No-Fault Case Law

The facts of the case involved plaintiff Nicholas Raffellini, who suffered back injuries in a car accident and sought recovery for damages under the supplementary uninsured/underinsured motorist (SUM) endorsement to his State Farm insurance policy. State Farm refused the demand for $75,000 in pain and suffering damages, claiming that he did not sustain a "serious injury" and therefore, his exclusive remedy was the receipt of no-fault benefits. The court considered whether a "serious injury" exclusion in the SUM endorsement was enforceable, and concluded that it is. The court held that the serious injury exclusion, as required by Regulation 35-D, which was promulgated by the Superintendent of Insurance, is consistent with the statutory language and its underlying purposes. Therefore, the order of the Appellate Division was reversed, and plaintiff's motion to strike defendant's fifth affirmative defense was denied. The decision was to reinstate State Farm's serious injury defense and hold the insurer entitled to pursue its serious injury defense.

The court considered the issue of whether the plaintiff was entitled to summary judgment on the complaint seeking no-fault medical payments. The plaintiff demonstrated their entitlement to judgment through billing forms, affidavits from billers, certified mail receipts, and signed return receipt cards which demonstrated that the defendant received the proof of the claims but failed to pay the bills or issue a denial of claim within the 30-day period required by law. The defendant failed to raise a triable issue of fact and did not make a showing of entitlement to judgment as a matter of law. The defendant's submissions were insufficient to establish that a verification request was received by the proper party. Thus, the court held in favor of the plaintiff and awarded them $13,491.40.

The court considered whether an "NF-10" denial of claim form issued by the defendant in response to a medical payment denial complaint was sufficiently specific to qualify as a valid denial. Additionally, they decided if the defendant, who failed to serve a sufficient "NF-10" denial of claim form within the critical 30-day period, should be precluded from denying the claim. The Court held that the plaintiff had failed to establish that the "NF-10" denial of claim form was not a proper response and that it was issued within the required 30 days specified by the Insurance Law. Based on this, the plaintiff failed to establish its entitlement to summary judgment, and the Court declined to take judicial notice of certain diagnostic codes contained on the "UB-92" form. Therefore, the order denying the plaintiff's motion for summary judgment on the complaint was affirmed.

The court considered a case about recouping no-fault benefits. The parties stipulated that the plaintiff's prima facie case was established, the defendant's denial claim forms were mailed on time, and the examination under oath was a point of contention. The main issue was whether the defendant's request for an examination under oath was scheduled within the correct time frame, and if the defendant's expert testimony was convincing. The court found that the examination under oath was not scheduled within the required time period of 30 days, and that the defendant's expert's testimony was not persuasive. Therefore, the court held in favor of the plaintiff, awarding them $822 for each case along with interest and attorney's fees.

The court considered the fact that Westchester Medical Center sought payment of no-fault medical insurance benefits for services rendered to Christopher Andrews and Michael Mascolo. Westchester Medical Center claimed that it provided medical services to Christopher Andrews and billed Encompass Insurance Company for those services, which Encompass Insurance Company failed to pay or deny. Westchester Medical Center sought summary judgment pursuant to Insurance Law § 5106(a) and 11 NYCRR 65-3.8(a)(1), as well as attorneys fees pursuant to 11 NYCRR 65-4.6(e. The main issue decided was whether Westchester Medical Center was entitled to summary judgment for the payment of no-fault medical insurance benefits. The court held that Westchester Medical Center was entitled to summary judgment in the amount of $11,733.84 as and for its claims asserted o/b/o Christopher Andrews, as well as attorney's fees. The cross-motion by Encompass Insurance Company and Alstate Insurance Company for an order granting them summary judgment dismissing the complaint against them was denied.

Relevant facts the court considered were that the plaintiff sought to collect money owed under first-party no-fault benefits from the defendant but failed to present any witnesses at the trial. The case hinged on whether or not the services for which the plaintiff sought compensation were medically necessary. Defendant answered the plaintiff's notice to admit, admitting the receipt of certain materials but reserving its right to challenge the validity of the plaintiff's documentary evidence at trial. Recent case law suggested that the formalities surrounding the introduction of business records into evidence must be observed. The court denied the plaintiff's motion for judgment in its favor and granted the defendant's motion to dismiss the complaint.

The relevant facts the court considered in this case were that Westmed Physician, P.C. sought to recover first party no-fault benefits totaling $1,350.20 for medical services rendered to its assignor on April 25, 2002 and May 16, 2002. However, the plaintiff's submissions were not sufficient to establish that it had mailed the $587.90 claim within the 180-day period prescribed by the governing insurance regulations. In support of its cross motion for summary judgment for the $587.90 claim, plaintiff submitted an affidavit of an employee stating that the bill was mailed on June 3, 2002, but this affidavit was deemed insufficient to establish the presumption of mailing. The main issue decided in the case was whether the plaintiff was entitled to recover the $587.90 claim for medical services rendered within the prescribed 180-day period, as required by the insurance regulations. The holding of the court was that plaintiff's motion for summary judgment should have been denied in its entirety, as its submissions were insufficient to establish that the claim was mailed within the 180-day period, and the affidavit provided was deemed insufficient to give rise to the presumption of mailing. Therefore, the appeal from the order of the Civil Court, which granted plaintiff's cross motion for summary judgment to the extent of awarding it the principal sum of $587.90, was modified to deny plaintiff's cross motion for summary judgment in its entirety.

The court considered two actions to recover first-party no-fault benefits in which defendant Travelers Insurance Company ("Travelers") made motions for summary judgment to dismiss the complaints. The issue at hand was whether the plaintiff, Ray Presutto, had provided medical treatment that was medically necessary to the injured party, Miguel A. Villatoro, and therefore entitled to receive benefits from Travelers. The court held that, based on an orthopedic evaluation, the defendant demonstrated that the services rendered were not medically necessary. In response, the plaintiff's submission was deemed conclusory and insufficient as proof to create a triable issue of fact requiring a trial. As a result, both of defendant's motions for summary judgment to dismiss the complaints were granted.

The court considered the plaintiff's motion for summary judgment in an action to recover assigned first-party no-fault benefits. The motion was supported by an affirmation from the plaintiff's counsel, an affirmation by the plaintiff, and various documents. The defendant argued that the affirmation by the plaintiff did not lay a proper foundation for the documents attached to the motion papers, and as a result, the plaintiff failed to establish a prima facie case. The main issue decided was whether the plaintiff made a prima facie showing of entitlement to summary judgment. The holding of the court was that the plaintiff failed to make a prima facie showing of entitlement to summary judgment, as the affirmation submitted by the plaintiff was insufficient to establish that he possessed personal knowledge of his office practices and procedures to lay a foundation for the admission of the documents as business records. Therefore, the judgment was reversed, the order granting plaintiff's motion for summary judgment was vacated, and the plaintiff's motion for summary judgment was denied.

The plaintiffs, Hospital for Joint Diseases, and other hospitals, sought to recover no-fault medical payments under insurance contracts. They filed an action against New York Central Mutual Fire Insurance Company, which requested additional information to verify the claims and made a timely follow-up request when the information was not received. The court considered whether the defendant acted within the statutory and regulatory framework governing the payment of no-fault automobile insurance benefits. The main issue was whether the defendant was obligated to pay or deny the plaintiff's claim within the 30-day period. The court held that since the requested verification was not provided, the 30-day period within which the defendant was obligated to pay or deny the claim did not begin to run, and thus, the first cause of action was premature. The order of the Supreme Court was affirmed, dismissing the first cause of action.