No-Fault Case Law

The court considered the fact that the defendant's denial of claim form was "timely and proper," and that the sole issue to be determined at trial was the medical necessity of the medical equipment at issue. The main issue decided was whether the medical equipment at issue was medically necessary, and the holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint should have been granted because the defendant's showing that the equipment was not medically necessary was unrebutted by the plaintiff. The court referenced previous cases where similar issues were decided in favor of the insurance company based on lack of medical necessity. Therefore, the court reversed the order of the Civil Court and granted the defendant's cross motion for summary judgment dismissing the complaint.

The court considered the motion for summary judgment by the plaintiff to recover first-party no-fault benefits, as well as the defendant's cross motion for summary judgment dismissing the complaint on the grounds of lack of medical necessity for the services rendered. The main issue decided was whether there was a lack of medical necessity for the medical services at issue. The holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint should have been granted, as the defendant had established that it mailed timely and valid denials, and the plaintiff did not dispute this finding on appeal. The court also found that the defendant's showing that the services were not medically necessary was unrebutted by the plaintiff, and therefore the motion was reversed and granted in favor of the defendant.

The court considered whether an insurer is obligated to pay or deny a claim for no-fault benefits until it has received verification of all the relevant information requested. It was determined that the defendant-insurer was not obligated to pay or deny the claim because it had not received a response to its verification requests for medical records. The main issue decided was whether the defendant's issuance of a general, blanket denial of benefits based on the assignor's failure to attend an independent medical examination was effective to deny the specific claim at issue. The court rejected the plaintiff's contention that the general, blanket denial precludes the defendant from asserting noncompliance with its verification requests. The holding of the court was that the summary judgment granting the defendant's motion to dismiss the complaint was reversed, and the defendant's motion for summary judgment was granted.

The main issue in this case was whether the defendant, Metropolitan Casualty Ins. Co., could deny all no-fault claims arising from injuries sustained by the plaintiff's assignor, Jarrod Ward, in a May 21, 2008 motor vehicle accident. The court considered the judgment from a separate action in which the Supreme Court, Kings County, declared that the defendant may deny all no-fault claims arising from the injuries sustained by the plaintiff's assignor. Based on this judgment, the underlying actions commenced by the plaintiff's medical diagnostics company to recover first-party no-fault benefits for medical services rendered to Jarrod Ward for injuries sustained in the accident are barred under the doctrine of res judicata. The court ultimately held the defendant's motion for summary judgment dismissing the complaints and granted the judgment accordingly. The court found that the Supreme Court judgment is a conclusive final determination, even though it was entered on the default of the plaintiff, since res judicata applies to a judgment taken by default that has not been vacated.

The court considered an appeal from an order deciding a motion for summary judgment in a no-fault benefits case. The main issues decided were whether the provider had established entitlement to summary judgment and whether the insurance company's request for verification of the claim had been timely and responded to. The holding of the case was that the insurance company's request for additional verification had been timely made and not responded to, so the 30-day period within which the company could pay or deny the claim did not commence. However, the court also held that the insurance company had timely denied the claim for lack of medical necessity, as supported by a peer review report that the provider did not rebut. Therefore, the insurance company's motion for summary judgment dismissing the complaint should have been granted.

The court considered a motion for summary judgment filed by the defendant, which claimed that the medical services provided were not medically necessary, and that the plaintiff's bills were denied on these grounds. The defendant submitted peer review reports as evidence of the lack of medical necessity, which established their prima facie entitlement to summary judgment. The plaintiff failed to raise a triable issue of fact in opposition to the motion, as their submitted doctor's affirmation did not meaningfully refute the conclusions of the peer review reports. Despite the plaintiff's contention that the court had overlooked an affirmation by Dr. Shapiro, the court found that this affirmation was still insufficient to raise a triable issue of fact. Therefore, upon reargument, the court held that the order granting the defendant's motion for summary judgment dismissing the complaint is adhered to.

The court considered an appeal from an order that denied the defendant's motion for summary judgment dismissing the plaintiff's second, third, fifth, sixth, and eighth causes of action in a case involving the plaintiff's attempt to recover assigned first-party no-fault benefits. The defendant argued that the medical services provided were not medically necessary and submitted peer review reports as evidence. The court found that the defendant had established a prima facie entitlement to summary judgment for the second, third, fifth, and eighth causes of action, as the peer review reports supported the lack of medical necessity. However, the defendant's motion did not shift the burden with respect to the sixth cause of action. The plaintiff's submission of an affirmation from its principal was deemed improper as it did not raise an issue of fact, and the court granted the defendant's motion to dismiss the second, third, fifth, and eighth causes of action.

The court considered a provider's claim to recover assigned first-party no-fault benefits, which was denied by the defendant insurance company on the ground of lack of medical necessity. The defendant's unopposed motion for summary judgment dismissing the complaint was denied by the Civil Court, leading to the appeal. The defendant's denial of claim forms, which were based on lack of medical necessity, were deemed timely and sufficient. Additionally, the defendant submitted a sworn peer review report that provided a factual basis and medical rationale for the lack of medical necessity. The court ultimately reversed the lower court's decision and granted the defendant's motion for summary judgment, as the plaintiff's health care practitioner's affidavit failed to meaningfully rebut the conclusions in the peer review report.

The main issue in this case was whether the defendant had a reasonable excuse for its default in responding to an action to recover assigned first-party no-fault benefits and if they had a meritorious defense to the action. The defendant argued that the delay was due to the process of the claim file being transferred to the insurance company that had just purchased the subject insurance policy from the defendant. The court found that the defendant failed to provide a reasonable excuse for its default as they had knowingly failed to take any action with respect to the lawsuit for approximately eight months. Therefore, the court reversed the order and denied the defendant's motion to vacate the default judgment. The holding of the case was that the Civil Court had improvidently exercised its discretion in granting the defendant's motion to vacate the default judgment.

The relevant facts considered by the court included a provider seeking to recover first-party no-fault benefits for healthcare services rendered to an assignor, as well as the argument by the insurance company that the assignment should be revoked due to misrepresentations by the assignor. The main issue decided by the court was whether the insurance company's defense was valid, and if the provider should be allowed to recover for services rendered to the assignor. The holding of the case was that the insurance company's defense failed as a matter of law, as the assignor could not unilaterally revoke the assignment after the services were rendered. Additionally, the court found that the insurance company did not demonstrate that the subject insurance policy was cancelled, and the documents submitted were not sufficient to warrant summary judgment dismissing the complaint. Therefore, the court denied the provider's motion for partial summary judgment on certain conditions.