No-Fault Case Law

The court considered the pretrial motion to preclude defendant's denial of claim forms and directed judgment in favor of the plaintiff in the principal sum of $8,715.82 in an action to recover first-party no-fault benefits. The main issue decided was whether defendant's NF-10 forms, which stated that each claim was denied based on an independent consultant's review, sufficiently apprised the plaintiff of the factual basis for the denials, in accordance with 11 NYCRR 65-3.8 (b)(4). The holding of the court was that defendant's NF-10 forms did sufficiently apprise the plaintiff of the factual basis for the denials, and therefore the motion to preclude defendant's NF-10 denial of claim forms should have been denied. The court reversed the order, denied the motion, and remanded the matter for further proceedings.

The relevant facts of this case involved the Plaintiff, Elmont Open MRI & Diagnostic Radiology, seeking to recover no-fault first party benefits in the amount of $879.73 for medical services allegedly provided to its assignor following a motor vehicle accident. The Plaintiff moved for summary judgment, but the Defendant opposed the motion and cross-moved for summary judgment as well. The court considered the submission of admissible evidence and the timely and proper submission of claims in question. The main issues decided were whether the Plaintiff had demonstrated its timely and proper submission of claims and whether the Defendant had timely issued a proper denial of claim form. The court held that the Plaintiff failed to make a proper evidentiary foundation for the introduction of its claim forms and that the Defendant's N-F 10 form was neither timely, proper, nor approved by the Insurance Department. As a result, both the Plaintiff's motion for summary judgment and the Defendant's cross-motion for summary judgment were denied. In summary, the court decided that the Defendant's N-F 10 form was not valid, and the Plaintiff failed to meet its burden for summary judgment. As a result, neither party was granted summary judgment.

The main issue in the case was the proper method of calculating statutory attorney's fees to be awarded to the plaintiff. The defendant argued that the court should aggregate the plaintiff's fifteen cause of action/claims and award attorney's fees as 20% of the aggregate amount of the bills encompassed in the complaint, with a maximum award capped at $850. The plaintiff argued that it is entitled to separate attorney's fees for each bill submitted and overdue, on each of the fifteen separate causes of action. The court relied on Regulation 11 NYCRR §65-4.6 (e) of the Insurance Law, which governs attorney's fees in no-fault actions, and previous case law to determine that the plaintiff is entitled to attorney's fees on a per claim basis for each odd numbered cause of action, at the rate of twenty percent of the amount settled for each claim, with a maximum of $850 per claim. Therefore, the holding of the case was that the plaintiff is entitled to attorney's fees on a per claim basis for each of the fifteen separate causes of action, with a maximum of $850 per claim.

The court considered the fact that 563 Grand Medical, P.C. commenced a proceeding pursuant to CPLR 7511 to vacate a master arbitrator's award which denied its claims for assigned first-party no-fault benefits. The main issue decided was whether the master arbitrator had a rational basis for finding that petitioner was not entitled to recover the benefits. The holding was that the master arbitrator's determination was not arbitrary, capricious, or irrational, and therefore the court properly denied the petition to vacate the master arbitrator's award. However, the court was required, pursuant to CPLR 7511 (e), to confirm the award.

The main issue in Delta Diagnostic Radiology, P.C. v Progressive Cas. Ins. Co. was whether the provider, Delta Diagnostic Radiology, P.C., was entitled to recover assigned first-party no-fault benefits from Progressive Casualty Insurance Co. The court considered that the affidavit submitted by Delta Diagnostic's officer was insufficient to establish that the officer possessed personal knowledge of the company's practices and procedures to lay a foundation for the admission of the documents attached to the motion papers as business records. The main holding of the case was that Delta Diagnostic failed to make a prima facie showing of its entitlement to summary judgment, and therefore the order denying their motion for summary judgment was affirmed, albeit on other grounds. Consequently, the denial of the motion for summary judgment was upheld by the court.

The court considered a dispute about the provision of no-fault first party benefits by the Plaintiff to its assignor, who had been injured in a motor vehicle accident while occupying a U-Haul vehicle on February 11, 2002. Republic Western Insurance Company (Republic Western) filed a motion to dismiss the action as untimely based on the applicable statute of limitations, arguing that the Plaintiff's cause of action ripened no later than October 9, 2002, and the action, commenced on April 17, 2006, was time-barred. Republic Western asserted that it was the self-insurer for U-Haul and was entitled to the application of a three-year statute of limitations. The Plaintiff argued that Republic Western failed to demonstrate that it is a self-insurer and that, even if it was, its obligations to pay for no-fault first party benefits is "firmly rooted in contract." The decision of the court was that a claim for no-fault first party benefits against a self-insured motor vehicle rental company will be subject to the six-year statute of limitation provided by CPLR § 213(2), and the motion of Republic Western to dismiss the action as untimely was denied.

The court considered the fact that St. Vincent's Hospital of Richmond and Lenox Hill Hospital filed a motion for summary judgment. St. Vincent's Hospital argued that payment of no fault benefits was overdue, while Lenox Hill Hospital sought to join the lawsuit based on a uniform policy of insurance. The main issues decided were whether St. Vincent's Hospital was entitled to summary judgment for the unpaid balance of a patient's bill, and whether Lenox Hill Hospital could join the lawsuit against State Farm Mutual Automobile Insurance Company. The holding was that a question of fact existed with respect to whether the fees charged by St. Vincent's Hospital were in excess of the Workers' Compensation fee schedule, and therefore a hearing was necessary to determine how much should have been billed. The court also decided to sever the second cause of action and allow Lenox Hill Hospital to proceed with a separate lawsuit against State Farm Mutual Automobile Insurance Company.

The case involves an action to recover assigned first-party no-fault benefits. The plaintiff, Delta Diagnostic Radiology, P.C., sought summary judgment, which was denied by the court. The plaintiff's motion for summary judgment was denied because the affidavit executed by plaintiff's corporate officer was insufficient to establish a foundation for the admission of documents as business records. Defendant's cross motion for summary judgment was granted due to plaintiff's failure to provide evidence rebutting the peer review report annexed to defendant's cross motion. The court found that there was no medical necessity for the MRIs performed by the plaintiff, as established by the defendant's peer review report. The court ultimately affirmed the order without costs. Ultimately, the court held that the plaintiff failed to make a prima facie showing of entitlement to summary judgment and that the defendant's cross motion for summary judgment was properly granted due to the plaintiff's failure to rebut the evidence provided by the defendant's peer review report.

The main issue in this case was whether the rationale for the conclusion in the peer review reports, upon which the defendant's denial of claim forms was based, was correct. The court considered the fact that the defendant timely mailed the two denial of claim forms at issue which stated that the plaintiff's claims were denied, based upon peer reviews, on the ground of lack of medical necessity. Plaintiff moved to preclude testimony by the medical expert proffered by the defendant on the grounds that his opinion would be hearsay and that plaintiff would be prejudiced by its inability to cross-examine the doctors who prepared the peer review reports upon which plaintiff's claims were denied. The court granted plaintiff's motion to preclude testimony by defendant's medical expert. The holding of the case was that the judgment was reversed and a new trial was ordered.

The court considered the facts that Delta Diagnostic Radiology, P.C. sought to recover assigned first-party no-fault benefits from Progressive Casualty Insurance Co. and that the defendant had initially denied plaintiff's claim for $879.73 but later paid it after the 30-day claim determination period. The main issue decided was whether the plaintiff was entitled to recover statutory interest and attorney's fees on the $879.73 claim. The holding of the case was that the plaintiff was entitled to summary judgment upon that portion of its cause of action seeking statutory interest and attorney's fees on the claim for $879.73, and the matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees due thereon, and for all further proceedings on the remaining claims.