No-Fault Case Law

The relevant facts considered by the court were that Bronx Expert Radiology, P.C. was suing New York Central Mutual Fire Insurance Company in order to recover first party no-fault benefits. The main issue decided was whether or not the defendant's medical expert should have been permitted to testify, as the expert's opinion may have been partly based on the review of medical records prepared by the plaintiff or other physicians. The holding of the court was that the defendant's medical expert should have been permitted to testify, as his testimony on lack of medical necessity would be limited to the basis for denial set forth in the original peer review report, and his opinion may have been based, at least in part, on his review of medical records related to the treatment provided to the assignor. The judgment was reversed, with $25 costs, and the matter was remanded for further proceedings.

The court considered the fact that Bronx Expert Radiology, P.C. submitted its claims for first party no-fault benefits to Great Northern Insurance Co. in March 2004, even though the health services were rendered in November 2003. Defendant denied the claims as untimely and requested plaintiff to provide a "clear and reasonable justification" for the delay, as required by the statute. The main issue decided was whether plaintiff had a reasonable justification for its delay in submitting the claims to defendant. The court held that plaintiff failed to meet its burden of establishing a reasonable justification for the untimely submission of its claims, as its proof was insufficient to justify the delay. The court also ruled that there is no requirement in the No-Fault statute or regulations imposing the need to show prejudice for untimely claims. Therefore, the appellate term reversed the trial court's decision and dismissed the complaint.

The relevant facts considered by the court in this case involved a subrogation action by Allstate Insurance Company to recover first-party no-fault benefits and uninsured motorist benefits paid to its subrogor. Plaintiff had moved for summary judgment, and the motion was granted on default. The defendant then moved to vacate the default judgment, and a default judgment was entered in favor of the plaintiff while the defendant's motion was pending. The main issue decided by the court was whether the defendant had demonstrated a reasonable excuse for his default as well as a meritorious defense to the action. The holding of the court was that the defendant did not provide a meritorious defense to the action and therefore the order of the Civil Court was reversed, and defendant's motion to vacate was denied.

The relevant facts considered by the court were that Delta Diagnostic Radiology, P.C. was seeking to recover assigned first-party no-fault benefits from Integon National Insurance Co., and defendant moved for summary judgment dismissing the complaint on the ground of lack of medical necessity. Plaintiff argued in opposition that defendant had failed to come forward with proof that the performed MRI was not medically necessary. The main issue decided by the court was whether the denial of claim form at issue was timely mailed and whether the billed-for MRI was medically necessary. The holding of the case was that the affidavit submitted by defendant's claims representative established that the denial of claim form was timely mailed, and the affirmed report by defendant's examining physician provided a factual basis and medical rationale for his opinion that the billed-for MRI was not medically necessary, and plaintiff failed to rebut such proof, so the Civil Court properly granted defendant summary judgment.

The relevant facts considered by the court were that Crossbay Acupuncture, P.C. was seeking to recover assigned first-party no-fault benefits from Nationwide Mutual Insurance Co. The main issue decided in this case was whether Crossbay Acupuncture, P.C. was entitled to summary judgment in their favor. The holding of the court was that Crossbay Acupuncture, P.C. was entitled to summary judgment as they had established their prima facie entitlement to such relief under the Insurance Law. The court found that since Nationwide Mutual Insurance Co. did not submit opposing papers, the Civil Court had improperly denied Crossbay Acupuncture, P.C.'s unopposed motion for summary judgment. The order was reversed, and the matter was remitted to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees.

The relevant facts considered by the court were that Pan Chiropractic, P.C. was suing Mercury Insurance Co. to recover assigned first-party no-fault benefits, and Mercury Insurance Co. denied the claim based on a peer review report. The main issue before the court was whether there was a question of fact as to the medical necessity of the services provided. The holding of the court was that the affidavit submitted by the defendant's claims representative sufficiently established the timely mailing of the denial of the claim form, and that defendant made a prima facie showing of its entitlement to summary judgment dismissing the complaint. The court reversed the order and granted defendant's cross motion for summary judgment dismissing the complaint. The burden was shifted to plaintiff to raise a triable issue of fact in opposition to the defendant's cross motion, which the court found was not done with the evidence presented.

The main facts in the case were that AKS Medical, as the assignee of Kisha Snipes, brought an action to recover first-party no-fault benefits from Progressive Insurance Company. AKS Medical moved for summary judgment on its fifth cause of action, seeking to recover $398.61. In opposition, Progressive Insurance Company argued that it never received the claim. The main issue decided was whether AKS Medical had established its prima facie entitlement to summary judgment by proving the submission of the claim form to Progressive Insurance Company. The court held that AKS Medical failed to establish submission of the $398.61 claim to Progressive Insurance Company and therefore denied summary judgment on its fifth cause of action.

The relevant facts that the court considered were that 563 Grand Medical, P.C. filed a petition to vacate a master arbitrator's award that upheld the denial of its claim for reimbursement of assigned first-party no-fault benefits. The court denied the petition, stating that the papers submitted by petitioner were insufficient on their face to warrant the granting of any relief. The main issue decided was whether the document submitted by the petitioner in support of the petition was sufficient as an affirmation, and the court held that it was not. The court affirmed the order of the Civil Court, without costs, stating that a special proceeding should terminate in a judgment, not an order.

The court considered the facts of a case where a medical supply company, acting as the assignee of a claimant, was seeking to recover first-party no-fault benefits from an insurance company. The main issue was whether the action was premature because the provider had commenced the action before the insurance company received responses to its verification requests. The court held that the insurance company had timely mailed requests for verification and follow-up requests for verification, and since the provider did not serve responses to the verification requests prior to commencing the action, the insurance company's cross motion to dismiss the action as premature should have been granted. Therefore, the judgment was reversed, the order granting the provider's motion for summary judgment was vacated, the provider's motion for summary judgment was denied, and the insurance company's cross motion for summary judgment dismissing the complaint was granted.

The relevant facts considered by the court in the case were that Dr. Albert Davydov had filed a lawsuit to acquire no-fault benefits for dental services provided as an assignment of benefits. After the non-jury trial took place, the Civil Court ruled in favor of Dr. Davydov in the total sum of $6,569.27. Following this decision, the defendant appealed the judgment that was made and was later entered. The issue at hand was with regards to the standing of Dr. Davydov to prosecute the case since the assignment of the no-fault benefits form was in favor of Dr. Albert Davydov, DDS, P.C. rather than Dr. Albert Davydov, DDS. The court held that the defendant could not contest the validity of the assignment of benefits due to their failure to timely seek verification and therefore, the judgment was affirmed.