No-Fault Case Law

The main issue in this case was whether a peer review report submitted by an insurance company, in support of its denial for lack of medical necessity, was sufficient to defeat a plaintiff's motion for summary judgment or to grant a defendant's cross motion for summary judgment. The court considered the fact that the plaintiff had established its prima facie case by submitting evidentiary proof that the prescribed statutory billing forms were mailed and received, and that payment of no-fault benefits were overdue. The plaintiff's motion for summary judgment was opposed by the defendant, who cross-moved for summary judgment on the grounds that the services provided by the plaintiff were not medically necessary based on the peer review report provided by the defendant's chiropractor. The court held that the peer review report submitted by the defendant was not sufficient to warrant granting of summary judgment to the defendant insurer, even when the plaintiff did not submit evidence to rebut the report. As a result, the case was to proceed to trial.

The court considered whether the submission of a notice to admit was enough to establish a prima facie case to recover no-fault first party benefits for unpaid medical expenses. The main issue was whether the use of a notice to admit was permissible to seek admissions to material issues regarding the receipt of claim forms, bills, and denials by the insurer. The holding of the case was that although the use of a notice to admit to establish that the defendant received the claim forms was permissible, it did not relieve the plaintiff from establishing that the claim forms were admissible as a business record exception to prove the truth of the matters asserted therein. As the plaintiffs failed to establish that the claim forms were business records, they did not establish a prima facie case, and their actions were dismissed.

The court considered the fact that the defendant had moved for summary judgment dismissing the complaint on the ground of lack of medical necessity, and the plaintiff did not submit opposition papers. The main issue decided was whether the services rendered were medically necessary. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted, as they had made a prima facie showing that the plaintiff's claims were properly and timely denied based upon a lack of medical necessity, which was unrebutted due to the plaintiff not opposing the motion.

The court considered a case where State Farm Mutual Automobile Insurance Company sought reimbursement for no-fault benefits paid on behalf of its subrogors from the New York City Transit Authority, through compulsory arbitration proceedings. The arbitrator issued two awards in favor of the Transit Authority dismissing State Farm's claims, and State Farm sought to vacate the awards. The main issue decided was whether the arbitrator's determination to deny State Farm's claims for assigned first-party no-fault benefits was supported by a reasonable hypothesis and not arbitrary and capricious. The holding was that the Civil Court properly denied the petition to vacate the arbitrator's awards, but was required to confirm the awards as well.

The main issue of the case was whether the defendant, Nationwide Mutual Insurance Company, had properly disclaimed coverage under the supplemental uninsured/underinsured motorist (SUM) benefits of an automobile insurance policy issued to the plaintiff, Sukeerti Bhatt. Plaintiff had promptly notified defendant of a motor vehicle accident in which she was involved, as required by the policy, and filed a claim for no-fault benefits shortly thereafter. However, plaintiff did not notify defendant of her claim under the SUM endorsement until almost three years after the accident. The court considered the question of whether the defendant must establish that it was prejudiced by the late notice of the SUM claim in order to properly disclaim coverage. The court ultimately held that defendant had failed to establish that it was prejudiced by plaintiff's delay in providing notice of the SUM claim, and therefore affirmed the denial of defendant's motion for summary judgment dismissing the complaint.

The court considered that the plaintiff, a chiropractor, had submitted proof that the statutory billing forms had been mailed and received, and that payment of no-fault benefits was overdue. The main issue decided was whether the defendant, State Farm General Insurance Company, had timely denied the plaintiff's no-fault claims, and whether the defendant's defense of lack of medical necessity was admissible. The holding of the case was that the plaintiff was granted summary judgment in the principal sum of $554.76 because they had established a prima facie entitlement to summary judgment, and the defendant failed to raise a triable issue. The unsworn chiropractor's report submitted by the defendant in support of its defense of lack of medical necessity was not in admissible form, and was thus excluded from consideration.

The court considered the fact that the plaintiff's claim for no-fault benefits was submitted beyond the 45-day statutory period, but included correspondence attempting to explain the delay in filing. The main issue decided was whether the defendant, an insurance company, provided the claimant with the opportunity to submit a reasonable justification for the late notice and whether the defendant gave appropriate consideration to the situation where the claimant had difficulty ascertaining the insurer's identity. The court held that the denial of the defendant's motion for summary judgment was sustained because the record did not indicate whether the defendant gave any consideration to the plaintiff's explanation for its tardy submission as required by the regulations.

The relevant facts of the case involved the defendant, AIU Insurance Company, seeking summary judgment to have a policy retroactively cancelled and deemed void ab initio due to a material misrepresentation in the insurance application. The plaintiff, Li-elle Service Inc., opposed the motion, claiming that the policy obtained using fraudulent misrepresentations could not be void ab initio. The defendant alleged that the insured, Jorge Garcia, misrepresented his residency, which led to the policy being cancelled. The main issue decided by the court was whether the policy was void ab initio and if the defendant had met its burden of proof to obtain summary judgment. The court held that there was a conflict of law between Virginia and New York, and that Virginia law prevailed. It also determined that the defendant had not provided sufficient proof that it relied on the misrepresentations when it undertook the risk, and therefore denied the defendant's motion for summary judgment.

The relevant facts considered by the court in Uptodate Med. Servs., P.C. v State Farm Mut. Auto. Ins. Co. involved an action by a provider to recover assigned first-party no-fault benefits for services rendered. The plaintiff had sought to recover assigned first-party no-fault benefits for services rendered to a different assignor in a prior arbitration proceeding, but the arbitrator determined that the plaintiff was ineligible to receive reimbursement of no-fault benefits because it was a fraudulently incorporated professional service corporation. The main issue decided by the court was whether the defendant should have been granted leave to amend its answer in order to interpose the affirmative defense of collateral estoppel, and if the plaintiff had a full and fair opportunity to litigate the issue previously decided in the arbitration proceeding. The holding of the court was that the defendant should have been granted leave to amend its answer as the proposed affirmative defense was neither devoid of merit nor palpably insufficient as a matter of law, and the defendant established that the issue previously decided by the arbitrator was identical to the issue in the present action. Therefore, the court granted the defendant's cross motion for summary judgment and dismissed the complaint.

The relevant facts considered by the court were that plaintiff, Vista Surgical Supplies, Inc., had moved for summary judgment to recover assigned first-party no-fault benefits, and defendant, GEICO Insurance Company, cross-moved for summary judgment, asserting that the supplies provided were not medically necessary based on a peer review report. The main issue was whether the supplies provided were medically necessary, and the court had to decide whether the denial of claim form submitted by defendant was defective and whether the peer review report established lack of medical necessity. The holding of the case was that the denial of claim form submitted by the defendant was not defective, and defendant established lack of medical necessity based on the peer review report, with plaintiff failing to provide evidence in opposition to show that the supplies provided were medically necessary. As a result, the court affirmed the order granting defendant's cross motion for summary judgment dismissing the complaint.