No-Fault Case Law

The court considered the appeal of Forrest Chen Acupuncture Services, P.C. as assignee of Igor Makler against Allstate Insurance Company, in which Forrest Chen Acupuncture Services sought to recover assigned first-party no-fault benefits. The main issue was whether the defendant's defenses were precluded by a defective denial of claim form. The court held that plaintiff made a prima facie showing for all purposes pursuant to CPLR 3212 (g), and since the defendant did not submit any opposition, plaintiff's motion for summary judgment should have been granted. The holding of the case was that the plaintiff's motion for summary judgment was granted, and the matter was remanded to the court for the calculation of statutory interest and an assessment of attorney's fees.

The Appellate Term, Second Department made a decision on November 20, 2007 in the case of Walter Karpinski Acupuncture, P.C. v Progressive Casualty Insurance Co. The main issue in the case was whether the provider had established a prima facie case to recover assigned first-party no-fault benefits. The court considered the affidavit by the plaintiff's officer, which stated in a conclusory manner that the documents attached to the motion papers were the plaintiff's business records. The court held that the affidavit submitted by the plaintiff's officer was insufficient to establish that the officer possessed personal knowledge of the plaintiff's practices and procedures, so as to lay a foundation for the admission of the documents as business records. As a result, the court affirmed the denial of the plaintiff's motion for summary judgment.

The court considered that a hospital was seeking to recover no-fault insurance benefits for services provided to a patient injured in a motor vehicle accident. The insurance company failed to request verification of the patient's assignment of benefits to the hospital in a timely manner, and the hospital filed a lawsuit against the insurance company for nonpayment. The main issue was whether the insurance company was precluded from contesting the validity of the assignment due to its failure to timely contest any deficiency in the assignment documents. The court held that the insurance company's failure to seek verification of the assignment in a timely manner precluded the carrier from contesting the issue, and thus affirmed the order of the Appellate Division.

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.