No-Fault Case Law

The relevant facts considered in this case were that Amercure Acupuncture, P.C. as assignee of Taylor Franklin, moved for summary judgment to recover assigned first-party no-fault benefits from GEICO Ins. Co. Defendant opposed the motion on the ground that it had properly reimbursed plaintiff for licensed acupuncture services at the rate consistent with the amount paid for acupuncture services provided by licensed chiropractors. The main issue decided was whether the defendant had issued timely denials of the claims. The holding of the court was that the judgment and order were reversed and vacated, and the plaintiff's motion for summary judgment was denied. The court granted summary judgment to the defendant, dismissing the complaint and concluding that the defendant had fully paid the amount owed to the plaintiff, based on the workers' compensation fee schedule.

The court considered the fact that the defendant had not received responses to its outstanding verification requests before the action was commenced. The main issue decided was whether the action was premature because of this, and the court held that the action was indeed premature. The court reversed the judgment, vacated the order entered, denied the plaintiff's motion for summary judgment, and granted the defendant's cross motion for summary judgment dismissing the complaint, without prejudice to the plaintiff commencing a new action.

The court considered the appeal of an order granting summary judgment in favor of a provider seeking first-party no-fault benefits from an insurance company. The main issue was whether the documents submitted by the provider's billing manager were admissible as business records and whether the denial of claim forms constituted a timely and adequate response by the insurance company. The holding of the court was to reverse the judgment in favor of the provider, vacate the order granting summary judgment, and deny the provider's motion. This was due to the insurance company raising a triable issue of fact through an affirmed peer review report and establishing that there was an issue of fact regarding the excessive fees charged by the provider. Therefore, the matter was remitted to the Civil Court for further proceedings.

The court considered an appeal from a judgment awarded to the plaintiff, Raz Acupuncture, P.C., in a case against Travelers Property Casualty Ins. Co. regarding a claim for first-party no-fault benefits. The main issue was whether the plaintiff had made a prima facie showing of its entitlement to summary judgment. The court held that the plaintiff's cross motion for summary judgment was not supported by sufficient evidence, as the affidavit provided did not demonstrate personal knowledge of the plaintiff's business practices and procedures. As a result, the judgment in favor of the plaintiff was reversed, and the plaintiff's cross motion for summary judgement was denied. The case was decided on January 12, 2010.

The court considered the fact that the plaintiff, Globe Medical Care O.L.P.C., had filed a complaint to recover first-party no-fault benefits from the defendant, Travelers Insurance Company. The Civil Court initially dismissed the complaint, citing the plaintiff's failure to file proof of service of the summons and complaint. However, the Appellate Term of the Supreme Court, First Department, reversed the judgment and directed a judgment in favor of the plaintiff for the principal sum of $3,072.08. The main issue decided was whether the failure to file proof of service warranted dismissal of the action, and the holding of the court was that it did not. The court also determined that the plaintiff had established a prima facie case to recover the no-fault benefits, and as the defendant failed to present evidence on the medical necessity of the services rendered, judgment was directed in the plaintiff's favor.

The court considered whether plaintiff Health Care Associates in Medicine violated the revised Mandatory Personal Injury Protection Endorsement by failing to submit proof of claim to defendant Geico Insurance within 45 days from the date services were rendered. The main issue was whether the bills were mailed within the statutory 45-day period and if Geico timely denied the bills or presented sufficient evidence to establish the untimeliness of the bills. The court held that Geico could not attack the validity of the bills it conceded were properly mailed and generated by arguing that they did not contain proof that they were mailed within 45 days. The court denied defendant's motion for dismissal of the case, indicating that a trial would be held to give Geico an opportunity to present its defense.

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.