No-Fault Case Law
Vinings Spinal Diagnostics v Progressive Cas. Ins. Co. (2008 NY Slip Op 51468(U))
April 29, 2008
The court considered the appeal from an order of the District Court of Nassau County, where the order denied the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment dismissing the complaint. The main issues decided were whether the plaintiff had made a sufficient showing of entitlement to summary judgment and whether the defendant's denial of claim form was timely. The court held that the plaintiff failed to make a prima facie showing of its entitlement to summary judgment because the affidavit submitted by the plaintiff's owner was insufficiently specific. However, the court also held that the defendant's cross motion for summary judgment dismissing the complaint was denied because there was an issue of fact as to whether the defendant's denial of claim form was timely. Therefore, the order was modified to deny the defendant's cross motion for summary judgment dismissing the complaint.
St. Vincent’s Hosp. of Richmond v Government Empls. Ins. Co. (2008 NY Slip Op 04072)
April 29, 2008
The court considered an action to recover no-fault medical payments, and the plaintiff's motion for summary judgment on the complaint was denied, resulting in the appeal. The main issue decided was whether the plaintiff had established its entitlement to judgment as a matter of law, and whether the defendant had submitted admissible evidence in opposition to the plaintiff's motion. The holding of the case was that the defendant raised a triable issue of fact as to whether it issued a proper denial of claim form, and the excerpts of the insured's medical records submitted by the defendant in opposition to its motion constituted admissible evidence sufficient to raise a triable issue of fact as to whether the defendant was entitled to deny the claim. Therefore, the order was affirmed insofar as appealed from.
A Khodadadi Radiology, P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 50910(U))
April 25, 2008
The court considered the fact that the plaintiff, a provider, had filed a motion for summary judgment to recover first-party no-fault benefits, but the defendant had timely denied the claim based on a peer review report stating that the services provided were not medically necessary. The main issue decided was whether the denial of the claim form was timely mailed according to the defendant's standard office practice and procedure, and whether the peer review report submitted by the defendant was sufficient to demonstrate an issue of fact with respect to the defense of lack of medical necessity. The holding of the case was that the denial of claim form was found to have been timely mailed, and the peer review report submitted by the defendant was deemed to be enough to show the existence of an issue of fact, so the order denying the plaintiff's motion for summary judgment was affirmed.
City Wide Social Work & Psychological Servs., P.L.L.C. v State-Wide Ins. Co. (2008 NY Slip Op 50909(U))
April 25, 2008
The relevant facts considered by the court were that plaintiff, City Wide Social Work and Psychological Services, P.L.L.C., sought to recover assigned first-party no-fault benefits, and defendant, State-Wide Ins. Co., failed to submit opposition to plaintiff's motion for summary judgment, resulting in the entry of a default judgment against defendant. The main issue decided was whether defendant's motion to vacate the default judgment should be granted. The court held that the default judgment should not be vacated, as defendant failed to demonstrate a reasonable excuse for its default and a meritorious defense to the action. The court found that defendant did not show that its proffered defenses were set forth in timely denial of claim forms, as required by Insurance Department Regulations, or that defendant possessed a defense which was not subject to preclusion. Therefore, defendant's motion to vacate the default judgment was denied.
State Farm Mut. Auto. Ins. Co. v Clouden (2008 NY Slip Op 03823)
April 25, 2008
The issue in the case was whether the Supreme Court erred in denying the dismissal of the claims to recover PIP and APIP benefits. Defendant James W. Celotto contended that Supreme Court made an error in denying his cross motion seeking dismissal of the claims. However, the court found that the complaint was never amended and did not contain any such claims. Therefore, it concluded that the court properly denied the cross motion. The Appellate Division, Fourth Department affirmed the order of Supreme Court, holding that there was no error in denying the cross motion for dismissal of the claims. Therefore, the complaint containing the claims to recover PIP and APIP benefits could not be dismissed.
Boris Kleyman, P.C. v Kemper Ins. Co. (2008 NY Slip Op 50877(U))
April 24, 2008
The court considered whether the plaintiff was entitled to summary judgment in a case to recover assigned first-party no-fault benefits. The main issue was whether the services rendered were medically necessary, and the court ultimately held that the plaintiff was entitled to summary judgment. The court found that the plaintiff had established its entitlement to summary judgment by proving the submission of a statutory claim form and that payment of no-fault benefits was overdue. The burden then shifted to the defendant to raise a triable issue of fact, but the peer review reports submitted by the defendant were found to be illegible, and therefore failed to demonstrate the existence of a triable issue of fact as to medical necessity. As a result, the plaintiff's motion for summary judgment was granted.
A.T. Med., P.C. v State Farm Ins. Co. (2008 NY Slip Op 50875(U))
April 24, 2008
The relevant facts of the case include that the plaintiff, A.T. Medical, P.C., sought to recover first-party no-fault benefits as an assignee of an individual. The court granted the plaintiff's motion for summary judgment, awarding them $3,458.29. However, the defendant, State Farm Insurance Company, appealed the decision, arguing that an injunction issued by Justice Kenneth Davis barred the plaintiff from commencing suit against them to recover the benefits. The Appellate Term agreed with the defendant, finding that the injunction indeed barred the plaintiff from making the summary judgment motion. As a result, the judgment was reversed, the order granting summary judgment was vacated, and the plaintiff's motion for summary judgment was denied without prejudice. Therefore, the plaintiff's motion for summary judgment was ultimately unsuccessful due to the injunction.
Executive MRI Imaging, P.C. v State Farm Ins. Co. (2008 NY Slip Op 50902(U))
April 21, 2008
The court considered the affidavit submitted by plaintiff's corporate officer in support of their motion for summary judgment, which failed to lay a proper foundation for the admission of the documents annexed to the moving papers. The main issue decided was whether the affidavit was sufficient to establish personal knowledge of the plaintiff's practices and procedures to lay a foundation for the admission of the documents as business records. The holding was that the affidavit submitted was insufficient, and as a result, the plaintiff failed to make a prima facie showing of their entitlement to summary judgment. Therefore, the court reversed the order granting plaintiff's motion for summary judgment and denied the motion.
Orthotic Surgical & Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 50869(U))
April 14, 2008
The court considered the case of Orthotic Surgical & Medical Supply, Inc. v GEICO Ins. Co. where the plaintiff was seeking to recover first-party no-fault benefits. The main issue decided was whether the affidavit submitted by an employee of plaintiff's former attorney laid a proper foundation for the documents annexed to plaintiff's moving papers, and whether the plaintiff failed to establish a prima facie case. The holding of the court was that the affidavit submitted was insufficient to establish that the employee possessed personal knowledge of the plaintiff's practices and procedures, and therefore failed to lay a foundation for the admission of the documents as business records. As a result, the plaintiff failed to make a prima facie showing of its entitlement to summary judgment. The judgment was reversed, the order granting the plaintiff's motion for summary judgment was vacated, and the plaintiff's motion for summary judgment was denied.
Health & Endurance Med., P.C. v Liberty Mut. Ins. Co. (2008 NY Slip Op 50864(U))
April 14, 2008
The main issue in this case was whether a billing provider could recover no-fault benefits for services performed by an independent contractor. The court considered the fact that the plaintiff was seeking to recover for services performed by an independent contractor and that the claim forms submitted by the plaintiff stated that the treating professional was an independent contractor. The court held that where a billing provider seeks to recover no-fault benefits for services not rendered by it or its employees, but by an independent contractor, it is not considered a "provider" of the medical services within the meaning of Insurance Department Regulations and is not entitled to recover "direct payment" of assigned no-fault benefits from the defendant insurer. Therefore, the court affirmed the order denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint.