgment, but the defendant requested a stay of trial as there was a pending criminal case against the plaintiff's assignor. The court found that the defendant had issued a request for verification and that the plaintiff's response lacked proof that the injury-causing accident resulted from the intoxication of the plaintiff's assignor. The court held that there was a basis for applying CPLR 3212 (f), allowing for a denial of the motion until necessary disclosure for the defense was obtained. The plaintiff's motion was denied, but they were granted leave to renew upon the completion of discovery. The defendant was also granted leave to renew its application for summary judgment upon the completion of discovery.

The court considered the issue of whether an insurer may use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which a licensed acupuncturist is entitled to receive for such services. The court held that an insurer may do so and that the provider, in this case, was not entitled to any additional reimbursement on the claims that exceeded the proper rate of reimbursement under the fee schedule for acupuncture services rendered by a chiropractor. The court also considered charges for services where there was a lack of medical necessity, and granted summary judgment in favor of the insurer on those charges due to a lack of evidence to rebut the insurer's findings. The court concluded that the insurer's motion for summary judgment was properly denied as to a remaining claim in dispute.

The relevant facts of the case were that the plaintiff, a medical provider, sued for first-party no-fault benefits and the defendant insurance company moved for summary judgment to dismiss the complaint. The main issues were whether the denial of claim forms were timely mailed and whether the services rendered by the plaintiff were medically necessary. The holding of the court was that the denial of claim forms were timely mailed, and the defendant's peer review report established a lack of medical necessity for the services at issue. The court also found that the plaintiff did not need the medical records from other providers to raise a triable issue of fact, and therefore failed to establish a basis to defeat the defendant's motion for summary judgment. The decision was modified to grant the branch of the defendant's motion seeking summary judgment dismissing the complaint.

The relevant facts considered by the court in the case of Davidov Medical, P.C. v Firemans Fund Insurance Company involved a provider seeking to recover assigned first-party no-fault benefits. The defendant contended that it had already paid the bills at issue, and moved for summary judgment dismissing the complaint. The main issue decided was whether the defendant had made a prima facie showing that it had paid the specific bills alleged by the plaintiff in its complaint to be outstanding. The holding of the court was that the defendant did not make a prima facie showing that it had paid the four specific bills alleged by the plaintiff, and therefore the defendant's motion for summary judgment dismissing the complaint was denied.