No-Fault Case Law

The court considered the fact that the insurance company was required to pay or deny a claim for no-fault benefits within 30 days of receiving the proof of claim. The insurance company requested additional verification 12 business days after receiving the claim form, reducing the 30-day period to 28 days. The insurance company received the requested verification on May 16, 2001, and was required to pay or deny the claim at issue on or before June 13, 2001. However, the insurance company did not deny the claim until June 14, 2001, making the denial untimely and precluding the insurance company from raising its defense of lack of medical necessity. As a result, the court granted the plaintiff's motion for summary judgment upon the unpaid portion of the claim and remanded the case for the calculation of interest and attorney's fees. The relevant issue was whether the insurance company's denial of the claim was untimely, and the holding was in favor of the plaintiff, granting summary judgment and remanding for further calculations.

The court considered the defendant's motion for summary judgment dismissing the complaint on the ground of res judicata, arguing that the plaintiff had previously commenced an identical action which was dismissed due to failure to comply with a so-ordered discovery stipulation. The plaintiff argued that the prior action was not dismissed with prejudice, so the current action was proper. The main issue decided was whether the plaintiff's noncompliance with the discovery order resulted in a dismissal with prejudice, and if so, whether it barred them from commencing a second action. The holding of the case was that since the plaintiff's prior action was dismissed after the court granted the defendant's motion to strike the complaint pursuant to CPLR 3126 (3), and since the noncompliance did not result in a dismissal with prejudice, the plaintiff was not barred from commencing a second action. Therefore, the court affirmed the order denying the defendant's motion for summary judgment.

The court considered the fact that the plaintiff, a health care provider, obtained a default judgment in the action to recover assigned first-party no-fault benefits. The defendant's motion to vacate the default judgment was denied on the grounds that their papers did not establish the existence of a meritorious defense. The main issue decided was whether the defendant established that it possessed a meritorious defense to the action. The holding of the case was that since the affidavit executed by the defendant's special investigator "suffice[d] to [demonstrate] issues as to who really operated and controlled plaintiff," the defendant established the existence of a meritorious defense to the action. Therefore, the court reversed the order and granted the defendant's motion.

The court in this case considered whether an insurance company had properly denied a medical equipment provider's claim for first-party no-fault benefits based on a peer review report which stated there was no medical necessity for the equipment. The main issue decided was whether the peer review report submitted by the insurance company was in admissible form, and if it raised a triable issue of fact. The holding of the court was that the insurance company failed to raise a triable issue of fact with respect to the claim at issue, as the peer review report submitted was not in admissible form. The judgment of the lower court was affirmed, and the decision was based on the failure of the insurance company to properly deny the claim based on a peer review report that was not in admissible form.

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits, and defendant had denied plaintiff's claims based on lack of medical necessity. The main issues decided in the case were whether defendant had established timely mailing of denial of claim forms, and whether the supplies provided by plaintiff were medically necessary. The holding of the case was that the defendant's cross motion for summary judgment was granted to dismiss the complaint seeking the sum of $925.75, as it was established that the supplies for that amount were not medically necessary. However, the defendant was not entitled to summary judgment for the claim seeking the sum of $235.63, as it was not established that those supplies were medically unnecessary.

The main issue in this case was the medical necessity of nerve testing of the assignor's upper and lower extremities in an action by a provider to recover assigned first-party no-fault benefits. The court considered the stipulated prima facie case of the plaintiff, the timely and proper denial of the claims by the defendant, and the dispute over the claims for certain diagnostic testing. The trial court entered into evidence the claim forms, denial of claim forms, and the transcript of the deposition testimony of defendant's peer review doctor. After the trial, the court awarded the judgment in the principal sum of $33.55 to the plaintiff. The appellate court affirmed the judgment, stating that the defendant's peer review doctor established a lack of medical necessity for the medical services, and the plaintiff did not offer any rebuttal evidence to show that the services were medically necessary.

The main issue in this case was whether the plaintiff was required to provide the defendant with an authorization executed by its assignor in order to obtain discovery of the defendant's no-fault file, and whether the plaintiff was responsible for the costs of reproduction of said file. The court dismissed the appeal from the order, stating that no appeal as of right lies from an order which decides a motion that was not made on notice. The court clarified that a motion is made on notice when a notice of motion or an order to show cause is served, and since no notice of motion or order to show cause was served in this case, the appeal was dismissed. The decision was made by Rudolph, P.J., McCabe and Scheinkman, JJ., and the appeal was dismissed.

The facts of the case involved a dispute between Multiquest, P.L.L.C. and Allstate Insurance Company over the reimbursement of first-party no-fault benefits for psychological services rendered in August and September 1999. The main issue decided was whether Multiquest was eligible to receive reimbursement for these services, as Allstate alleged that Multiquest was fraudulently incorporated. The court held that an Insurance Department Regulation was inapplicable to claims for services rendered prior to April 4, 2002, and in a similar case, it was held that the Regulation should be given retroactive effect. However, Allstate established that Multiquest had performed the psychological services in violation of Limited Liability Company Law, thus making them ineligible for reimbursement of no-fault benefits. The holding of the case was that Multiquest was ineligible to obtain reimbursement of the benefits and Allstate was entitled to summary judgment dismissing the complaint.

The relevant facts considered by the court in the case of Quality Health Products, Inc. v Auto One Insurance Company were that the plaintiff sought to recover first-party no-fault benefits that had been assigned to them. The main issue that was decided was whether the defendant, Auto One Insurance Company, had timely determined the plaintiff's claim for benefits. The holding of the court was that the plaintiff had established a prima facie entitlement to summary judgment, and therefore, the motion for summary judgment was granted. The court also determined that the defendant's denial of the claim was untimely, and as a result, the defendant was precluded from raising fraudulent billing as a defense in the action. The matter was remanded to the lower court for the calculation of statutory interest and an assessment of attorney's fees.

The court considered the defendant's motion to strike the plaintiff's complaint or to compel discovery, specifically seeking the production of plaintiff's certificate of incorporation, answers to written interrogatories, and an examination before trial of plaintiff's owner, Valentina Anikeyeva. Defendant had sent a good-faith letter requesting the discovery, but plaintiff rejected the demands. The court denied defendant's motion, but modified the order to compel plaintiff to produce certain requested information and to allow an examination before trial. Defendant's entitlement to discovery was based on detailed reasons to believe that plaintiff was fraudulently incorporated and ineligible for no-fault benefits. The court held that plaintiff's failure to challenge the discovery demands within the prescribed time obligated them to produce the requested information, except for matters which were palpably improper or privileged. Defendant was entitled to production of plaintiff's certificate of incorporation and certain interrogatory answers to ascertain plaintiff's eligibility for reimbursement of no-fault benefits. The court also found special circumstances that warranted the disclosure of plaintiff's corporate income tax returns. However, the defendant's motion to compel production of Anikeyeva's personal income tax returns was denied at that time, but Justice Golia dissented in part, arguing that the unique circumstances of the case justified the need for such disclosure.