No-Fault Case Law

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.

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.