No-Fault Case Law

The main issue in this case was the payment of no-fault first-party benefits for medical services provided by Lenox Hill Radiology, as the assignee of Mr. Almadovar, which were allegedly unpaid by New York Central Mutual Fire Insurance Company. The court considered the plaintiff's performance of MRIs on the assignor and the bill submitted to the defendant for the services. The defendant had made a partial payment and denied the balance of the plaintiff's claim on the basis that the fees charged for the MRIs were in excess of the workers' compensation fee schedule. The main issue decided was that the defendant's motion for summary judgment was denied, while the plaintiff's cross motion for summary judgment was also denied. The court also granted dismissal of the defendant's second and third affirmative defenses, but denied the plaintiff's motion for sanctions against the defendant for alleged frivolous conduct. The holding of the case was that the defendant's motion for summary judgment was denied and the plaintiff's cross motion was also denied, while certain affirmative defenses were dismissed.

The court considered a case in which Alpha Chiropractic, P.C. sought to recover first-party no-fault benefits from State Farm Mutual Auto Insurance Company for medical services provided to various individuals. The main issue decided by the court was whether the attorney's fees awarded to the plaintiff should be based on each of the eight claims submitted for medical services or on the aggregate sum of the eight claims. The court held that the judgment of the Civil Court of the City of New York, Queens County, awarding plaintiff the principal sum of $1,200.53, plus interest and attorney's fees, was affirmed without costs. The court based its decision on a similar case, Fortune Med., P.C. v New York Cent. Mut. Fire Ins. Co., and concluded that the attorney's fees should be awarded upon each of the claims submitted for medical services provided to the assignor.

The court considered the fact that the defendant's documentary submissions were sufficient to give rise to a presumption that the defendant's verification requests were timely mailed and received by the plaintiff. The main issue decided was whether the plaintiff's claim for payment was premature, as the plaintiff did not respond to the defendant's verification requests, and an insurer is not required to pay or deny a claim until it receives verification of all relevant requested information. The holding of the case was that the defendant was entitled to summary judgment dismissing the action, as there was no triable issue as to whether the plaintiff provided the defendant with the requested information.

The court considered a lawsuit brought by One Beacon Insurance Group, LLC against various individual and professional entities, alleging a systematic scheme to defraud the insurance company. The plaintiff contended that the defendants were fraudulently incorporating medical corporations in order to obtain benefits from the plaintiff, and sought injunctive relief to stay all current and future proceedings against the defendants. The defendants, including the Halima et al. defendants and the Minick defendants, opposed the requested relief and sought dismissal and a change of venue. The court ultimately granted injunctive relief for the defaulting defendants and required documentation from appearing defendants to prove ownership by a licensed physician, denied the motions for dismissal by the Minick defendants, and denied the motion to change venue by Mark Slamowitz. The main issues decided in this case were the entitlement to injunctive relief, the sufficiency of the complaint to state a cause of action, and the appropriateness of the venue for the lawsuit. The holding of the court was to grant injunctive relief in favor of the plaintiff, deny the motions for dismissal, and deny the motion to change venue. The court also directed the defendants to provide documentation of ownership by a licensed physician for the professional corporations seeking no-fault benefits.

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.