No-Fault Case Law

The main issue in this case was whether the appellant was entitled to recover first-party no-fault benefits from the respondent insurance company. The court considered the evidence submitted by the appellant in support of their motion for summary judgment, which included copies of the respondent's denial of claim forms acknowledging receipt of the claims, as well as an affidavit of an officer of the appellant provider. The main issue decided was whether the appellant had established its prima facie entitlement to summary judgment, which hinged on the submission of the statutory claim forms to the respondent. The court found that while the motion papers contained necessary evidence, there was a discrepancy with the affidavit of the appellant's officer, which was allegedly signed in blank and undated. As a result, the court held the matter in abeyance and remanded it to the lower court to report whether the affidavit included in the record on appeal was the same one considered by the motion court.

In the case, 563 Grand Medical, PC sought to recover first-party no-fault benefits from Prudential Property & Casualty Insurance Company for medical services provided to a patient. The court granted Prudential's motion to dismiss the complaint, as the master arbitrator's award was less than $5,000, and therefore, the plaintiff was not entitled to initiate the action for a trial de novo under Insurance Law § 5106 (c). The court concluded that the plain language of the statute indicated that the amount of the master arbitrator's award must be at least $5,000 before an insurer or claimant could commence an action to adjudicate the dispute de novo. Moreover, the court denied the plaintiff's application to convert the action to a special proceeding to vacate the master arbitrator's award, as the plaintiff failed to assert any grounds for vacating the award as required by CPLR 7511 (b) or 11 NYCRR 65-4.10. Therefore, the order granting Prudential's motion to dismiss the complaint and denying the plaintiff's application to convert the action was affirmed.

The court considered an action to recover first-party no-fault benefits involving multiple assignors and the submission of multiple bills on different dates. The issue was how attorney's fees should be calculated when dealing with action involving multiple assignors. The New York State Insurance Department interpreted the relevant regulation to state that the attorney's fee awarded to the provider should be based on the aggregate amount of payment required to be reimbursed, and not on a "per bill" basis. The court adopted the Department of Insurance's interpretation of the regulation and held that for each assignor in the action, the plaintiff was entitled to an attorney's fee in the amount of $60 or 20% of the total amount of first-party benefits awarded for services provided to that assignor, plus interest thereon, whichever amount is greater, subject to a maximum of $850.

The relevant facts that the court considered in this case involved a medical provider seeking first-party no-fault benefits for MRI services rendered to its assignor, based on medical necessity. The main issue decided by the court was whether the diagnostic center could be denied first-party no-fault benefits based upon a lack of medical necessity when it merely performed MRIs pursuant to the instructions of its assignor's examining physician, without directly examining the patient. The holding of the case was that the diagnostic center could not be automatically denied first-party no-fault benefits based on a lack of medical necessity, as the burden of proof shifted to the defendant to establish the lack of medical necessity, and then back to the plaintiff to present its own evidence of medical necessity. The court ultimately found that the defendant's expert's testimony regarding the lack of medical necessity was sufficient to demonstrate a lack of medical necessity and shifted the burden to the plaintiff to show that the MRIs were medically necessary. Since the plaintiff failed to submit evidence to establish medical necessity, they were not entitled to judgment in their favor, and the court directed the judgment to be entered in favor of the defendant dismissing the action.

The relevant facts considered in Citywide Social Work & Psychological Servs., P.L.L.C. v State Farm Mut. Auto. Ins. Co. are that the plaintiff, a medical services provider, was seeking first-party benefits (recovery of unpaid health services bill, statutory interest and statutory attorneys' fees) pursuant to the No-Fault Insurance Law for the medical services rendered to a patient, who assigned the right to collect No-Fault benefits to the plaintiff. The main issues decided were whether triable issues of fact existed that precluded the granting of summary judgment in the plaintiff's favor and whether the defendant's defenses of fraudulent billing practices and the plaintiff being a fraudulently licensed medical facility were precluded. The holding of the case was that the plaintiff's motion for summary judgment was denied because the defendant had demonstrated the existence of a triable issue of fact and because the summary judgment motion was premature due to the need for discovery seeking corporate information to determine whether the owners and employees of the plaintiff corporation were properly licensed and incorporated, which is relevant to the question of whether the plaintiff is eligible for reimbursement.

The main issue in the case was the venue of an action to recover assigned first-party no-fault benefits. Defendant moved for an order changing the venue of the action to Bronx County, arguing that neither the plaintiff nor the defendant were residents of Richmond County. The court considered whether the defendant's submissions demonstrated that it did not "transact business" within Richmond County, as required by the Civil Court Act. The court held that the defendant's submissions did not establish that it did not transact business in Richmond County, as there was the possibility that the defendant issued insurance policies covering Richmond County residents and engaged in purposeful activity in the county. Therefore, the court denied the defendant's motion to change the venue of the action.

The court considered a case of Pine Hollow Medical, P.C. seeking to recover first-party no-fault benefits for medical services provided to plaintiff's assignor. Defendant objected to the competency of plaintiff's witness to establish the reliability of the information recorded in the business records. The court held that where an entity routinely relies on the business records of another entity and fully incorporates said information into records made in the regular course of its business, the subsequent record is admissible despite the preparer lacking personal knowledge of the information's accuracy. Plaintiff established a business record foundation for the admission of the records produced on the basis of the information imparted by them to the billing company. Defendant's argument regarding the proof of assignment was deemed without merit as it failed to timely object to the completeness of the assignment form. Therefore, the judgment was affirmed without costs.

The relevant facts considered in this case were that Empire State Psychological Services, P.C. sought to recover first-party no-fault benefits for health care services rendered to their assignor, Samantha Williams, and the defendant, Travelers Insurance Company, denied these bills on the grounds of absence of medical necessity. The main issue decided was whether plaintiff had established the fact and the amount of the loss sustained and whether payment of no-fault benefits was overdue. The court held that plaintiff failed to make out a prima facie case as it did not establish the fact and the amount of the loss sustained by submitting prescribed statutory billing forms or its substantial equivalent, and thus, reversed the judgment, granted defendant's motion for judgment as a matter of law, and dismissed the complaint.

The main issue in this case was whether the appellant was timely notified of the insurance company's notification provisions. The appellant was in an automobile accident and filed a no-fault claim with the insurance company, from which she initially received benefits. The benefits were later cancelled after an independent medical examination found her injuries non-serious. She later claimed underinsured coverage under the SUM provisions of her policy, but the insurance company disclaimed coverage based on her failure to timely notify them of her claim. The court reversed the order and judgment of the Supreme Court, Nassau County, and ordered a new determination of the petition after a hearing on the issue of prejudice to the insurance company. The legal holding of this case is that the insurance company had to show prejudice before relying on the policy provisions requiring timely notice of the SUM claim, and a hearing was required on this issue prior to the determination of the petition.

The case involved an action for a declaratory judgment by the plaintiff, an injured police officer, against the defendant, the Incorporated Village of Lake Success, seeking to determine whether he is obligated to reimburse the village for the money paid to him pursuant to General Municipal Law § 207-c. The plaintiff was also seeking underinsured motorist benefits from a separate defendant, the American Protection Insurance Company, the insurer of the police vehicle. The main issue was whether the village was entitled to assert a lien against any arbitration award the plaintiff might recover from the insurance company in the amount that the village had paid to him pursuant to General Municipal Law § 207-c. The court held that the village was not entitled to assert a lien pursuant to General Municipal Law § 207-c (6), and therefore improperly granted the village's cross-motion. The court concluded that the plaintiff was not obligated to reimburse the village for the money it paid pursuant to General Municipal Law § 207-c, and the village was not entitled to a lien against any award the plaintiff receives in his underinsured motorist arbitration.