No-Fault Case Law

The court considered the fact that the defendant insurer had admitted receiving the no-fault claims and had made partial payment on the claims. The main issue decided was whether the plaintiff had submitted proof that the claims had been mailed and received, and that they were overdue. The holding of the case was that the defendant insurer was not allowed to argue that the plaintiff had failed to submit the required proof, and that judgment was properly entered in favor of the plaintiff. The court also decided that the defendant waived any objections based on lack of proof of assignment since it did not seek verification of the assignment.

The relevant facts considered by the court in Umed Med., P.C. v State Farm Ins. Co. included an action by a provider to recover first-party no-fault benefits, and whether the insurer raised a triable issue of fact by proffering sufficient evidence to demonstrate a founded belief that the injuries did not arise out of an insured incident, but were staged. The main issue decided was whether the insurer's submission of a sworn affidavit of its special investigator was sufficient to demonstrate a founded belief, despite containing hearsay allegations. The holding of the case was that the branch of the plaintiff's motion seeking summary judgment on its third cause of action should have been denied, as the insurer's evidence was deemed insufficient to require a trial on material issues.

The court considered the fact that the plaintiff, IVB Medical Supply, Inc., sought to recover first-party no-fault benefits following an accident. The defendant, State Farm Mutual Insurance Co., argued that the insurance policy had been canceled prior to the accident. The main issue decided was whether the plaintiff was entitled to summary judgment, and whether the insurance policy had been validly canceled. The court held that the plaintiff failed to make a prima facie showing of entitlement to summary judgment, as the affidavit submitted did not prove the officer's personal knowledge of the company's practices. Additionally, the court found that the defendant did not meet its burden in proving the cancellation of the insurance policy, as it did not provide evidence that the cancellation notice was mailed. As a result, the court affirmed the denial of the plaintiff's motion for summary judgment and the rejection of the defendant's cross motion for summary judgment.

The relevant facts considered by the court in this case include the plaintiff's motion for summary judgment to recover assigned first-party no-fault benefits, which was supported by an affirmation of the plaintiff's counsel, an affidavit by a corporate officer of the plaintiff, and various documents attached to the motion papers. The defendant argued that the affidavit by the plaintiff's corporate officer failed to demonstrate personal knowledge of the facts set forth therein, and as a result, plaintiff failed to establish a prima facie case. The main issue decided by the court was whether the affidavit submitted by the plaintiff's corporate officer was sufficient to establish that the officer possessed personal knowledge of the plaintiff's practices and procedures to lay a foundation for the admissibility of the documents as business records. The court held that the affidavit was insufficient to establish personal knowledge, and therefore, plaintiff failed to make a prima facie showing of its entitlement to summary judgment. As a result, the motion for summary judgment was properly denied. Ultimately, the holding of the case was that the plaintiff failed to establish a prima facie case for summary judgment, and the denial of the motion for summary judgment was affirmed by the court.

The court considered the case of Forrest Chen Acupuncture Services, P.C. v. GEICO Insurance Co. in which the provider sought to recover assigned first-party no-fault benefits for acupuncture treatments provided in 2001. GEICO Insurance Co had paid the claims at a reduced rate, citing the absence of a fee schedule for such treatments and authorizing benefits at a "reasonable and customary fee for physical therapy." Plaintiff argued that this reduction was not authorized, but the court ruled in favor of the defendant, stating that the Superintendent of Insurance's interpretation of the regulations will be upheld in deference to his special competence and expertise with respect to the insurance industry unless it runs counter to the clear wording of a statutory provision. The court affirmed the denial of the plaintiff's motion for summary judgment and granted the defendant's cross motion for summary judgment based on Insurance Law § 5108 (b), which allows the insurer to determine that unusual procedures or unique circumstances justify an excess charge. The decision was made on April 26, 2007.

The court reversed the original judgment without costs and vacated the order entered on December 16, 2005. I & B Surgical Supply, an assignee of Jean Elie, commenced an action to recover $3,024.05 in first-party no-fault benefits for medical supplies. Defendant, New York Central Mutual Fire Ins. Co., moved for summary judgment to dismiss the plaintiff's claims for $1,280.30 and $1,017. The defendant's passive case established that the denial of these claims was timely and that the plaintiff did not establish the existence of a triable issue of fact. However, regarding another claim for $726.75, the defendant did not prove that its time to pay or deny the claim was tolled. The court held that the lower court improvidently considered and granted the plaintiff's cross motion for summary judgment and that plaintiff did not establish a triable issue of fact as to the aforementioned claims. Therefore, the motion for summary judgment was granted to the extent of awarding partial summary judgment dismissing plaintiff's claims for the sums of $1,280.30 and $1,017, and the matter was remanded for all further proceedings.

The relevant facts considered in this case involved an action to recover assigned first-party no-fault benefits by a plaintiff health care provider who sought full reimbursement for acupuncture services rendered by a licensed acupuncturist based on their billed amounts. The defendant, an insurer, had partially denied the plaintiff's claims, stating that the fees charged exceeded the maximum allowance under applicable fee schedules. The main issue decided in this case was the appropriate fee to be paid for acupuncture services rendered by a licensed acupuncturist. The court held that in the absence of a separate fee schedule for acupuncture services performed by licensed acupuncturists, the permissible charge for such services should be the prevailing fee in the geographic location of the provider, subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established by the superintendent. Ultimately, the judgment was reversed, the order granting plaintiff's motion for summary judgment was vacated, and plaintiff's motion for summary judgment was denied, with the action being dismissed in favor of the defendant.

The court considered whether the hospital was entitled to judgment as a matter of law in a case to recover no-fault insurance payments. The court held that the insurer raised triable issues of fact because it requested medical verification of the claim and timely denied it based on a peer review report. The court found that the insurer was not required to set forth a medical rationale in its denial of claim form, and declined to award summary judgment in favor of the insurer. The court also found that the insurer's remaining contention was improperly raised for the first time on appeal, and ruled that the appellant was not allowed to challenge a point that had not been previously considered by the lower court.

The court considered a case regarding a medical facility suing an insurance company for regulations regarding insurance contracts. The issues decided by the court included the error of having an insurer denying a claim for first-party no-fault benefits on the ground of lack of medical justification to include a medical rationale in its denial of claim form. The holding of the case was reversed in that it was affirmed that the insurer and not the claimant should be required to set forth a medical rationale in the prescribed denial of claim form. The court also found that the medical facility made a prima facie showing of entitlement to judgment as a matter of law, however, in response the insurance company raised a triable issue of fact with respect to its argument that the claimed benefits were properly denied on the ground of lack of medical justification.

The court addressed an appeal in a case involving A.B. Medical Services, PLLC, and GEICO Casualty Insurance Co. in relation to no-fault benefits under an insurance contract. The Appellate Term of the Supreme Court modified the previous order of the Civil Court, denying A.B. Medical Services' motion for summary judgment. The plaintiff failed to make a prima facie showing of entitlement to judgment as a matter of law. Even if they had done so, the defendant was successful in raising a triable issue of fact in response. The defendant's denial of claim forms were not insufficient, as the Appellate Term concluded, and the court disagreed with their reasoning. The Department of Insurance regulations do not actually require the carrier to set forth a medical rationale in the prescribed denial of claim form, so the insurer's denial was sufficient. Therefore, the court reversed the order of the Appellate Term and the Civil Court, and denied the plaintiff's motion for summary judgment.