No-Fault Case Law

The court considered the motion for summary judgment by plaintiff Richmond Radiology, P.C. to recover no-fault benefits from defendant GEICO Insurance Company. The main issue decided by the court was whether there was a triable issue of fact as to the medical necessity of the services provided, as raised by defendant's opposition to the motion. The holding of the court was that the doctor performing the peer review did not conclude that he had insufficient information, but rather raised a triable issue of fact based on the lack of substantiation in the reports and documents reviewed. As a result, plaintiff's motion for summary judgment was properly denied, and the court declined defendant's request for summary judgment. Therefore, the order denying plaintiff's motion for summary judgment was affirmed.

The main issue in this case was whether the defendant, GEICO Ins. Co., was entitled to summary judgment dismissing the complaint brought by Radiology Today, P.C. as the assignee of Charles Rawlins, to recover assigned first-party no-fault benefits. The court considered the fact that the plaintiff's assignor had failed to appear for independent medical examinations (IMEs), and the defendant had moved for summary judgment based on this failure. The defendant submitted evidence that the IME notices were properly addressed and mailed, and the medical professionals who were to perform the IMEs confirmed that the plaintiff's assignor failed to appear. The court ultimately held that the defendant's unopposed motion for summary judgment dismissing the complaint should have been granted.

The main issue in this case was whether the MRIs provided by the plaintiff were medically necessary, as the defendant argued that they were not based on a peer review report. The court considered whether the documents annexed to the plaintiff's motion for summary judgment were admissible as business records, and determined that they were, shifting the burden to the defendant to demonstrate the existence of a triable issue of fact. The defendant provided evidence in admissible form to demonstrate the existence of a triable issue of fact as to medical necessity, based on an affirmed peer review report. As a result, the court held that the judgment in favor of the plaintiff was reversed, the order granting plaintiff's motion for summary judgment was vacated, and plaintiff's motion for summary judgment was denied. The court declined to grant summary judgment to the defendant.

The court considered an action by a provider to recover assigned first-party no-fault benefits, wherein the parties had consented to have the case marked off the trial calendar in March 2007. In August 2008, the plaintiff moved to restore the case, but the Civil Court denied plaintiff's motion "with leave to renew upon a proper showing/reasonable excuse as to why plaintiff did not move to restore within one year of the case being marked off the trial calendar." The main issue decided was whether an action that has been marked off the trial calendar, whether by consent of the parties or stricken by the court, which is not restored to the calendar within one year, may only be restored thereafter if the plaintiff demonstrates a meritorious cause of action and a reasonable excuse for the delay in moving to restore the case. The holding of the case was that the plaintiff failed to satisfy the requirements for restoration, and therefore, the order denying the motion to restore the case to the trial calendar was affirmed.

The main issue in this case was whether the equipment provided to the plaintiff's assignors was medically necessary, and whether the plaintiff was entitled to recover no-fault benefits. The court considered the affidavits of the plaintiff's president and the denial of the claims by defendant based on peer review reports. The court held that the plaintiff made a prima facie showing of entitlement to summary judgment by submitting the statutory claim forms and proofs of overdue payment. However, the defendant's timely denial of the claims based on peer review reports, which provided a factual basis and medical rationale for the doctor's opinion that the supplies were not medically necessary, established a triable issue of fact. The court affirmed the denial of plaintiff's motion for summary judgment.

The main issues in the case were whether the provider was entitled to summary judgment to recover assigned first-party no-fault benefits and whether the insurance company was entitled to summary judgment due to the assignor's failure to appear for scheduled examinations under oath. The court considered the fact that the insurance company had established that the EUO notices were mailed and that the assignor failed to appear. Additionally, the court considered the argument that an EUO was not necessary and that the EUO notices were defective. The holding of the case was that the insurance company's cross motion for summary judgment was properly granted, as they had established that the EUO notices were mailed and that the assignor failed to appear. The provider's motion for summary judgment was properly denied because they failed to make a prima facie showing of their entitlement to summary judgment.

The court considered the denial of plaintiff's motion for summary judgment and the granting of defendant's motion to sever the causes of action. The main issue decided was whether plaintiff was entitled to summary judgment as a matter of law to recover no-fault benefits against defendant insurer. The holding was that the trial court properly denied plaintiff's motion for summary judgment and properly granted defendant's motion to sever the 14 causes of action. Plaintiff made a prima facie showing of entitlement to judgment as a matter of law, but defendant raised a triable issue of fact by submitting its denial of claim forms setting forth that the services for which plaintiff sought to recover no-fault benefits were not medically necessary. The court did not abuse its discretion in granting defendant's motion to sever the 14 causes of action.

The court considered a dispute between a medical service provider and an insurance company regarding the payment of services rendered to an individual injured in an automobile accident. The insurance company claimed that the injured individual was entitled to workers compensation and therefore coverage for the medical services should be decided by the Workers Compensation Board. The main issue considered was whether the insurance company provided sufficient evidence to support their claim that workers compensation was primary in this case. The court ultimately held that the insurance company failed to provide admissible evidence to prove that the injured individual was employed at the time of the accident and therefore workers compensation was primary. As a result, the court denied the insurance company's motion for summary judgment, allowing the case to proceed to trial.

The court considered the relevant facts of the case, which involved a no-fault insurance carrier seeking to recover no-fault benefits paid on a fraudulent claim from a provider. The central issue decided in this case was whether a no-fault insurance carrier can sue a provider to recover benefits paid on a fraudulent claim. The holding of the case was that the carrier was not entitled to enter a default judgment and recover the money paid to the provider, as the carrier had not raised the issue of fraud in a timely denial but had paid the claim in part and denied it in part. The court's decision was based on the fact that the No-Fault Law and regulations require insurers to promptly investigate and pay claims, and any defense, including fraud, must be raised in a timely denial in accordance with the time restrictions of the law and regulations. Therefore, since the carrier failed to timely deny the claim on the grounds of fraud, it was not entitled to recover the previously paid benefits and to sue the provider.

The relevant facts the court considered in Buffalo General Hospital v Erie Ins. Co. involved health care providers who provided medical care to various patients. These patients were insured by the respondents, who denied the patients' first-party no-fault insurance claims, leading the claims of the patients to be assigned to the appellants. The appellants then served the Superintendent of Insurance in Albany with Buffalo City Court summonses and complaints, and the respondents argued that this did not constitute proper personal jurisdiction over them. The court decided that in accordance with Insurance Law § 1212, the respondents were properly served, and the orders of Buffalo City Court (No. E14033/2008 and No. E12518/2008) to dismiss the matters for lack of personal service were reversed. The holding of the court was that the respondents' motions to dismiss were improperly granted, and the case was remanded to Buffalo City Court for further proceedings not inconsistent with this decision.