No-Fault Case Law

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.

The relevant facts considered by the court were that Westchester Medical Center (WMC) was seeking payment for medical services provided to Jose Correa, as an assignee of Correa's claim for no-fault benefits. It was undisputed that WMC billed Allstate Insurance Company for $121,755.40 for Correa's admission, and Allstate made a partial payment of $37,560.01, leaving an unpaid balance of $84,195.39. The main issue decided was whether WMC was entitled to the balance of the payment from Allstate, and the holding was that WMC's motion for summary judgment was denied, while Allstate's motion for summary judgment was granted and the complaint was dismissed. The court found that Allstate had provided sufficient evidence that its coverage limits had been exhausted, and therefore it was not liable for the charges sought by WMC. Furthermore, the court held that WMC had presented no evidence to place in issue the proof of exhaustion of benefits as a complete defense to its claim. Therefore, summary judgment was granted to the defendant, Allstate.

The main issues considered in this case were whether plaintiff was entitled to partial summary judgment in the principal sum of $2,243.46 in an action to recover assigned first-party no-fault benefits, and whether defendant was entitled to summary judgment. The court below granted partial summary judgment to the plaintiff and denied the defendant's cross motion for summary judgment. On appeal, the defendant argued that the affidavit submitted by plaintiff's corporate officer did not lay a proper foundation for the admission of the documents annexed to plaintiff's moving papers, and therefore plaintiff failed to establish a prima facie case. The court agreed, finding that plaintiff failed to make a prima facie showing of its entitlement to summary judgment. The defendant also failed to demonstrate as a matter of law its entitlement to summary judgment, as it did not sufficiently establish that it mailed the verification requests and follow-up verification requests, or set forth a standard office practice or procedure designed to ensure that such items were properly addressed and mailed. As a result, the court properly denied defendant's cross motion for summary judgment. Therefore, the holding of this case was that plaintiff's motion for summary judgment was denied, and defendant's cross motion for summary judgment was affirmed.

The relevant facts considered by the court were that Rockaway Medical & Diagnostic, P.C. was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Insurance Co. The main issue decided was whether State Farm Mutual Insurance Co. had provided sufficient evidence to demonstrate that there was an issue of fact as to whether the injuries sustained by plaintiff's assignor arose from an insured incident. The holding of the case was that the affidavit submitted by defendant's investigator was sufficient to demonstrate a "founded belief that the alleged injuries do not arise out of an insured incident", thus defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, and therefore plaintiff was not entitled to summary judgment.

The court considered the petition to vacate the master arbitrator's award in a case involving a dispute over first-party no-fault benefits. The main issue decided was whether there was a rational basis for the master arbitrator's determination upholding the arbitrator's award, which denied the petitioner's claims for benefits. The court found a rational basis for the master arbitrator's determination and upheld the denial of the petitioner's claims. The holding of the case was that the judgment was modified to add a provision confirming the master arbitrator's award, and as modified, it was affirmed without costs. The court also stated that the lower court properly denied the petition to vacate the master arbitrator's award, and pursuant to CPLR 7511 (e), was required to confirm the award.

The court in this case considered whether three MRIs performed on an automobile accident victim were eligible for first-party no-fault benefits. The insurance company, the defendant, denied the claims based on a low-impact study and the affidavit of an engineer. The main issue was whether the low-impact study was sufficient to deny summary judgment in a first-party no-fault action, where the plaintiff has made a prima facie showing of entitlement to judgment. The court ruled that the low-impact study and the engineer's affidavit were not sufficient, as they were conducted without a medical file review or an independent assessment of the injuries. The court held that the insurance company failed to provide medical evidence to demonstrate that the claimed injuries had no nexus to the accident, and therefore, summary judgment was awarded to the plaintiff medical provider.

The main issue in this case was whether the petitioner, Health & Endurance Medical, P.C., was entitled to direct payment of no-fault insurance benefits as a "provider of health care services" under the relevant regulations. After arbitration, it was determined that HEM was not a provider of health care services and, therefore, not entitled to direct payment of the benefits. The Supreme Court denied HEM's petition to vacate the award of the master arbitrator. However, the Appellate Division reversed the decision and vacated the awards of the master arbitrator and arbitrator, remitting the matter to the arbitrator for further proceedings. It was determined that the arbitrator had improperly raised the issue of the applicability of the regulations, and had not ruled on the only issue raised by the respondent, Deerbrook, relating to the need for the services in question.

The main issues in this case were a denial of a claim for first-party no-fault benefits by an insurance company, and a petition to vacate the master arbitrator's award upholding the denial. The court considered the rational basis for the determination of the master arbitrator in upholding the denial of benefits. The holding of the case was that there was a rational basis for the master arbitrator's determination, and the court properly denied the petition to vacate the award. However, the court also modified the judgment by confirming the master arbitrator's award, as required by the CPLR, thus affirming the denial of the first-party no-fault benefits.