No-Fault Case Law

The main issue decided in the case was whether a provider was entitled to recover first-party no-fault benefits when the insurance company claimed it did not receive the necessary claim forms. The court's holding was that the provider failed to establish its entitlement to summary judgment because it did not prove that it mailed the claim forms to the insurance company. The court found that the provider's primary doctor and principal shareholder's affirmation and attorney's affirmation were insufficient to establish either actual mailing of the claim forms or a standard office practice or procedure designed to ensure that items are properly addressed and mailed. Therefore, the district court's denial of the provider's motion for summary judgment and granting of the insurance company's cross motion for summary judgment was affirmed.

The court heard an appeal from an order denying a provider's motion for summary judgment in a case to recover assigned first-party no-fault benefits. The defendant had denied the claim due to a lack of medical necessity and argued that documents submitted by the plaintiff were not admissible as business records. However, the court found that the defendant failed to establish the lack of medical necessity as a defense and that the plaintiff's motion for summary judgment should be granted. The court held that the documents were indeed admissible as business records and remitted the matter to the District Court for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106(a) and the regulations thereof.

The court considered a case where a medical supply company was seeking to recover no-fault benefits through an assigned claim. The main issue was whether the company was entitled to summary judgment for unpaid bills when the insureds failed to appear for independent medical examinations. The court held that the medical supply company was entitled to summary judgment for the unpaid bills, as the insurer failed to prove proper mailing of the examination scheduling letters and also failed to establish that the insureds did not appear for the examinations. As a result, the court reversed the lower court's decision, granted summary judgment for the unpaid bills, and remanded the case for the calculation of statutory interest and attorney's fees.

The court considered the denial of the plaintiff's no-fault claim by the defendant, Liberty Mutual Insurance Co., based on the results of an independent peer review. The main issue decided was whether the defendant's NF-10 form sufficiently apprised the plaintiff of the factual basis for the denial. The court held that the NF-10 form did provide enough information to inform the plaintiff of the basis for the denial, in accordance with 11 NYCRR 65-3.8[b][4]. Additionally, the court found that the initial peer review report relied upon by the defendant, along with additional documentation received from the plaintiff, raised a triable issue as to the medical necessity of the services and tests performed by the plaintiff. Therefore, the court affirmed the amended order of the Civil Court, denying the plaintiff's motion for summary judgment.

The court considered the issues of whether plaintiff Cambridge Medical, P.C. was required to comply with defendant Adirondack Insurance Exchange's discovery demands, and whether plaintiff's alleged owner, Eileen S. Debbi, M.D., should be compelled to testify regarding the ownership and operation of the plaintiff. Defendant contended that Dr. Debbi was not the true owner of Cambridge Medical, and that the real owner was Mark Levitan of Nissa Management, Inc. Plaintiff opposed, arguing that the deposition was sought to harass and delay the trial. The court held that plaintiff was bound by Article 31 of the CPLR, which grants as of right discovery in all civil plenary proceedings, and granted defendant's motion to compel the production of Dr. Debbi for examination before trial and to respond to defendant's discovery demands. Plaintiff's application for a protective order was denied.

The relevant facts of the case were that the plaintiff, a medical provider, was seeking to recover first-party no-fault benefits from the defendant insurance company. The plaintiff moved for summary judgment and the defendant cross-moved for summary judgment dismissing the complaint. The District Court denied the plaintiff's motion on the grounds that the affidavit by the plaintiff's billing manager did not establish that the documents annexed to plaintiff's motion were admissible as business records. The court also granted the defendant's cross motion for summary judgment as to plaintiff's claim for $230.09 and denied the defendant's cross motion for summary judgment as to plaintiff's claim for $1,572.26. The main issue that was decided in this case was whether the plaintiff had made a prima facie showing of its entitlement to summary judgment. The holding was that the plaintiff failed to make a prima facie showing of its entitlement to summary judgment since the affidavit submitted by the plaintiff's billing manager did not establish that the documents annexed to plaintiff's moving papers were admissible pursuant to CPLR 4518. As a result, the court affirmed the lower court's decision to deny the plaintiff's motion for summary judgment with respect to the claim for $1,572.26.

The court considered the circumstances of a motor vehicle accident in which the plaintiff, Mary Proper, sought no-fault insurance benefits from the defendant, State Farm Mutual Automobile Insurance Company. The defendant had paid for some of her medical treatment and lost wages, but the plaintiff alleged that they did not fully provide the benefits she was entitled to. The main issues decided by the court were whether the plaintiff had provided admissible evidence to show that she suffered damages, and whether the burden of proving damages had been met. The holding of the court was that the plaintiffs failed to support their claim with admissible evidence of damages, and therefore, the court affirmed the dismissal of the complaint. The burden of proving damages was not met by the plaintiffs, and speculation and bare assertions were insufficient to support their claim.

The relevant facts the court considered in this case involved an automobile accident in which Beverly Bemiss was involved. She had an insurance policy through Central Mutual Insurance Company for Supplementary Uninsured/Underinsured Motorists (SUM) coverage. Bemiss was involved in a multi-tortfeasor accident and her injuries required surgery. One of the tortfeasors, Kowalczyk, settled for her policy limits, and Bemiss agreed to a settlement below the policy limits with another tortfeasor, Genski, without notifying her insurer, Central Mutual. The main issue decided in this case was whether or not consent-to-settle and subrogation-protection provisions in an insurance policy's SUM endorsement remain in force once an insured has exhausted the available policy limits of a single tortfeasor in a multi-tortfeasor accident. The holding of the court was that the insured, Bemiss, violated Condition 10 of the SUM endorsement when she settled with Genski without the insurer's written consent, impairing the insurer's subrogation rights. The court also found that once the insured had exhausted the policy limits of one tortfeasor, she was entitled to make a claim for the remaining policy limits under her SUM coverage without having to pursue a claim against the second tortfeasor. Therefore, the order of the Appellate Division was affirmed with costs.

The main facts considered by the court were that Crossbridge Diagnostic Radiology was seeking first-party no-fault benefits after the insurer, Encompass Insurance, had denied their claim on the grounds that the policy benefits had been exhausted. Crossbridge argued that the denial was untimely and that there was no admissible evidence to establish that the policy benefits were actually exhausted. The main issue decided was whether the evidence presented by Encompass Insurance was admissible and sufficient to establish that the policy benefits had been exhausted. The holding was that the evidence presented by Encompass Insurance was not in admissible form, and therefore did not establish a triable issue of fact. The judgment of the Civil Court granting Crossbridge's motion for summary judgment was affirmed as a result.

The court considered a motion by the plaintiff to compel the deposition of the defendant in a case involving recovery of assigned first-party no-fault benefits. The defendant opposed the motion and cross-moved for a protective order. The main issue was whether the defendant should be compelled to appear for a deposition, and whether the request for a protective order was justified. The holding of the court was that the plaintiff's motion to compel the defendant to appear for a deposition within 30 days was granted, and the branch of the defendant's cross motion seeking a protective order was denied. The court emphasized the importance of full disclosure of all material and necessary facts in the prosecution or defense of an action, and the entitlement to reasonable discovery of any facts bearing on the controversy.