No-Fault Case Law

The court considered the facts of an action to recover first-party no-fault benefits for services rendered to the plaintiff's assignor. The plaintiff had moved for summary judgment, but the defendant opposed the motion. The lower court denied the plaintiff's motion, leading to the appeal. The main issue decided was whether the plaintiff's motion for summary judgment was properly denied, and the court found that it was, as the defendant raised a triable issue. The holding of the case was that, under the circumstances presented, the plaintiff's motion for summary judgment was properly denied, and the lower court's order was affirmed.

The court considered the case of a provider seeking to recover first-party no-fault benefits for an MRI provided to its assignor. The provider filed a motion for summary judgment, which was denied by the court due to a peer review report created by the defendant that raised a triable issue of the MRI's medical necessity. The defendant had informed the provider that the processing of the claim would be delayed until confirmation of medical necessity was received, and after receiving the verification, the denial was issued based on the peer review report. The main issue decided was the defendant's failure to seek verification directly from the plaintiff, as required by regulations. The court upheld the denial of the provider's motion for summary judgment and affirmed the lower court's decision, stating that the argument was rejected for the same reasons provided in another similar case.

The relevant facts the court considered were that a provider sued for non-payment of no-fault benefits and the defendant sent a letter to the prescribing physician requesting verification of the medical necessity of the MRI. The plaintiff contended that the request should have been made directly to them. The main issue decided by the court was whether the insurance regulations were violated when the insurance company sent the letter to the prescribing physician instead of directly to the plaintiff. The holding of the case was that the letters sent by the insurance company sufficed to toll the statutory claim determination period, and that the request for verification could be made to parties other than the applicant if the insurance company informed the applicant of the nature of the verification sought.

The court considered the sufficiency of the evidence submitted in support of the plaintiff's motion for summary judgment in a case involving a provider seeking to recover first-party no-fault benefits. The main issue decided was whether the affidavit by plaintiff's corporate officer laid a proper foundation for the admission of the documents annexed to the plaintiff's motion papers as business records. The court held that the affidavit submitted by plaintiff's corporate officer was insufficient to establish the officer's personal knowledge of plaintiff's practices and procedures, and as a result, plaintiff failed to make a prima facie showing of its entitlement to summary judgment. Therefore, the court affirmed the denial of the plaintiff's motion for summary judgment.

The relevant facts considered in the case were that a medical provider, Metroscan Medical Diagnostics, P.C., filed a complaint to recover assigned first-party no-fault benefits from Progressive Casualty Insurance Company. Progressive moved for summary judgment, arguing that the action was premature due to the plaintiff's failure to adequately respond to initial and follow-up verification requests. The main issue decided was whether the verification requests sent by the defendant were specific enough and whether the plaintiff's failure to provide a completed assignment of benefits form allowed the defendant's time to pay or deny the claim to be tolled. The holding of the case was that the lower court's decision to grant the defendant's motion for summary judgment was affirmed, as the plaintiff failed to provide a completed assignment of benefits form, which in turn tolled the 30-day statutory period for the defendant to pay or deny the claim. Therefore, the defendant had established that payment of no-fault benefits was not overdue, and the action was premature.

The relevant facts considered by the court were that the plaintiffs had submitted claims for first-party no-fault benefits for health care services provided to their assignor, and that payment of these benefits was overdue. The main issue decided was whether the defendant could demonstrate the existence of a triable issue of fact regarding the timely denial of the claims based on fraudulent billing. The holding of the case was that the defendant failed to submit adequate proof that it mailed timely verification requests, which would have extended the 30-day claim determination period, and as a result, the denials were untimely. The defendant was precluded from raising most defenses, including its defense of fraudulent billing, and the order granting plaintiffs' motion for summary judgment was affirmed.

The petitioner was State Farm Mutual Automobile Insurance Company, and the respondent was William Tubis. Tubis sustained injuries in a car accident with a vehicle insured by Legion Insurance Company. Tubis applied for no-fault benefits and uninsured/underinsured motorist benefits from State Farm about three months later. Legion was declared insolvent in 2003, and Tubis sent State Farm a demand for arbitration for uninsured motorist benefits in 2004. The main issue was whether Tubis's claim for uninsured motorist benefits was time-barred, as the insurance policy required that notice of the claim be given "as soon as practicable". The court held that Tubis did not notify the insurance company of his uninsured motorist claim as soon as practicable and State Farm promptly submitted reply papers, disclaiming coverage, which satisfied its statutory obligation. The petition to stay arbitration was granted and arbitration was permanently stayed.

The court considered the plaintiffs' complaint, the defendant's motion to dismiss, and the plaintiffs' cross motion for summary judgment and to amend the complaint. The main issue decided was the sufficiency of the complaint and the denial of the plaintiffs' right to amend the complaint. The holding of the court was that the plaintiffs did not seek leave to amend the complaint to plead the essential elements of a cause of action to recover no-fault benefits for specific claims, and therefore, their argument for the right to replead was not properly before the Court. The court also found that nurses' reviews denying no-fault claims for lack of medical necessity were not per se invalid, and that the insufficiency or lack of merit of the complaint was clear and free from doubt.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, which granted the defendant's motion to strike the plaintiff's complaint unless the plaintiff served a bill of particulars and responded to discovery demands within 45 days. The plaintiff had filed a cross motion for summary judgment, which was denied by the court. The main issue decided was whether the plaintiff had made a prima facie showing of its entitlement to summary judgment, and whether the plaintiff's failure to submit written opposition to the defendant's motion to strike the complaint resulted in the order being entered on default. The holding of the court was that the plaintiff had failed to make a prima facie showing of its entitlement to summary judgment, and that the order requiring the plaintiff to serve a bill of particulars and respond to the defendant's disclosure demands was entered on default, therefore the appeal from so much of the order as granted the defendant's motion was dismissed.

The court considered the fact that the plaintiff, Support Billing & Management Co., was seeking first-party no-fault benefits, and that their motion for summary judgment was denied by the lower court due to the presence of two peer review reports that raised an issue of fact regarding the medical necessity of the benefits. The main issue decided was whether the peer review reports, which contained facsimile signatures of the doctor who performed the reviews, were admissible as evidence. The court held that the peer review reports were not in admissible form because they only contained stamped facsimile signatures, and defendant failed to establish that they were placed there by the doctor. As a result, the plaintiff was granted summary judgment on both of its claims, and the case was remanded for a calculation of statutory interest and assessment of attorney's fees.