No-Fault Case Law

The court considered the denial of first-party no-fault benefits by the insurance company based on peer review reports that found a lack of medical necessity for the services provided by the plaintiff. The main issue was whether the denial of the claims was valid and whether the insurer sufficiently informed the plaintiff of the reasons for the denial. The court held that the denial of the claims was not vague or misleading, as the insurer's NF-10 denial of claim forms clearly stated the basis for the denial and the accompanying explanation of benefits forms provided further explanation. The court also held that it was improper for the court to grant summary judgment to the defendant based on the issue of medical necessity since this was not the subject of the plaintiff's motion for summary judgment. Therefore, the judgment denying the plaintiff's motion for summary judgment and granting summary judgment to the defendant was reversed.

The court was asked to determine the medical necessity of electromyogram testing and nerve conduction velocity testing performed on the plaintiff's assignor, Vanessa Garcia, for injuries sustained in a motor vehicle accident. The main issue in the case was whether the testing was done in a manner that rendered the results medically unnecessary, despite the fact that the tests were prescribed correctly. The court relied on previous decisions in similar cases to define what constitutes "medical necessity" and ultimately held that even if the tests were not conducted properly, reimbursement is warranted as long as they were medically necessary. The court found in favor of the plaintiff, as the defendant did not meet the burden of demonstrating a lack of medical necessity for the services rendered. Therefore, the plaintiff was awarded $2,832.14, plus statutory interest, attorney fees, and costs and disbursements.

The court considered an action by a provider to recover assigned first-party no-fault benefits for services rendered to three assignors. The main issues decided were the denial of the provider's claims for services rendered to two assignors and the denial of the third assignor's claim based on failure to appear at a scheduled examination. The holding of the case was that provider made a prima facie showing of its entitlement to summary judgment with respect to two of the assignor's claims. However, with respect to the third assignor's claim, the evidence of notice that was sent to the assignor for the examination had not been rebutted, so it was incumbent upon the provider to establish that the assignor complied with the condition precedent. The judgment affirmed the denial of plaintiff's cross motion for summary judgment on its first and third causes of action and the granting of partial summary judgment to the defendant on those causes of action. However, the judgment also provided that plaintiff's cross motion for summary judgment is granted to the extent of granting plaintiff summary judgment on its second cause of action, but was remanded back to the court below for further proceedings.

The relevant facts considered in this case involved a provider seeking to recover assigned first-party no-fault benefits. The provider moved for summary judgment, which was initially granted by the court. The defendant insurance company subsequently appealed the decision, arguing that the affirmation submitted by the provider's officer did not lay a proper foundation for the admission of the documents annexed to the provider's moving papers. The main issue to be decided was whether the provider had established a prima facie case for entitlement to summary judgment by demonstrating that the no-fault claim forms were submitted to the defendant in admissible form as business records. The holding of the court was that the affirmation submitted by the provider's treating doctor was not sufficient to establish a foundation for the claim forms, and that the provider failed to make a prima facie showing of entitlement to summary judgment. Therefore, the judgment was reversed, and the provider's motion for summary judgment was denied.

In this case, Mid Atlantic Medical, P.C. sought to recover first-party no-fault benefits from Victoria Select Ins. Co. Plaintiff sought summary judgment, while the defendant cross-moved to dismiss the complaint based on a Virginia court's order rescinding the insurance policy. The court denied plaintiff's motion for summary judgment and granted defendant's cross-motion to dismiss the complaint. Plaintiff appealed the decision. Defendant was not allowed to invoke collateral estoppel against plaintiff since plaintiff was not a party to the Virginia proceeding. However, the court found that defendant raised a triable issue of fact as to whether there was coverage under the insurance policy. Therefore, the plaintiff's motion for summary judgment was properly denied. The decision was ultimately modified, with defendant's cross-motion to dismiss the complaint being denied and the order affirmed without costs.

The main issue in this case was whether the plaintiff was entitled to summary judgment on its claim for first-party no-fault benefits from the defendant insurance company. The court considered whether the defendant's denial of the plaintiff's claims was timely and based on valid grounds, such as the supplies provided not being medically necessary and the assignor's failure to appear for two independent medical examinations (IMEs). The holding of the court was that the plaintiff's motion for summary judgment was granted on the claims for $1,021 and $289, as the defendant had failed to establish the assignor's nonappearance at the IMEs. However, the court denied the plaintiff's motion for summary judgment on the $694 claim, as the defendant had provided a sufficient and timely peer review report for denial. The case was remanded for the calculation of statutory interest and assessment of attorney's fees on the awarded claims.

The relevant facts the court considered were that the defendant, an insurance company, sought to vacate a default judgment in a case to recover assigned first-party no-fault benefits. The defendant was required to establish both a reasonable excuse for the default and a meritorious defense. The court found that there was no support in the record for the determination that the defendant had a reasonable excuse for the default, as the only proffered excuse was set forth by the defendant's attorney, who did not allege personal knowledge of his assertions. Therefore, the court reversed the order granting the defendant's motion to vacate the default judgment and denied the motion. The holding of the case was that the court found the defendant did not have a reasonable excuse for the default and therefore the motion to vacate the default judgment was denied.

The court considered the fact that Uniondale Chiropractic Office brought a claim against State Farm Mutual Automobile Insurance Company to recover no-fault first party benefits. The action involved twenty-three bills for chiropractic services totaling $1,975.28. The main issue was whether Uniondale Chiropractic Office was entitled to summary judgment on these claims. The court held that Uniondale Chiropractic Office was entitled to summary judgment on twenty of the twenty-three claims, as the defendant admitted timely receipt of twenty of the plaintiff's claim forms. The court also held that the defendant's denial of receipt of the plaintiff's claims was insufficient to rebut the presumption of receipt upon proof of proper mailing, and therefore, the plaintiff was entitled to summary judgment on the three bills totaling $246.24 which the defendant denies receiving.

The court considered the stipulated facts that the insurance policy was issued after the effective date of a mandatory personal injury endorsement, which required that claims be submitted within 45 days of service. When the plaintiff did not submit claims within the required time, the defendant timely denied the claims. The plaintiff argued that the defendant was required to produce the policy to prove it contained the endorsement. Citing relevant case law, the court found that once the policy was issued after the effective date of the endorsement, the new regulations applied, whether or not the policy actually contained the endorsement. The court held that in this case, the defendant did not need to produce proof that the policy was issued after the endorsement was required, since the parties had stipulated to that fact. Therefore, the 45-day claim submission requirement applied, and the plaintiff's failure to meet this requirement precluded recovery.

The court considered a case regarding a provider seeking to recover no-fault benefits from an insurance company, based on seven causes of action and an eighth cause of action seeking attorney's fees. The provider moved for summary judgment, which was granted by the lower court, but the insurance company cross-moved for summary judgment to dismiss the complaint, which was denied. The main issue decided was whether the provider made a prima facie showing of its entitlement to summary judgment, and whether the insurance company was entitled to summary judgment based on timely verification requests. The holding of the court was that the provider failed to establish a prima facie case for summary judgment, and the insurance company was not entitled to summary judgment based on the timely verification requests. 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 insurance company's cross motion for summary judgment was granted to dismiss the provider's second through seventh causes of action.