No-Fault Case Law

The main issues in this case were whether the defendant was entitled to discovery pertaining to its defenses of lack of medical necessity and fraudulent billing, including the deposition of Dr. Arkady Levitan. The court considered the fact that the defendant timely denied the plaintiff's claims and that the plaintiff's assignor appeared for an independent medical examination (IME) performed by the defendant within the required 30 days. The court held that the defendant was entitled to discovery and granted the defendant's motion for discovery. Therefore, the order of the Civil Court, Bronx County, which denied the defendant's motion to compel discovery, was reversed, and the defendant's motion for discovery was granted.

The main issue in this case was whether the denial of claim forms for first-party no-fault benefits by the insurance company were defective. The court considered whether the denial forms were sufficient, as they stated that the claims were denied based on a peer review report provided to the plaintiff. The holding of the appellate court was that where the insurer provides a factually sufficient peer review report to the plaintiff within the 30-day claim determination period, an NF-10 that states the claim was denied based on the peer review report provided to the plaintiff is sufficient to preserve a defense of lack of medical necessity. The court affirmed the denial of the branches of the plaintiff's motion which sought summary judgment upon the claims in question because the insurer's opposition to the motion included an affidavit from the peer reviewer which incorporated the unsworn peer review report, and therefore the plaintiff was not entitled to summary judgment.

The case involves Fernando Castillo-Gomez appealing an order that denied his motion to dismiss a proceeding as untimely and granted a petition by the Government Employees Insurance Company. The respondent had been in an accident caused by an uninsured vehicle and had sent a letter to his insurer claiming no-fault insurance benefits, uninsured motorist benefits, and supplemental uninsured motorist benefits. The insurer responded by commencing a proceeding to stay arbitration on the grounds that the offending vehicle was insured on the date of the accident, and the respondent moved to dismiss the proceeding as untimely. The Supreme Court stayed arbitration, finding the proceeding to be timely. However, the Appellate Division reversed the order, stating that the proceeding to stay arbitration was time-barred based on the compliance requirements of CPLR 7503 (c), meaning that since the respondent's April 9, 2003 notice of intention to arbitrate complied with all of the statutory requirements, it was sufficient to commence the 20-day period of limitations.

The relevant facts the court considered in this case were that plaintiff AB Medical Services, PLLC, sought to recover first-party no-fault benefits for medical services rendered to its assignor. Plaintiff moved for partial summary judgment, while defendant cross-moved for summary judgment dismissing the complaint. The main issue decided by the court was whether plaintiff had established its prima facie entitlement to summary judgment by annexing the claim forms being sued upon to its motion papers. The court found that plaintiff did not annex any exhibits to its moving papers, and the document entitled "EXHIBITS SERVED WITH THE PLAINTIFF'S SUMMARY JUDGMENT MOTION" was rejected by the court below and not considered in reaching its determination. Therefore, the court affirmed the order denying plaintiff's motion for partial summary judgment without costs and without prejudice to renewal upon proper papers.

The court considered the defendant's concession of receiving the claim forms and the lack of authentication of the assignor's signature as not constituting a defect in the absence of any statutory or regulatory requirement for the same. The main issue decided was whether the plaintiff established a prima facie case and if the burden shifted to the defendant to demonstrate the existence of a triable issue of fact. The holding was that the defendant's opposition papers established that the plaintiff's assignor failed to appear for pre-claim independent medical examinations, rebutting the presumption that the services rendered were medically necessary, and therefore raised a triable issue of fact. As a result, the plaintiff's motion for summary judgment was properly denied.

The court considered the fact that the defendant had received the claim forms in question in an action to recover assigned first-party no-fault benefits. The main issue was whether the plaintiff had established a prima facie case, and if the defendant had demonstrated the existence of a triable issue of fact. The holding of the case was that the lack of authentication of the assignor's signature did not constitute a defect, as there was no statutory or regulatory requirement for the same. Additionally, the defendant's opposition papers established that the plaintiff's assignor had been sent a request to appear for pre-claim independent medical examinations and had failed to appear, leading to the conclusion that the services rendered by the plaintiff were not medically necessary. As a result, the defendant's opposition papers raised a triable issue of fact, leading to the denial of the plaintiff's motion for summary judgment.

The relevant facts in this case included a dispute over whether a provider established prima facie entitlement to summary judgment in an action to recover assigned first-party no-fault benefits. The main issue decided in this case was whether the plaintiff had sufficiently established the mailing of the claim forms to the defendant, and whether the defendant had demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage. The holding of the case was that the plaintiff's moving papers were insufficient to establish the mailing of the claim forms, but the deficiency was cured by the denial of claim form relating to all of the claims which adequately established that plaintiff sent, and that defendant received, the claim forms. Additionally, the defendant's assertion of a defense that the collision was in furtherance of an insurance fraud scheme was found to be based upon a "founded belief that the alleged injuries do not arise out of an insured incident," and therefore, the lower court properly denied plaintiff's motion for summary judgment.

The court considered the case of Andrew Carothers, M.D., P.C. v. Travelers Insurance Company, where the plaintiff sought first-party benefits, attorney's fees, and statutory interest against the defendant, pursuant to the New York Insurance Law and the No-Fault regulations. The defendant moved to preclude the admission of plaintiff's bills into evidence, arguing that the bills were defective since the relationship between the provider and treating physician was not noted. The main issue decided by the court was whether the plaintiff was entitled to direct payment of no-fault benefits if the alleged medical treatments were provided by an independent contractor. The court held that the defendant failed to demonstrate that the services were rendered by an independent contractor and that the plaintiff's prima facie entitlement to no-fault benefits was established, granting judgment in favor of the plaintiff in specific amounts for each assignor, as well as statutory interest and attorney's fees.

The court considered whether Allstate Insurance Company had a reasonable excuse for the default in the case regarding first-party no-fault benefits. They were required to establish both a reasonable excuse for the default and a meritorious defense. The court held that Allstate Insurance Company failed to establish a meritorious defense, as they had failed to proffer a meritorious defense. Despite their claims, the court held that they were not entitled to delay payment of benefits and that their defense had no merit as a matter of law. Therefore, the court reversed the order that had granted Allstate's motion to vacate the default judgment and found that the motion should have been denied.

In the case of Post Traumatic Med. Care P.C. v Travelers Home & Mar. Ins. Co., the court considered an action to recover assigned first-party no-fault benefits, in which the plaintiff sought summary judgment and was required to respond to defendant's discovery demands. The main legal issue decided was whether the plaintiff was entitled to judgment as a matter of law, by showing that the prescribed statutory billing forms were mailed and received, and that payment of no-fault benefits was overdue. The court held that the plaintiff's submissions were insufficient to establish that payment was overdue, and defendant's papers did not cure such deficiency, thus the plaintiff's cross motion was properly denied. The Appellate Term affirmed the order without costs, and the decision date was October 27, 2006.