No-Fault Case Law

The court considered the motion for a directed verdict in an action to recover assigned, first party no-fault benefits. The main issue was whether defendant's expert's testimony should be precluded on the ground that the expert did not personally undertake the peer review underlying defendant's denial of the two claims at issue. The court held that it was error to preclude the expert's testimony, as he would be subject to full cross-examination and his testimony as to lack of medical necessity would be limited to the basis for denial set forth in the original peer review report. The matter was remanded for trial, and the defendant's expert was not precluded from testifying because his opinion was based, at least in part, on his review of the assignors' medical records. Plaintiff could not challenge the reliability of the assignors' medical records and reports.

The court considered the attorney's fee awards in court cases seeking payment of no-fault economic loss benefits and the disputed question of the proper formula to use for computation of a no-fault attorney's fee award. The main issue was the proper formula to use for computation of a no-fault attorney's fee award to a prevailing plaintiff's counsel in routine no-fault litigation, as well as the situations in which a plaintiff is not entitled to an attorney's fee award. The holding was that a prevailing no-fault claimant may claim an award of attorney's fees and that a single provision governs an attorney's fee award in routine court litigation for a no-fault unpaid economic loss claim, with specific calculations for the fees.

The plaintiff in this case sought to recover no-fault first-party benefits for medical services provided to its assignor on February 14, 2004, in the total sum of $1,791.73, which were not paid. The plaintiff alleged that the defendant's denial, alleging lack of medical necessity, was improper as it was not on a properly prescribed denial of claim form and omitted many fields in violation of specific regulations. The defendant argued that, because its denial was timely, the plaintiff would only be entitled to summary judgment if medical necessity for the services rendered was eliminated as a matter of law. The court held that the plaintiff's claim was timely submitted and that the defendant failed to pay or properly deny the claim within 30 days and was thus precluded from raising a defense to the plaintiff's suit. The court also ruled that interest on overdue payments would run from 30 days after receipt of the claim, while in cases where the carrier had issued a proper and timely denial, interest would run from the institution of arbitration or suit, if no such action is taken within 30 days after the plaintiff's receipt of the denial of claim. The plaintiff was granted the entry of a judgment in the principle sum of $1,791.73, plus interest at the rate of 2% per month compounded from April 9, 2004, and counsel fees in the sum of 20% of the principle award plus the interest thereon, but no more than $850.

The case concerned an appeal from a judgment involving an action to recover no-fault medical payments under contracts of insurance. The judgment was in favor of Mount Sinai Hospital, as assignee of Salvatore Gigante, against Travelers Property Casualty Insurance Company for the amount of $30,092.49. Mount Sinai was able to demonstrate its entitlement to judgment as a matter of law by providing billing forms, a certified mail receipt, a signed return receipt card, and an affidavit of its third-party biller, showing that the defendant received the no-fault billing and failed to respond within the requisite 30-day period. The defendant failed to raise a triable issue of fact in opposition to the motion, so the Supreme Court's granting of Mount Sinai's motion for summary judgment on the third cause of action was proper. The defendant's remaining contention was deemed without merit by the court of appeals.

The court considered a motion to vacate a notice of trial and certificate of readiness in a case involving a dispute over first-party no-fault benefits. The main issue decided was whether the defendant's motion to vacate the notice of trial and certificate of readiness should be granted, as there was an outstanding request for discovery and the plaintiff had filed a notice of trial claiming that discovery was complete. The court held that the defendant's motion to vacate the notice of trial and certificate of readiness should have been granted, as it was based on a certificate of readiness containing the erroneous statement that discovery was completed or waived. Therefore, the order denying the defendant's motion was reversed, and the defendant's motion to vacate the notice of trial and certificate of readiness was granted.

The relevant facts in this case involve an action to recover assigned first-party no-fault benefits. The plaintiff's motion for summary judgment was supported by an affirmation from plaintiff's counsel, an affidavit by a corporate officer of plaintiff, and various documents. The affidavit executed by plaintiff's corporate officer was found to be insufficient to establish plaintiff's prima facie case. The court also denied the defendant's cross motion for summary judgment, which was based on the alleged failure of plaintiff's assignor to appear for two independent medical examinations. The defendant did not present sufficient evidence in admissible form to make a prima facie showing of its entitlement to judgment. The main issue decided was whether both the plaintiff and defendant had presented sufficient evidence to establish their entitlement to summary judgment. The holding of this case was that the court modified the order by denying defendant's motion for summary judgment, affirmed the order as modified, and ruled that both motions for summary judgment were properly denied.

The court considered a motion by defendant to compel the plaintiff to produce Dr. Nesen for a deposition in an action to recover assigned first-party no-fault benefits. The main issue decided in this case was whether the plaintiff should be required to produce Dr. Nesen for a deposition, as there was an issue as to whether Dr. Nesen was an employee of the plaintiff or an independent contractor at the time the treatment was rendered. The holding of the court was that the order was modified to grant the defendant's motion to compel the plaintiff to produce a witness with knowledge of Dr. Nesen's employment status for a deposition, but not to produce Dr. Nesen himself. The court found that it was unclear whether Dr. Nesen was employed by the plaintiff at the time the defendant sought such relief, and therefore erred in compelling the plaintiff to produce Dr. Nesen for a deposition. The decision was made by Pesce, P.J., Weston Patterson and Golia, JJ. on February 14, 2007.

The plaintiff sought to recover first-party no-fault benefits for health care services rendered to its assignors. The defendant sought to dismiss the complaint for the plaintiff's failure to comply with discovery or, in the alternative, to compel discovery. The court ordered the plaintiff to respond to written interrogatories and produce a representative for a deposition, but the plaintiff failed to fully comply. The defendant then sought to dismiss the complaint for the plaintiff's continued failure to provide certain discovery, or, in the alternative, for summary judgment. The court held that the defendant's motion to dismiss the complaint pursuant to CPLR 3126 should have been granted, due to the plaintiff's failure to fully comply with the court order and failure to oppose the defendant's motion.

The court considered the defendant's motion for summary judgment in a case to recover first-party no-fault benefits for health care services rendered by the plaintiff to its assignor. The defendant claimed that the plaintiff's assignor had failed to appear for independent medical examinations (IMEs) which had been scheduled prior to the defendant's receipt of the claim forms. In support of the motion, the defendant submitted evidence of mailing of the claim denials and the IME scheduling letters to the assignor. The court denied the defendant's motion for summary judgment, finding that there was a triable issue of fact as to medical necessity. The main issue decided was whether the defendant had established, prima facie, that it mailed the notices of the IMEs and that the plaintiff's assignor failed to appear for the IMEs. The holding of the case was that the defendant failed to meet its burden of proof in admissible form because it did not submit evidence in admissible form from anyone with personal knowledge of the nonappearances, and therefore its motion for summary judgment was properly denied.

In this case, there was a dispute over whether or not an insurance company had to pay out uninsured motorist benefits to a man who reported a hit-and-run accident. The man failed to file a sworn statement with the insurance company as required under the policy's supplementary uninsured motorist endorsement. The court found that this failure vitiated his coverage and denied his claim for benefits. The court also held that the policy language was not ambiguous, and the man's notice of the accident through a no-fault benefits application did not negate his breach of the policy requirements. Therefore, the court reversed the judgment, granted the petition to permanently stay arbitration, and ruled in favor of the insurance company.