No-Fault Case Law

The case involved a proceeding pursuant to CPLR article 75 to stay arbitration of an uninsured motorist claim. The appellant, Taylor Raynor, allegedly was injured in an accident caused by an uninsured vehicle and sent her insurer, Allstate Insurance Company, a notice of intention to arbitrate, claiming no-fault benefits, uninsured motorist benefits, and supplemental insurance benefits. Allstate then commenced a proceeding to stay arbitration, arguing that the offending vehicle was insured on the date of the accident. The main issue was whether the proceeding was time-barred, as the appellant's notice of intention to arbitrate was not responded to within 20 days, as required by law. The court held that the proceeding was indeed time-barred and granted the appellant's cross motion to dismiss.

The court considered the statutory and regulatory framework governing the payment of no-fault automobile benefits. The main issue decided was whether the plaintiff had established prima facie entitlement to judgment as a matter of law on its claim for benefits. The holding was that the plaintiff had failed to establish its prima facie entitlement to judgment, as the evidence demonstrated that the defendant made a partial payment and a partial denial of the claim within 30 days after receipt thereof. The court also found that the minor factual discrepancy contained in the defendant's denial of claim form did not invalidate the denial, and the denial was not conclusory or vague, and did not otherwise involve a defense which had no merit as a matter of law. Therefore, the Supreme Court properly denied the plaintiff's motion for summary judgment on the complaint.

The relevant facts the court considered were that Allstate Insurance Company and other parties moved for partial summary judgment, and the defendants, Belt Parkway Imaging, P.C., et al., opposed the motion. The issue at hand was whether a provider of health care services is eligible for reimbursement under section 5102(a) (1) of the Insurance Law if the provider fails to meet any applicable New York State or local licensing requirement. The Court of Appeals held that "insurance carriers may withhold payment for medical services provided by fraudulently incorporated enterprises" (see State Farm Mut. Auto. Ins. Co. v Mallela, 4 NY3d 313, 319, 321 [2005]). Mallela was decided on March 29, 2005. The Legislature subsequently enacted Insurance Law § 5109, which became effective on August 2, 2005. The holding of the case was that if the services rendered by the PC defendants were medically unnecessary, then plaintiffs have stated a cause of action for unjust enrichment. The court unanimously affirmed the denial of the motion for partial summary judgment.

The Court considered a case involving an action to recover assigned first-party no-fault benefits, where the plaintiff moved for summary judgment upon the first and second causes of action, and the defendant cross-moved for summary judgment dismissing those causes of action on the ground of failure to comply with verification requests. The main issue decided was whether the defendant had established the mailing of its initial and follow-up verification requests, and whether the plaintiff had provided the requested verification. The Court held that the defendant's verification requests sought copies of NF-5 forms signed by plaintiff's assignors, but as the plaintiff had already provided the authorizations to release information and the assignments executed by the assignors, the plaintiff had complied with the requests. The Court also held that the defendant had failed to establish the mailing of its initial and follow-up verification requests. Therefore, the order was affirmed without costs.

The relevant facts of the case involved a medical imaging company seeking to recover first-party no-fault benefits from an insurance company for services rendered to a patient. The insurance company denied the claims on the grounds of lack of medical necessity. The main issue decided by the court was whether the insurance company's denial of the claims on the basis of lack of medical necessity was justified. The court held that the insurance company had provided a sufficient medical rationale and factual basis to demonstrate a lack of medical necessity for the services at issue, shifting the burden to the medical imaging company to rebut the insurance company's showing. As the medical imaging company failed to submit any medical evidence sufficient to raise a triable issue of fact as to medical necessity, the court granted the insurance company's motion for summary judgment dismissing the complaint.

In the case, Elmont Open MRI & Diagnostic Radiology, P.C. v Clarendon Natl. Ins. Co., the main issue before the court was whether the peer review report provided by the defendant was sufficient to demonstrate a lack of medical necessity for the services at issue. The defendant had timely denied the plaintiff's claims on the ground of lack of medical necessity, and the District Court initially denied the defendant's motion for summary judgment, stating that the peer review report was insufficient. However, upon appeal, the Appellate Term reversed the decision, holding that the peer review report submitted by the defendant did provide a sufficient factual basis and medical rationale to demonstrate a lack of medical necessity. As a result, the defendant was entitled to summary judgment dismissing the complaint, as the plaintiff failed to submit any medical evidence to raise a triable issue of fact. Therefore, the Appellate Term reversed the lower court's decision and granted the defendant's motion for summary judgment.

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.