No-Fault Case Law

The main issue of this case was whether the denial of claim form was timely mailed by the defendant in an action to recover assigned first-party no-fault benefits. The court considered the affidavit submitted by the defendant's litigation examiner, which failed to establish that the denial of claim form was timely mailed based upon the defendant's standard office practice or procedure. The court found that the affidavit did not sufficiently set forth the steps which comprise the defendant's mailing practices and procedures. Therefore, the court held that the defendant failed to establish that its defense of lack of medical necessity was not precluded, and reversed the order granting the defendant's motion for summary judgment, denying the motion instead. The main holding of the court was that the defendant did not establish that the denial of claim form was timely mailed, and therefore failed to prove its defense of lack of medical necessity.

The relevant facts that the court considered were that Dr. Robert Schepp, through a group of professional service corporations, submitted a large number of no-fault claims to several insurance companies. The insurers denied many claims on the ground that the professional corporations were ineligible for no-fault reimbursement, citing violations of state licensing requirements and the fact that radiology services were performed by independent contractors. The main issue decided was whether the professional service corporations were ineligible for no-fault reimbursement due to licensing requirement violations and the use of independent contractors. The court held that while the professional service corporations were permitted to recover no-fault claims paid prior to April 4, 2002, they could not recover claims submitted after this date by using independent contractors for radiology services, and that the corporations lacked standing to bring the lawsuits. The court granted the motion for summary judgment in part and denied it in part.

The court considered the denial of claim forms by the defendant, and the independent chiropractic examination report along with the affidavit of the chiropractor, which provided a factual basis and medical rationale for the opinion that the services rendered were not medically necessary. The main issue decided was whether the denial of claim forms were timely and whether the independent chiropractic examination report and affidavit provided sufficient evidence to show lack of medical necessity for the services rendered. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint should have been granted, as the defendant demonstrated that it had timely denied the claims and provided sufficient evidence to support the lack of medical necessity for the services.

The case involved an action to recover no-fault medical benefits under insurance contracts by St. Vincent's Hospital & Medical Center and Mount Sinai Hospital. The plaintiffs appealed from an order of the Supreme Court, Nassau County, which denied their motion to hold the defendant in contempt for failure to comply with an information subpoena. The order also granted the defendant's cross motion to vacate a judgment entered upon its default in appearing or answering the complaint. The court affirmed the order, stating that the Supreme Court properly exercised its discretion in vacating the default judgment, and found the remaining contentions of the plaintiff without merit or not properly before the Court. The main issue decided was whether the default judgment should be vacated, and the holding was that the Supreme Court properly exercised its discretion in doing so.

The court considered the defendant's claim that the medical service provider, Lenox Neuropsychiatry Medical, P.C., was fraudulently incorporated in violation of 11 NYCRR § 65.3.16(a)(12) and its motion to dismiss the plaintiff's complaint. The main issue decided was whether the defendant insurance company must present evidence, in support of its claim, warranting an order from the court directing extensive discovery or EBT's (examinations before trial). The court held that the defendant had not articulated a "founded belief" that the plaintiff was actually controlled by a non-licensed professional so as to warrant a broad-based trial on fraud or extensive discovery on fraudulent incorporation. However, the court did find it material and necessary for the defendant to conduct a limited EBT of the purported owner of the medical service provider to ascertain the extent of his work with other clinics and the extent of his knowledge as to the actual operations of these clinics.

The court considered the appeal from a denial of a motion to "revise" the award of attorney's fees in a first party no-fault benefits action brought by Adam Marigliano, LMT, a/a/o Santos Climaco, Jose Contreras Rutreyes, Visitacion Corado, Jorge Acosta, Jessica Acosta, Horacio Velasquez, Ana Corado, and Maria Guzman against New York Mutual Fire Insurance Co. The main issue decided was whether the denial of the motion to "revise" the award of attorney's fees was proper. The holding of the court was to affirm the order denying the motion, citing the reasons given by Shlomo S. Hagler, J., at Civil Court and referencing a similar case, LMK Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co., 46 AD3d 1290, 1292 [2007], lv granted 10 NY3d 717 [2008].

The issue in this case was whether the respondent followed the provisions of the insurance policy that require prompt notice be given of any third-party litigation or any claim for uninsured/underinsured motorist (SUM) benefits, and if not, whether the insurance company was prejudiced by the delayed notice. The appellant, Liberty Mutual Insurance Company, contended that the respondent failed to provide timely notice of his lawsuit against a third party and his claim for SUM benefits. However, the court found that while the respondent failed to provide prompt notice as required by the policy, the insurance company was not prejudiced in any meaningful way by the delay. Therefore, the court concluded that the insurance company's application to stay arbitration was properly denied. The court considered the facts that the respondent was involved in an automobile accident and, three weeks after the accident, his counsel sent a letter to the insurance company notifying it of the accident and the potential implications for the insurance policy, and that the insurance company was put on notice of the existence of the accident within three weeks of its occurrence and received ample information to properly investigate the claim and protect its interests. The court held that although the respondent did not satisfy his obligation to provide prompt notice, the insurance company failed to demonstrate that the respondent's delay in notifying it of the third-party action or the SUM claim compromised its ability to investigate the circumstances surrounding the accident or to protect its interests under the policy. Therefore, the order denying the application to stay arbitration was affirmed.

The case involved an appeal from a trial court order that granted the defendants' motion to vacate a judgment in favor of the plaintiff in an action to recover no-fault insurance benefits. The defendants' employee had mistakenly believed that the action had been discontinued after advising the plaintiff's counsel's office that no-fault benefits had been exhausted, which the appellate court found to be a reasonable excuse for their delay in appearing and answering. Additionally, the defendants established that the policy limits had been partially exhausted through the payment of claims for prior services, a potentially meritorious defense to the action. The plaintiff did not demonstrate prejudice from the defendants' short delay in appearing and answering, and the court held that the trial court had properly exercised its discretion in granting the defendants' motion to vacate the judgment.

The main issue in the case was whether the plaintiff had established a prima facie case for summary judgment in an action to recover assigned first-party no-fault benefits. The court held that the plaintiff had established its prima facie entitlement to summary judgment by proving the submission of a claim form, setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. The court also addressed the defendant's attempt to demonstrate an issue of fact as to the medical necessity of the services rendered, and found that the defendant's claims representative's affidavit did not establish actual mailing of the denials nor give rise to the presumption that they were mailed. As a result, the defendant was precluded from raising its proffered defense of lack of medical necessity, and the judgment in favor of the plaintiff was affirmed.

The main issues in this case were whether the plaintiff had properly submitted claims for no-fault benefits, whether she had standing to sue, and if the insurance company had valid reasons for denying the claims. The court considered evidence of claims submitted by medical providers, the plaintiff's assignment of benefits to those providers, and the regulations regarding assignment of benefits. The court held that the plaintiff did not need to prove she had issued payment for treatment, but did need to show that claims were submitted and not paid within 30 days. The court found that the plaintiff's causes of action seeking reimbursement for services provided by Dr. Patricia D'Imperio were valid, but those seeking reimbursement for services provided by other medical providers had been properly dismissed. The court also found that the plaintiff had demonstrated a cause of action and that the litigation was not frivolous, so the award of attorney's fees to the defendant was reversed. The court remanded the case for further determination of the plaintiff's cross motion to strike the defendant's answer.