No-Fault Case Law
Amaze Med. Supply, Inc. v Utica Mut. Ins. Co. (2009 NY Slip Op 52690(U))
March 19, 2009
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.
New York Hosp. Med. Ctr. of Queens v Countrywide Ins. Co. (2009 NY Slip Op 50764(U))
March 17, 2009
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.
Vista Surgical Supplies, Inc. v Utica Mut. Ins. Co. (2009 NY Slip Op 50493(U))
March 17, 2009
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.
PLP Acupuncture, P.C. v Progressive Cas. Ins. Co. (2009 NY Slip Op 50491(U))
March 17, 2009
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.
Westchester Med. Ctr. v American Tr. Ins. Co. (2009 NY Slip Op 01979)
March 17, 2009
The relevant facts that the court considered were that Westchester Medical Center (WMC) initiated an action to recover no-fault medical benefits owed to Daphne McPherson, and that the defendant, American Transit Insurance Company, did not pay or deny such benefits within the required 30 days. The main issue was whether the defendant's request for additional verification of the claim and subsequent denial of benefits was timely, based on alleged receipt of verification that McPherson was entitled to workers' compensation benefits. The holding of the court was that the defendant did make a timely request for additional verification of the claim, and that its denial of benefits was timely. As a result, the judgment in favor of WMC was reversed, and the defendant was awarded summary judgment dismissing WMC's cause of action.
Audobon Physical Med & Rehab, P.C. v GEICO Ins. Co. (2009 NY Slip Op 50456(U))
March 16, 2009
The relevant facts included a provider seeking to recover assigned first-party no-fault benefits, moving for summary judgment, and an insurance company opposing the motion. The main issues were whether payment of no-fault benefits was overdue and whether verification requests for independent medical examinations (IMEs) were properly mailed and whether the assignor failed to appear at the IMEs. The holding was that plaintiff's motion for summary judgment upon its first cause of action was granted, denying the defendant's summary judgment request on the second cause of action, and remanding the matter to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees upon said cause of action.
Park Slope Med. & Surgical Supply, Inc. v New York Cent. Mut. Fire Ins. Co. (2009 NY Slip Op 50441(U))
March 12, 2009
The court considered a case in which a medical supply provider sought to recover assigned first-party no-fault benefits. The provider moved for summary judgment, while the insurance company cross-moved for summary judgment, claiming lack of medical necessity for the supplies provided. The court denied both motions, finding that an issue of fact existed as to whether the supplies were medically necessary. The insurance company established a prima facie case of lack of medical necessity, but the provider's submission of an affidavit from a doctor demonstrated the existence of an issue of fact as to medical necessity. As a result, the court affirmed the decision to deny the insurance company's cross motion for summary judgment.
Daras v GEICO Ins. Co. (2009 NY Slip Op 50438(U))
March 10, 2009
The relevant facts the court considered in this case involved a medical provider seeking to recover no-fault benefits from an insurance company. The provider moved for summary judgment, but the insurance company argued that the provider did not establish a prima facie case and that the assignor failed to appear for scheduled independent medical examinations (IMEs). The court found that the provider had submitted claim forms and established the amount of the loss sustained, and that payment of the benefits was overdue, thus meeting the prima facie requirement for summary judgment. The insurance company did not provide proof that the IME requests were timely mailed to the assignor and that the assignor failed to appear for the examinations. As a result, the court granted the provider's motion for summary judgment and remanded the matter for the calculation of interest and an assessment of attorney's fees.
PDG Psychological, P.C. v Travelers Ins. Co. (2009 NY Slip Op 50437(U))
March 10, 2009
The court considered the fact that the plaintiff sought to recover assigned first-party no-fault benefits and attempted to lay a foundation for the admission of its claim forms by presenting the testimony of an employee. The main issue decided was whether the plaintiff provided sufficient evidence to prove its case. The holding of the case was that the plaintiff did not meet its burden to proffer evidence in admissible form and failed to demonstrate that the witness possessed sufficient personal knowledge of the office practices and procedures to lay a foundation for the admission of the documents as business records. Therefore, the court affirmed the judgment that dismissed the complaint due to the plaintiff's failure to make a prima facie showing.
PDG Psychological, P.C. v Progressive Cas. Ins. Co. (2009 NY Slip Op 50436(U))
March 10, 2009
The court considered the testimony of witnesses and the admissibility of plaintiff's purported claim form in an action to recover assigned first-party no-fault benefits. Plaintiff's file clerk testified and sought to admit the claim form, but defendant objected on hearsay grounds. The court also heard testimony from defendant's litigation specialist. Despite this, the Civil Court did not admit plaintiff's bill into evidence and granted defendant's motion for a directed verdict. The main issue was whether plaintiff had made a prima facie case to recover the benefits. The court held that the testimony did not demonstrate sufficient personal knowledge to establish the admissibility of the bill as a business record, and therefore plaintiff failed to establish a prima facie case. The judgment dismissing the complaint was affirmed.