No-Fault Case Law

The relevant facts considered by the court were that several medical service providers moved for summary judgment seeking to recover assigned first-party no-fault benefits, and the insurance company defendant opposed the motion on the ground that the plaintiffs' assignor failed to attend independent medical examinations (IMEs). The main issue decided was whether the insurance company's denial of claims based on the assignor's failure to attend IMEs was valid, and whether the insurance company established proper mailing of the IME scheduling letters. The holding of the court was that the insurance company failed to timely deny the claims in question, and as a result, it was precluded from interposing most defenses with respect to those claims. Therefore, the court reversed the order, granted plaintiffs' motion for summary judgment for the specified claims, and remanded the case for the calculation of statutory interest and assessment of attorney's fees.

The court in this case considered a dispute between D & R Medical Supply, as assignee of Fenelon Daniel, and Progressive Insurance Company over first-party no-fault benefits. Plaintiff filed a lawsuit claiming that defendant had failed to pay or deny their claims within the statutory time period. The key question before the court was whether plaintiff was required to provide additional verification of the claims, specifically medical reports from referring physicians, in response to the defendant's request for such information. Despite the fact that the defendant had requested the reports, the plaintiff informed the defendant that they did not have these documents in their possession. The court found that the statutory time period for payment or denial of the claim was not tolled due to the plaintiff's failure to provide the additional verification materials. The court also found that the defendant had a means of obtaining the requested reports from the referring physicians and denied defendant's cross motion for summary judgment. Therefore, the court granted plaintiff's motion for summary judgment, allowing plaintiff to enter judgment against the defendant in the amount of $2,448.13, plus interest, attorneys fees, and costs.

The relevant facts of this case involved an action to recover no-fault medical benefits under an insurance contract. The plaintiff, Westchester Medical Center, appealed from an order denying its motion for summary judgment on the complaint in a case against Lincoln General Insurance Company. The court held that the plaintiff made a prima facie showing that it was entitled to judgment as a matter of law by submitting evidence that the prescribed statutory billing forms had been mailed and received. The defendant failed to pay or deny the claim within the requisite 30-day period which would have allowed the defendant to raise a triable issue of fact. The 30-day statutory period was not tolled by the defendant's two letters holding the plaintiff's claim pending an investigation of the loss, and the defendant's other contentions also failed to toll the 30-day statutory period. The court granted the motion for summary judgment to the plaintiff.

The court considered the circumstances in which the Defendant, Allstate Insurance Company, failed to respond to a complaint filed by Westchester Medical Center seeking payment for medical services provided to the Plaintiff's assignor, Jamel Harris. The main issue decided was whether the Defendant's delay in answering the complaint was excusable, whether the Defendant had a meritorious defense, and whether the Plaintiff would be prejudiced by allowing the Defendant to interpose an answer. The court held that the Defendant's explanation for the delay was excusable, provided a meritorious defense, and that the delay was short and would not prejudice the Plaintiff. Therefore, the court granted the Defendant's motion to vacate the default judgment and allowed the Defendant to interpose an answer.

The court considered the matter of the rehabilitation of Interboro Mutual Indemnity Insurance Company. The main issue in the case was whether no-fault interest should apply to medical claims submitted to Interboro before or during the period of rehabilitation. The court decided that no-fault interest should not apply to claims submitted to Interboro prior to February 1, 2007. It also decided that the failure to transmit timely denials should not apply to claims received or adjusted during the rehabilitation period. Finally, the court granted the motion filed by Interboro to clarify that interest is not available on claims due before or during the rehabilitation period, and ordered Interboro to submit an amended order.

The main issue in this case was whether the plaintiffs were entitled to summary judgment in their action to recover first-party no-fault benefits. The court considered the fact that the defendant had served the plaintiffs with various discovery demands, and the plaintiffs moved for summary judgment. The defendant argued that the billing submitted by the plaintiffs contained material misrepresentations, and that one of the plaintiffs was ineligible for reimbursement due to fraudulent incorporation. The court held that the plaintiffs were entitled to summary judgment on some of their claims, as they had established their prima facie entitlement to recovery. However, the court found that there were issues of fact regarding the claims of one of the plaintiffs, and remanded the case for further proceedings on the remaining claims. The holding of the court was that the plaintiffs' motion for summary judgment was granted in part, and the case was remanded for further proceedings.

The court considered the fact that plaintiff moved for summary judgment in an action to recover first-party no-fault benefits, and defendant opposed the motion arguing the incident was a staged loss. The main issue was whether plaintiff proved its entitlement to summary judgment, and also whether defendant had a founded belief that the alleged injuries did not arise out of an insured incident. The court held that plaintiff did establish its entitlement to summary judgment by proving submission of statutory claim forms and that payment of benefits was overdue. However, the court also found that the defendant's submissions were sufficient to demonstrate a founded belief that the injuries did not arise out of an insured incident. Therefore, the order denying plaintiff's motion for summary judgment was affirmed, though on different grounds.

The court considered a dispute between two hospitals and an insurance company regarding the failure to pay for medical services provided under a no-fault insurance policy. The main issue decided was whether the insurance company had failed to make timely payment on the claims submitted, and whether the hospitals were entitled to interest and attorneys fees due to the delay in payment. The court held that the hospitals had established their entitlement to judgment as a matter of law, and that the insurance company had failed to pay the claims within thirty days of presentation, making the claims "overdue" within the meaning of the Insurance Law and requiring an award of interest and attorney fees. The court granted the hospitals' motion for summary judgment and denied the insurance company's cross-motion for summary judgment.

The relevant facts of the case included an action by a provider to recover assigned first-party no-fault benefits, where the plaintiff moved for summary judgment and the defendant opposed the motion. The defendant asserted that the alleged injuries did not arise from an insured incident and that the assignor failed to comply with a condition precedent to coverage. The main issues were whether the defendant's allegations of fraud were pleaded with the requisite particularity and whether the defendant's affirmative defense was stated with particularity. The holding was that the judgment was affirmed, as the defendant failed to establish the fact or founded belief that the alleged injuries did not arise out of an insured incident, and failed to make a sufficient showing of special circumstances to warrant the production of the assignor's income tax returns.

The main issue in this case was whether the defendant, an insurance company, timely mailed a denial of claim form based upon its standard office practice and procedure. The court found that the denial of claim form was timely mailed. The court also considered whether there was prima facie showing of lack of medical necessity for the services provided by the plaintiff, an acupuncturist. Defendant's affirmed peer review report and the affidavit of its peer review acupuncturist established prima facie that there was no medical necessity for the services. The court held that defendant was entitled to summary judgment dismissing the complaint. The main holding of the case was that the defendant established a lack of medical necessity and that the denial of claim form interposing said defense was timely.