No-Fault Case Law

The court considered an action to recover assigned first-party no-fault benefits, in which the plaintiff moved for summary judgment with respect to the claims for services rendered to assignors Alexander Ryabchenko, Martin Sarnacki, and Ronka Weislaw. The main issue decided was whether the plaintiff established a prima facie entitlement to summary judgment by proof of submission of statutory claim forms, setting forth the fact and amounts of the losses sustained, and that payment of no-fault benefits is overdue. The holding of the court was that the plaintiff failed to establish that they submitted the claim forms to the defendant, and that the denial of claim forms and letters were inadequate to establish receipt of the claim forms. Therefore, the order of the court below granting summary judgment was reversed and plaintiffs' motion for summary judgment was denied.

The relevant facts considered in this case are that New York Massage Therapy P.C. sought recovery of first-party no-fault benefits from State Farm Mutual Insurance Company for medical services rendered to its assignor after an automobile accident, amounting to $810.32. State Farm denied the claim based on the plaintiff's failure to appear for a scheduled EUO and alleged fraud, claiming the accident was staged. The main issue decided was whether State Farm had successfully proven that the accident was staged and the burden of proof had shifted to the plaintiff. The court held that State Farm failed to come forward with admissible evidence to establish its belief that the injuries did not arise from an insured accident, and that the "suspicious indicators" used as a basis for denial were speculative and not determinative. Therefore, judgment was entered in favor of the plaintiff for the amount of $810.32, plus statutory interest and attorney's fees.

The main issue in this case was whether the plaintiff had properly established a prima facie entitlement to payment of no-fault benefits, and whether the defendant had provided a proper denial of the claim. The court found that the plaintiff had established a prima facie entitlement through the timely submission of the claim, but the defendant's denial was untimely, factually insufficient, conclusory, and vague. The court also found that the defendant's witness did not provide sufficient evidence to establish a standard office procedure regarding mailing, and that this lack of evidence was fatal to the defendant's case. Therefore, judgment was entered for the plaintiff in the amount of $879.73, plus interest and attorneys' fees.

Progressive Casualty Insurance Company denied the claim of Stephen Fogel Psychological, P.C.'s on the grounds that Kim Choy Chong (assignor of the claim) did not appear for the Independent Medical Examinations (IMEs) as requested before the statutory claim forms were submitted. The case was brought to recover no-fault benefits on an insurance policy. Progressive moved for summary judgment, claiming that Kim breached a condition precedent to payment in the policy by failing to appear for IMEs. Fogel also moved for summary judgment, claiming entitlement to payment despite Kim's failure to appear. The main issue was the requirement of appearance at an IME under the insurance policy. The court affirmed the denial of Progressive's motion for summary judgment and Fogel's cross motion for summary judgment The holding was that the appearance of the insured for IMEs at any time is a condition precedent to the insurer's liability on the policy and that the insurer may deny a claim retroactively to the date of loss for a claimant's failure to attend IMEs.

The court considered the fact that plaintiff failed to establish its prima facie entitlement to summary judgment through the submission of competent evidence, as plaintiff's counsel did not assert a basis of his personal knowledge of the facts and did not lay a sufficient foundation to establish the admissibility of the claim form. Defendant's denial of claim form did not concede the admissibility of the purported claim form or the facts set forth therein. Plaintiff subsequently served an affidavit executed by its president, which was denominated a "Supplemental Affidavit," but was in reality a reply affidavit. The main issue was whether plaintiff was entitled to summary judgment, as well as the issue of defendant's cross motion to compel discovery. The holding was that plaintiff's motion for summary judgment should have been denied, as plaintiff failed to establish its entitlement to judgment as a matter of law by submitting sufficient evidence in admissible form. Defendant's cross motion to compel discovery should also be denied with leave to renew upon proper papers.

The relevant facts considered by the court were that Mega Supply & Billing, Inc. was seeking to recover first-party no-fault benefits for medical supplies furnished to its assignor. The main issue decided was whether Mega Supply & Billing, Inc. had established a prima facie entitlement to summary judgment, and if New York Central Mutual Fire Insurance Co. had properly denied the claim. The holding of the case was that Mega Supply & Billing, Inc. did not establish a prima facie entitlement to summary judgment, as it did not prove the mailing of the subject claim. Additionally, New York Central Mutual Fire Insurance Co. failed to establish that its claim denial form was mailed within the prescribed 30-day period, and their cross motion for summary judgment was properly denied. Consequently, the order was affirmed without costs.

The relevant facts considered by the court in this case were that Vista Surgical Supplies, Inc. sought to recover first-party no-fault benefits for medical supplies it provided to its assignor. The main issue decided by the court was whether the defendant, Travelers Insurance Company, had established that it mailed denial forms within the prescribed 30-day period. The holding of the court was that the plaintiff, Vista Surgical Supplies, Inc., was entitled to summary judgment as it had established a prima facie entitlement to such judgment. The court also remanded the matter to the lower court for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106 and the regulations promulgated thereunder.

The main issues of the case were whether plaintiff's causes of action sounding in tort and bad faith were properly stated, and whether the demands for punitive damages were appropriate. The court held that plaintiff's tort and bad faith causes of action were not properly stated, as there was no independent duty or relationship between plaintiff and defendant separate from the contractual obligation and therefore no independent tort claim could be made. The court also held that the bad faith claim was properly dismissed, as no separate cause of action exists in tort for an insured's alleged bad faith in failing to perform its contractual obligations. Additionally, the demands for punitive damages were also properly dismissed because there was no basis for determining that defendant's conduct constitutes a tort independent of the contract. The order was affirmed, with costs.

The relevant facts the court considered were that Starrett Medical L.C.P.C was seeking to recover assigned first-party no-fault benefits from GEICO Casualty Insurance Company. The issues decided were whether the plaintiff's moving papers established entitlement to summary judgment and whether the defendant's denial of claim forms set forth a sufficient factual basis and medical rationale for denial based on lack of medical necessity. The holding of the court was that the plaintiff's moving papers were insufficient to establish the mailing of claim forms, but this deficiency was cured by the defendant's denial of claim forms. Additionally, the court held that the defendant was precluded from asserting lack of medical necessity as a defense due to the insufficient factual basis for the denial. Consequently, the order granting the plaintiff's motion for summary judgment was affirmed.

The relevant facts in this case involved a health care provider filing a lawsuit to recover reimbursement from a no-fault insurer for services rendered to the provider's assignors. The insurer had received eight separate bills, all unpaid and were not denied. Two main issues were presented: determining the statutory attorney's fees due to the plaintiff, and the statutory interest due to the plaintiff, as well as when the interest should accrue. The Court held that interest accrued on each claim 30 days from the date of submission of each claim, with the plaintiff being awarded attorney's fees for each individual claim. The Court rejected the insurer's argument to aggregate the claims and determined that the statutory attorney's fees were to be awarded as per each bill submitted through an NF-3 proof of claim.