No-Fault Case Law

The court considered the fact that the plaintiff, Omni Chiropractic, P.C., as the assignee of YACKUELIN RODRIGUEZ, was seeking to recover assigned first-party no-fault benefits from Travelers Insurance Co. The sole witness for the plaintiff testified that he generated and mailed the bills at issue. The Civil Court found in favor of the defendant, determining that the plaintiff had failed to establish that the bills were unpaid. Plaintiff appealed, but the judgment was affirmed, as the provider failed to establish that payment of the no-fault benefits at issue was overdue. The main issue decided was whether the provider had established their prima facie case for the recovery of assigned first-party no-fault benefits. The holding of the case was that the judgment in favor of the defendant was affirmed, as the provider failed to establish that payment of the benefits at issue was overdue.

The main issue in this case was whether Delta Diagnostic Radiology, P.C. was entitled to recover assigned first-party no-fault benefits from Country-Wide Insurance Company. The court considered the fact that Country-Wide Insurance Company's follow-up verification requests were premature and without effect, and thus denied the defendant's motion for summary judgment. The holdng of the case was that defendant's motion for summary judgment was properly denied because of the premature and ineffective follow-up verification requests, which violated General Construction Law § 20 and Insurance Department Regulations. The court affirmed the order without costs, with one judge dissenting.

The main issues in this case were whether the defendant had established the mailing of verification requests and whether the action was premature due to plaintiff's failure to respond to verification requests. The court considered the affidavit of the defendant's claims specialist, who attested to the mailing of the verification requests, and determined that it was sufficient to establish the mailing. The court also considered the plaintiff's argument that the defendant failed to demonstrate personal knowledge of the mailing or set forth defendant's standard office practices and procedures, but found that the affidavit was adequate. The holding of the case was that the order, insofar as appealed from, was affirmed, and the defendant's cross motion for summary judgment dismissing the complaint was granted.

The main issue in St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. was whether the defendant's verification requests properly tolled the 30-day claim determination periods. The Court held that the defendant's follow-up verification requests were premature and had no effect, as they were mailed on the 30th calendar day after the original requests, which was in violation of the relevant regulation. The Court also held that the plaintiff's motion for summary judgment was properly granted as to the remaining claims because the defendant failed to timely deny the claims and was precluded from raising most defenses. However, the Court reversed the award for services rendered on February 22, 2006, and vacated the order granting summary judgment on this claim, as the defendant established that it timely denied this claim. This case highlighted the importance of adherence to procedural requirements in the no-fault claim process, and the consequences of failing to meet those requirements.

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.