No-Fault Case Law

The relevant facts considered by the court were that Long Island Multi-Medicine Group, P.C. sought to recover assigned first-party no-fault benefits, and defendant Travelers Ins. Co. denied a number of the claims on the basis that they were not timely submitted. Plaintiff moved for summary judgment, which was granted, and defendant appealed, arguing that it had not waived its defense of untimeliness. The main issue decided was whether defendant waived its defense of untimeliness, and the court held that defendant had failed to establish that it timely denied the subject claims, and therefore failed to raise a triable issue of fact with respect to the claims at issue. The judgment was affirmed on other grounds.

The court considered the petitioner's request for summary judgment based on newly discovered evidence regarding a hit and run. The petitioner claimed the respondent intentionally failed to disclose that his father, who died in 2001, was the named insured under the insurance policy for which he was making claims. The court also considered the petitioner's motion to vacate the arbitration award on the ground that there was no valid agreement to arbitrate. The main issue decided was whether there was a valid contract between the deceased insured and the insurer, and whether there was a rational basis for the arbitration award. The holding of the court was that there was no valid contract between the respondent and the insurer due to the fact that the respondent's deceased father was the named insured. Therefore, the arbitration award was vacated and summary judgment was granted to the petitioner on the issue of non-coverage.

The court considered the motion for summary judgment filed by All Mental Care Medicine, P.C. to recover assigned first-party no-fault benefits. Defendant asserted that it timely denied the claims because the assignor failed to appear for two independent medical examinations (IMEs). However, defendant failed to establish by proof in admissible form that the IME requests were timely mailed to the assignor and that the assignor failed to appear for the IMEs. As a result, the court granted partial summary judgment to the plaintiff, awarding it the sums of $240.20 and $1,201. The matter was remanded to the court below for the calculation of statutory interest and attorney's fees thereon. The court ultimately reversed the order denying plaintiff's motion for summary judgment and granted partial summary judgment on the claims for $240.20 and $1,201.

The court considered a case in which a provider was seeking to recover assigned first-party no-fault benefits, but the defendant had been granted summary judgment on default. The main issue decided was whether the plaintiff's motion to vacate the default judgment and deny the defendant's motion for summary judgment should be granted. The court held that the plaintiff's claim of law office failure did not amount to a reasonable excuse for the default, as it was conclusory, undetailed, and uncorroborated. Therefore, the court reversed the order granting the plaintiff's motion to vacate the default judgment and denied the defendant's motion for summary judgment. The court did not consider any other issues in the case.

The court considered the fact that New Century Osteopathic and George Laikeas, M.D. d/b/a Medical Plaza had filed a complaint to recover assigned first-party no-fault benefits, but the court denied their motion at trial and dismissed the complaint because the plaintiffs presented no evidence. The main issue decided was whether a prior order which stated that the plaintiffs' motion for summary judgment made a prima facie showing dispensed with the need for the plaintiffs to establish a prima facie case at trial. The holding of the case was that the appeal by the plaintiffs was dismissed, as the court denied their oral motion and no appeal lies from an order which does not decide a motion made on notice. Additionally, no appeal lies from a decision to dismiss the complaint. Therefore, the court's decision to deny the motion and dismiss the complaint was upheld.

The relevant facts considered by the court were that the plaintiff, a medical supply provider, submitted unpaid bills for medical equipment it provided to the defendant's assignor and moved for summary judgment because the defendant failed to pay or deny the claim within the required 30 days. The defendant opposed the motion by arguing that the plaintiff failed to establish a prima facie case and by asserting that its partial payment to the plaintiff raised an issue of fact about whether the plaintiff was paid the appropriate amount for medical services. The main issue decided was whether the defendant was barred from raising the defense of fee schedule noncompliance and partial payment according to the fee schedule because of its failure to submit a timely denial. The holding of the case was that the defense of fee schedule noncompliance and partial payment made in accordance with the fee schedule was precluded because the defendant failed to disclaim coverage in a timely manner. As a result, summary judgment was granted to the plaintiff.

In this case, the plaintiff, A.M. Medical Services, sought to recover assigned first-party no-fault benefits from Progressive Casualty Insurance Company. The defendant moved for summary judgment to dismiss the complaint, arguing that the health care services attempted to be collected were rendered by independent contractors, and plaintiff was therefore not entitled to direct payment of benefits. The plaintiff's opposition was based on trial transcripts of three related actions against another insurance company that found plaintiff's treating providers were employees. The appellate court found that plaintiff's submission of claim forms stating that the billed-for services were rendered by independent contractors was sufficient evidence to award the defendant insurer summary judgment. The court determined that plaintiff did not supply proper proof of loss, and plaintiff's argument that their treating providers were employees was irrelevant. Therefore, the court affirmed the judgment without costs. In summary, the relevant facts considered by the court included the submission of claim forms and trial transcripts suggesting the health care services were rendered by employees. The main issue decided was whether an insurer could be awarded summary judgment based on defense that services were rendered by independent contractors, to which the court answered yes. The holding of the case was that claim forms stating services were rendered by independent contractors are sufficient evidence for an insurer to be awarded summary judgment.

The court considered the denial of the defendant's motion to vacate a judgment entered upon its default in appearing or answering the complaint, which was in favor of the plaintiffs and against it in the principal sum of $43,030.53. The defendant failed to demonstrate a reasonable excuse for the default. The plaintiffs established that they served the defendant through delivery of the summons and complaint upon the Assistant Deputy Superintendent and Chief of Insurance. The defendant did not contend that the address on file with the Superintendent of Insurance was incorrect, and the mere denial of receipt of the summons and complaint was insufficient to rebut the presumption of proper service created by the affidavit of service. Even if the defendant's motion were treated as one made pursuant to CPLR 317, it failed to meet its burden of showing that it did not receive actual notice of the summons in time to defend the action. The main issues decided were the denial of the defendant's motion to vacate a judgment entered upon its default, and the failure of the defendant to demonstrate a reasonable excuse for the default. The holding of the case was that the Supreme Court providently exercised its discretion in denying the defendant's motion to vacate the judgment.

The court in this case addressed the legality of the no-fault insurer's use of the prevailing geographic rate or the reasonable and customary rate for health care services in calculating first-party benefits due to a claimant or health-care provider. Globe Surgical Supply, as the assignee of Remy Gallant, commenced a class action lawsuit against GEICO Insurance Company for systematically reducing its reimbursement for medical equipment and supplies, specifically, durable medical equipment (DME), based on prevailing rate or the reasonable and customary rate. The court analyzed the no-fault statutory and regulatory scheme and the regulation 68 in relation to the reimbursement for DME, as well as the litigation that took place. The court denied the certification of the class action on behalf of all persons who had reimbursement payments of claims for medical equipment and supplies adjusted or reduced by GEICO to an amount less than the amount charged in the proof of claim, specifically to a "reasonable reimbursement of 150%."

The main issue in the case was whether the defendant insurance company was required to pay or deny the medical claims of two insured individuals within 30 days as prescribed by the relevant no-fault regulations. The plaintiff, Westchester Medical Center, sought summary judgment on the first cause of action regarding the claim of Josh Logan, arguing that the defendant failed to timely pay or deny the claim. The defendant, Clarendon National Insurance Company, had paid the claim of Edward Caruso and made a partial payment on the claim of Josh Logan. The court held that although the plaintiff demonstrated its entitlement to judgment as a matter of law on the first cause of action, the defendant raised a triable issue of fact as to whether it timely and properly denied the claim based on Logan's alleged intoxication at the time of the accident. Therefore, that branch of the plaintiff's motion for summary judgment on the first cause of action was denied.