No-Fault Case Law

The relevant facts the court considered in the case of Dilon Med. Supply Corp. v Travelers Ins. Co. were that the plaintiff had proved its prima facie case for first-party no-fault benefits, and the sole issue at trial was the medical necessity of the supplies provided to the assignor. Defendant's expert medical witness testified that the durable goods provided were not medically necessary. The main issue decided was whether the supplies provided were medically necessary, and the holding of the court was that the trial court's determination in favor of the defendant was based on a fair interpretation of the evidence, as plaintiff failed to offer any rebuttal evidence to show that the supplies were medically necessary. Therefore, the judgment dismissing the complaint was affirmed.

The relevant facts the court considered were that the defendant moved for summary judgment dismissing the complaint on the grounds that their insured and insured's vehicle were not involved in the hit-and-run accident that the plaintiff was seeking no-fault benefits for. The defendant presented affidavits from their insured and their insured's wife stating that they lived in a different city and had not been in Brooklyn in over 30 years. The plaintiff only provided an affirmation from their attorney arguing that the defendant's papers did not make a prima facie showing entitling them to summary judgment. The main issue decided was whether the defendant made a prima facie showing that their insured's vehicle was not involved in the hit-and-run accident, and if the plaintiff presented sufficient facts to demonstrate a triable issue of fact to defeat the motion for summary judgment. The holding of the case was that the defendant did make a prima facie showing that their insured's vehicle was not involved in the accident, and the plaintiff failed to present sufficient facts to demonstrate a triable issue of fact, so the Civil Court properly granted the defendant's motion for summary judgment dismissing the complaint.

The main issue of the case was whether the denial of the claim based on lack of medical necessity was timely, and if the denial was based on a legitimate peer review report. The court found that the denial of plaintiff's claim was timely, and that the peer review report submitted by the defendant was sufficient to establish a triable issue of fact as to the medical necessity of the supplies in question. The court reversed the judgment, vacated the order granting the plaintiff's motion for summary judgment, and denied the motion for summary judgment, holding that the denial of the claim was timely and that there was sufficient evidence to show a triable issue of fact. The court did not address the propriety of the Civil Court's determination with respect to the plaintiff's prima facie case.

The court considered that the defendant failed to establish that the statutory time period in which it had to pay or deny the plaintiff's claim was tolled, as its follow-up verification request was sent prior to the expiration of the 30-day period within which the requested verification had to be provided. The main issue decided was whether the defendant was precluded from asserting its defense of lack of medical necessity, and the holding was that the defendant failed to timely deny plaintiff's claim and is precluded from raising most defenses, including its proffered defense of lack of medical necessity. The judgment of the lower court granting the plaintiff's motion for summary judgment was affirmed.

The relevant facts of the case include that Andrea Henry was injured in a car accident and received MRI's of the cervical, thoracic, and lumbar spines. Elmont Open MRI & Diagnostic Radiology, who performed the MRI's, submitted bills to Progressive Casualty Insurance Company, who provided no-fault benefits for Henry. Progressive denied the bills based on the peer review report of Dr. Harvey Goldberg, claiming the MRI's were not medically necessary. Elmont argued that Dr. Goldberg's reports were inadequate to entitle Progressive to summary judgment. The main issue decided was whether Progressive's denial of benefits was justified, and the holding of the court was that defendant's motion for summary judgment was denied, and plaintiff's cross-motion for summary judgment was granted. The court ordered Progressive to pay the plaintiff $2751.34, as well as interest, legal fees, and costs.

The court considered whether a provider was entitled to recover assigned first-party no-fault benefits from an insurance company. The main issue was whether the insurance company had properly and timely denied the claim based on a lack of medical necessity for the supplies. The court held that there was an issue of fact as to the medical necessity of the supplies and that the insurance company had established that the claim was properly and timely denied. Therefore, the judgment was reversed, the order granting the provider's motion for summary judgment was vacated and the provider's motion for summary judgment was denied.

The court considered whether an insurance company must notify prospective medical service providers that it will not reimburse them for services provided to an assignor after a determination has been made that further medical services are not necessary. The main issues were whether the notice requirements for verification requests applied to IMEs noticed and performed prior to the insurance company's receipt of claim forms, and whether the insurance company was required to notify the medical service provider about the IME cutoff based on lack of medical necessity. The court decided that notification was not necessary, as the notice requirements for verification requests did not apply to preclaim IMEs, and there was no statutory requirement for the insurer to notify medical service providers about an IME cutoff. The holding of the case was that the insurance company was not required to notify medical service providers about an IME cutoff, and the case would proceed to trial.

The court considered the claim submitted by the plaintiff for payment of no-fault benefits under the Insurance Law, as a result of services provided due to an automobile accident. The defendant denied all the claims based on lack of coverage and allegations of fraud. The main issue decided was whether the plaintiff was entitled to recover the amount claimed, and if the defendant's defense of lack of coverage due to fraud was valid. The court held that the plaintiff had established a prima facie entitlement to summary judgment, as it had submitted the claim and payment was overdue, and the defendant had failed to deny the claim within the required time frame. The defendant's allegations of fraud were found to be unsupported and unsubstantiated, and therefore the plaintiff was awarded judgment in the amount of $2,610.00, with interest and attorney's fees, while the cross motion by the defendant was denied.

The main issue at hand in the case of LMK Psychological Servs., P.C. v. State Farm Mut. Auto. Ins. Co. involves a dispute over whether lawyers' fees awarded to healthcare providers based on overdue insurance claims should be calculated based on a per-insured or per-bill basis. State Farm argued that the attorney's fees should be calculated based on each insured, while the providers advocating for attorneys' fees calculated on each bill. The court held that the attorney’s fees should be based on the aggregate of all bills for each insured. The court also decided that an insurance company that does not issue a proper and timely denial is still not entitled to the benefit of the tolling provision, therefore the Superintendent of Insurance will calculate appropriate interest on each claim. These conclusions were drawn because of the regulations set forth in the Insurance Law by the Superintendent of Insurance, and the holding of the case was that the order of the Appellate Division should be reversed and the case remitted to Supreme Court for further proceedings in accordance with the court’s opinion.

The case involved a provider seeking to recover assigned first-party no-fault benefits. The provider moved for summary judgment, but the defendant argued that the plaintiff's affidavit did not establish the admissibility of the annexed documentation as business records. The court denied the plaintiff's motion, finding that they had failed to establish a prima facie case. The plaintiff appealed, but the appellate court affirmed the lower court's decision, stating that the affidavit submitted was insufficient to establish the officer's personal knowledge of the plaintiff's practices and procedures. The court also rejected the plaintiff's argument that the lower court had improperly considered untimely papers submitted by the defendant in opposition to the motion. The holding of the case was that the order denying the plaintiff's motion for summary judgment was affirmed.