No-Fault Case Law

The court considered a motion for summary judgment by the defendant to dismiss the complaint or, in the alternative, for an order compelling plaintiffs to respond to its discovery demands on Mallella issues. The plaintiffs sought to recover first-party No-Fault benefits for medical services allegedly rendered to their assignor following an automobile accident. The defendant contended that the incident was an intentionally caused loss and sought summary judgment dismissing the complaint. The court denied the defendant's motion for summary judgment, stating that cases where summary judgment could be granted to the defendant based upon a lack of coverage/staged accident defense supported by an investigator's affidavit were unavailable. The court also granted the defendant's motion to compel discovery, ordering the deposition of one of the plaintiffs' physicians, but did not find a basis to order any other depositions at that time.

The main issue in this case was whether the defendant demonstrated proper proof of mailing of denial of claim forms within the required time frame. The plaintiff had commenced the action to recover no-fault first party benefits for health care services provided to its assignor following a car accident. The defendant moved for summary judgment, claiming that the chiropractic and acupuncture services provided were not medically necessary based on a physical examination. The court held that the defendant failed to establish proper proof of mailing of the denial of claim forms within thirty days of receipt, as required by law, and therefore denied the motion for summary judgment. The court found that the defendant's affidavit did not demonstrate personal knowledge of the actual mailing, and the defendant's standard office practice and procedure did not ensure that items were properly addressed and mailed.

The court considered a provider's attempt to recover assigned first-party no-fault benefits and denied the plaintiff's motion for summary judgment, finding it premature. The court also denied the defendant's cross motion for summary judgment. However, subsequent to the court's decision, the Civil Court dismissed the action, rendering the appeal academic. As a result, the plaintiff's appeal was dismissed. The main issue decided was whether the denial of the plaintiff's motion for summary judgment was premature, and the holding was that the appeal was dismissed as academic due to the subsequent dismissal of the action.

The court considered the determination of the master arbitrator upholding the arbitrator's award, which denied the petitioner's claim for assigned first-party no-fault benefits. The main issue decided was whether the master arbitrator's decision had a rational basis and was not arbitrary and capricious. The holding of the case was that the court affirmed the order without costs, stating that upon a review of the record, they found that the master arbitrator's determination had a rational basis and was not arbitrary and capricious. Therefore, the court properly denied the petition to vacate the master arbitrator's award and granted the cross petition to confirm the award.

The main issue in this case was whether the plaintiff had made a prima facie showing in their motion for summary judgment to recover first-party no-fault insurance benefits. The court considered the admissibility of the plaintiff's claim form, which was annexed to their motion papers. The court ruled that the affirmation of the plaintiff's counsel did not lay a sufficient foundation to establish the claim form's admissibility under the business records exception to the hearsay rule. As a result, the court reversed the judgment, vacated the order granting summary judgment, and denied the plaintiff's motion for summary judgment. The court did not grant the defendant's request to award summary judgment dismissing the complaint, and ultimately, the judgment in favor of the plaintiff was reversed.

The court considered a motion for summary judgment by the plaintiff and a cross-motion for summary judgment by the defendant regarding a claim for first-party no-fault benefits. The defendant had denied the claim on the grounds of lack of medical necessity and had paid only a portion of the claim. The main issue decided was whether the defendant had established a lack of medical necessity and whether their denial of the claim was timely. The holding of the court was that the defendant had established a lack of medical necessity based on an affirmed peer review report, and since the plaintiff did not present any evidence to refute this, the defendant's cross-motion for summary judgment dismissing the complaint was granted. The court affirmed the order without costs.

The relevant facts the court considered in this case were that Park Slope Medical and Surgical Supply, Inc. brought this action to recover the sum of $817.25 for medical equipment provided to its assignor. Country-Wide Insurance Company argued that Park Slope failed to comply with verification requests for NF-3s and an assignment of benefits, and the complaint should be dismissed as it was prematurely filed. The main issues decided were whether the insurance carrier was required to send a second verification request until thirty days had elapsed since the first request and whether the thirty-day period for an insurer to pay or deny a claim was tolled in this case. The holding was that the insurance carrier's follow-up verification request on the 30th day after the original request for verification was considered timely and in accordance with regulations, and therefore the action was dismissed.

The civil court case of All-Boro Med. Supplies, Inc. v Progressive Northeastern Ins. Co. involved a dispute over the denial of a claim of first-party no-fault benefits in the amount of $442.50 by plaintiff All-Boro Medical Supplies, Inc., as an assignee of Tony Stringer, due to the failure of Mr. Stringer to appear for an examination under oath (EUO) on multiple occasions. The court considered whether the failure to appear for the EUO constituted a valid basis for denial of the claim. The main issue decided by the court was whether the insurer had the right to schedule an EUO of Mr. Stringer before it had received the claim, and whether the defendant was required to adhere to the statutory and regulatory scheme for the processing of no-fault claims. The holding of the court was that the failure to appear for the EUO was not a valid basis for denial of the claim. It was decided that the plaintiff was entitled to judgment as a matter of law in the amount of $442.50, together with interest and attorneys fees pursuant to Insurance Law § 5106 and regulations promulgated thereunder, plus costs and disbursements.

The case involved Westchester Medical Center suing Progressive Casualty Insurance Company to recover no-fault medical payments. The plaintiff alleged that the defendant failed to either pay or deny its claim within 30 days as required by Insurance Law. The defendant argued that the 30-day period in which to pay or deny the claim was not triggered until it received requested medical records and also claimed Forthmuller was driving while intoxicated at the time of the accident. The court found that the plaintiff made a prima facie showing of its entitlement to judgment but the defendant raised a triable issue of fact regarding the timely denial of the claim and Forthmuller's alleged intoxication and its role in the accident. The court modified the lower court order and denied the defendant's cross motion for summary judgment dismissing the first cause of action, affirming the judgment of the Supreme Court.

The case involved a dispute over no-fault medical benefits under an insurance contract after a woman was injured in an accident and treated at a hospital. The insurance company requested information about the woman's blood alcohol level at the time of the accident, but did not receive a response. The insurance company later denied the claim on the grounds that the woman was driving while intoxicated, which prompted the hospital to file a lawsuit to recover the no-fault benefits. The main issue was whether the insurance company was entitled to all available information relating to the woman's condition at the time of the accident, and whether the woman's intoxication was the cause of her accident and injuries. The court held that the insurance company's verification requests were not untimely or improper and that the woman's intoxication was not proven to be the cause of her accident, so the denial of the claim was upheld and the hospital's motion for summary judgment was denied.