No-Fault Case Law

The court considered an appeal to vacate an arbitrator's award and a master arbitrator's award in a proceeding to recover first-party no-fault benefits that had been denied. The main issue was whether the arbitrator and the master arbitrator had properly denied the petitioner's claim for assigned first-party no-fault benefits. The court held that the standard for judicial review of an award in a compulsory arbitration proceeding is whether the award had evidentiary support and was not arbitrary and capricious. Applying this standard, the court found no basis to vacate the arbitrator's award and the master arbitrator's award, and affirmed the lower court's decision to confirm the awards. The appellate court noted that a special proceeding should terminate in a judgment, not an order.

The case involved Progressive Medical, Inc. seeking to recover assigned first-party no-fault benefits. The issue was the medical necessity of the equipment billed for by the medical provider. The defendant's peer review doctor testified that the medical equipment billed for was not medically necessary, but the plaintiff objected to the testimony on the grounds that it was based on records that were not in evidence and upon a study, the reliability of which had not been established, and the court sustained the objection and ordered the testimony stricken. The court dismissed plaintiff's complaint, finding that plaintiff "specifically declined to present a prima facie case." The Appellate Term reversed the judgment and remitted the matter to the District Court for the entry of a judgment in favor of plaintiff in the principal sum of $1,123.75, plus statutory interest and attorney's fees. They found that the only issue for trial was defendant's defense of lack of medical necessity and that there was no basis for the court's finding that plaintiff was required to submit a claim form in order to establish prima facie "the health benefit's medical necessity." Additionally, they found no basis to disturb the court's decision to strike defendant's witness's testimony.

The case AP Orthopedics & Rehabilitation, P.C. v Allstate Ins. Co. was about an insurance company's defense that the medical expenses bill for a shoulder surgery was not medically ascertainable within a year of the accident. The insurance company timely denied the bill to raise this defense. Defendant presented the testimony of its claims examiner as proof of the defense, testifying that there were no further bills submitted for the shoulder after the accident, and there was no indication that the claim for shoulder surgery was related to the accident. The main issue decided in the case was what type of proof was required by the insurance company to prove that the injury is not medically ascertainable within a year of the accident. The court held that there was no obligation to pay for services rendered after a year if it is not clear with certainty that further expenses may be incurred. The court found that the insurance company had met its burden of proving that the injury to the assignor's shoulder was not ascertainable within one year of the accident and thus, the insurance company did not have to pay for the plaintiff's medical services.

The court considered that the plaintiff had commenced actions to recover first-party no-fault benefits in March 2003, with the cases being consolidated for trial in December 2004. The actions were marked off the trial calendar on January 6, 2006, and the plaintiff moved to restore them in January 2009. The main issue decided was whether the plaintiff had met the requirements to restore the actions, including demonstrating the merits of its claims, a lack of prejudice to the defendant, a lack of intent to abandon the action, and a reasonable excuse for the delay in moving to restore the actions. The holding of the court was that the plaintiff failed to offer a reasonable excuse for its three-year delay in seeking to restore the actions, and therefore the motion should have been denied.

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits, and that the defendant had filed a cross motion for summary judgment based on lack of medical necessity. The main issue decided was whether the affidavits submitted by the defendant were sufficient to prove the timely mailing of the denial of claim form. The holding of the court was that the affidavits submitted by the defendant were indeed sufficient to establish that the denial of claim form was timely mailed in accordance with the defendant's standard office practice and procedure. As a result, the court affirmed the order without costs. The court also noted that the plaintiff's remaining contentions were improperly raised for the first time on appeal.

The relevant facts in this case involved a medical supply company seeking to recover no-fault benefits from an insurance company. The medical supply company moved for summary judgment, but the insurance company opposed the motion on the grounds that the patient had failed to appear for scheduled independent medical examinations (IMEs). The insurance company argued that it had timely denied the claims based on this failure. The main issue decided by the court was whether the insurance company's opposition was sufficient to establish that the patient had not appeared for the IMEs, thus justifying the denial of the claims. The court held that the insurance company's affidavits were insufficient to establish that the patient had failed to appear for the IMEs, and as a result, the insurance company failed to raise a triable issue of fact. Therefore, the court affirmed the judgment in favor of the medical supply company.

In this case, First Aid Occupational Therapy, PLLC brought a claim to recover assigned first-party no-fault benefits from Country-Wide Insurance Company. Plaintiff moved for summary judgment, which was granted by the Civil Court. Defendant argued that the action was premature due to plaintiff's failure to provide requested verification for the claims underlying the second, third, and fourth causes of action. Defendant also contended that plaintiff utilized the wrong billing code for the claims underlying the first and fifth causes of action. The Appellate Term held that the action was indeed premature, as defendant's follow-up verification requests were sent before the expiration of the 30-day period within which plaintiff was supposed to respond to the initial requests for verification. Additionally, the Court held that defendant failed to raise a triable issue of fact in admissible evidentiary form with respect to the billing for the services in question. Therefore, the judgment was reversed, and the motion for summary judgment was denied, while the cross motion for summary judgment dismissing the causes of action was granted.

The court considered the facts of a dispute between Innovative Chiropractic and Progressive Insurance Company over the recovery of assigned first-party no-fault benefits. The main issue decided was whether the Civil Court erred in awarding summary judgment to the plaintiff, and whether the defendant should have been granted summary judgment. The holding of the case was that the judgment was reversed, the order granting the plaintiff's motion for summary judgment was vacated, and the plaintiff's motion for summary judgment was granted to the extent of awarding the plaintiff summary judgment on the claim for $33.70 for services rendered on January 19, 2007. Additionally, summary judgment was granted to the defendant dismissing the complaint with respect to the remaining portion of the plaintiff's claim, which sought to recover the sum of $200. The case was remitted to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees on the award of $33.70.

The main issue in this case was whether the provider had submitted sufficient evidence to establish a prima facie case to recover first-party no-fault benefits. The court considered the affirmation of the provider's counsel, an unsigned "affidavit" by the provider's owner, and various documents annexed to the motion for summary judgment. However, the court held that the unsigned "affidavit" did not constitute evidence in admissible form, and the affirmation of the provider's counsel was insufficient to establish the provider's prima facie case. As a result, the court affirmed the lower court's decision to deny the provider's motion for summary judgment. In summary, the court considered the evidence submitted by the provider to support their claim for first-party no-fault benefits. The main issue decided was whether the evidence presented was sufficient to establish a prima facie case. The holding of the case was that the unsigned "affidavit" and the affirmation of the provider's counsel were not enough to establish the provider's prima facie case, and therefore their motion for summary judgment was properly denied.

The court considered a case in which providers were seeking first-party no-fault benefits. The providers moved for partial summary judgment, while the defendant cross-moved for summary judgment dismissing various claims on the ground of lack of medical necessity. The defendant submitted peer review reports and affirmations from doctors showing a lack of medical necessity for the services in question, establishing a prima facie case. The plaintiffs' opposition was insufficient to raise a triable issue of fact, therefore the defendant's cross motion was granted. The holding of the court was that the order of the District Court was affirmed without costs.