No-Fault Case Law

The relevant facts of the case include Elmont Open MRI & Diagnostic Radiology, P.C.'s claim to recover first party no-fault benefits for cervical and lumbar MRIs performed on Almarto Wiggins, which were denied by State Farm Insurance Company on the grounds of lack of medical necessity. The main issue decided in the case was whether the peer review report and testimony provided by a neurologist, regarding the medical necessity of the MRIs, were sufficient to rebut the presumption of medical necessity that attaches to a timely filed no-fault claim. The court held that the peer review report and testimony were insufficient to rebut the presumption of medical necessity, as the neurologist was not qualified to testify about generally accepted chiropractic practices or reasons a chiropractor would order MRIs. As a result, the court ruled in favor of the plaintiff, Elmont Open MRI & Diagnostic Radiology, P.C., and ordered State Farm Insurance Company to pay $1791.73, along with interest, legal fees, and costs and disbursements.

The court considered whether an insurer was required to pay or deny a claim for no-fault benefits within 30 days after the claimant provided proof of the claim, and whether the insurer's failure to do so would preclude it from raising most defenses to the claim. The main issue was whether the insurer's timely request for additional verification of the claim justified the delay in payment or denial of the claim. The court held that the insurer did not have to pay or deny a claim until it received verification of all of the relevant information requested. The court further held that the plaintiff's motion for summary judgment was denied, and the defendant's cross-motion for summary judgment dismissing the complaint was granted, without prejudice to the commencement of a new action.

The case involved an insurance company that failed to respond to a lawsuit filed by a medical center to recover no-fault medical benefits. The medical center had obtained a judgment against the insurance company after the latter failed to appear or answer the complaint. The insurance company sought to vacate the judgment by demonstrating a reasonable excuse for its delay and the existence of a meritorious defense to the action. However, the insurance company failed to provide sufficient evidence to demonstrate a reasonable excuse for its failure to timely respond or a meritorious defense. The court reversed the order that had granted the insurance company's motion to vacate the clerk's judgment and remitted the matter to the Supreme Court for a determination on the medical center's motion to hold the insurance company in contempt. The holding was that the insurance company's motion to vacate the judgment should have been denied.

The relevant facts considered by the court were that in an action by a provider to recover assigned first-party no-fault benefits, the defendant had moved for summary judgment dismissing the complaint and the Civil Court had stayed the action pending an application to the Workers' Compensation Board for a determination of the parties' rights under the Workers' Compensation Law. The main issue was whether the defendant proffered sufficient evidence to demonstrate the existence of an issue of fact as to whether the plaintiff's assignor was injured while acting within the course of his employment. The holding of the court was that the defendant offered sufficient evidence based on the application for no-fault benefits form signed by the plaintiff's assignor under penalty of perjury which stated that the assignor was in the course of his employment when he was injured, thus raising a question of fact as to whether the assignor was acting as an employee at the time of the accident. Additionally, the court modified the order to provide that if the plaintiff fails to file proof of an application to the Workers' Compensation Board within 90 days, the defendant's motion for summary judgment dismissing the complaint will be granted unless the plaintiff shows good cause why the complaint should not be dismissed.

The main issues in this case involved an action to recover assigned first-party no-fault benefits for services rendered by medical providers to their assignor in 2002. The plaintiffs moved for summary judgment, while the defendant cross-moved for summary judgment dismissing the complaint or, in the alternative, for relief pursuant to CPLR 3124 and CPLR 3126. The court, on its own motion, stayed the action with respect to plaintiff A.B. Medical Services, PLLC, without determining the branch of the plaintiffs' motion seeking summary judgment in favor of A.B. Medical Services, PLLC. The court granted the application for leave to appeal, reversed the portion of the order that stayed the action, and remitted the matter to the District Court for a determination of the branch of plaintiffs' motion seeking summary judgment in favor of A.B. Medical Services, PLLC. In doing so, the court did not pass upon the merits of the branch of the defendant's cross motion seeking summary judgment dismissing the complaint insofar as asserted by A.B. Med.

The court considered an appeal from an order of the Civil Court of the City of New York, Queens County, which granted plaintiff's motion for summary judgment in an action by a provider to recover assigned first-party no-fault benefits. Defendant appealed from the order, arguing that the documents annexed to plaintiff’s motion for summary judgment were not admissible as business records and that there was an issue of fact as to the medical necessity of the services provided. The court found that the affidavit of plaintiff's billing manager was sufficient to establish that the documents annexed to plaintiff's motion for summary judgment were admissible as business records, reversing the decision of the Civil Court. However, the court also found that there was an issue of fact as to medical necessity, and therefore plaintiff's motion for summary judgment should have been denied. As a result, the matter was remitted to the Civil Court for all further proceedings.

The relevant facts the court considered in this case involved Bedford Park Neurology, P.C. as the assignee of Mario Vasconcellos, seeking to recover first-party no-fault benefits from New York Central Mutual Fire Insurance Company. The main issue decided was whether Bedford Park Neurology, P.C. had standing to recover on a claim form seeking the sum of $2,992, as the claim form only identified a physician as the provider and did not reference the corporation to whom the benefits had been assigned. The court found that the claim form sought to recover payment on behalf of the physician who rendered the services and not on behalf of the corporation, and that the corporation was not entitled to payment based on the claim form submitted. Therefore, the holding of the case was that the branch of the defendant's motion seeking to dismiss so much of the plaintiff's complaint as sought to recover upon the claim form seeking the sum of $2,992 should have been granted.

The relevant facts considered by the court were that the plaintiff sought payment from the defendant for no-fault benefits as an assignee of an individual. The defendant argued that the plaintiff failed to establish a prima facie case and that they had timely denied the bill based on the lack of medical necessity. The main issue decided by the court was whether the plaintiff had established a prima facie entitlement to summary judgment. The court held that the defendant raised a triable issue of fact and as a result, the plaintiff's motion for summary judgment should have been denied. Therefore, the judgment awarding the plaintiff the principal sum of $575.30 was reversed and the defendant's motion for summary judgment was granted.

The court considered an action by a healthcare provider to recover assigned first-party no-fault benefits. The Civil Court granted the provider's motion for summary judgment and denied the insurance company's cross motion for summary judgment, awarding the provider a sum of $292.24. The main issue decided on appeal was whether the documents annexed to the provider's motion for summary judgment were admissible as business records and whether the denial of claim form denying the provider's claim on the ground of medical necessity was timely and valid. The holding of the case was that the documents submitted were admissible as business records, but the denial of claim form was found to be timely and valid, causing the provider's motion for summary judgment to be denied and remanding the case for further proceedings.

The court considered the timing of the verification request and whether the defendant's time to pay or deny the claim had been tolled. The main issue was whether the plaintiff's failure to provide requested verification within 30 days after the initial request meant that the defendant's time to pay or deny the claim did not begin to run. The court held that the 30-day period within which the defendant was required to pay or deny the claim did not commence to run, and therefore the plaintiff's action was premature. The judgment was reversed, and the defendant's cross motion for summary judgment dismissing the complaint was granted on the ground that the action was premature.