No-Fault Case Law

The relevant facts considered by the court in the case were that Globe Surgical Supply, as assignee of Remy Gallant, brought a breach of contract claim against GEICO Insurance Company for reducing the amounts it would reimburse claimants based on their own determination of what should be a "reasonable and customary" charge for certain durable medical equipment (DME). Globe sought to have the case certified as a class action. The main issue decided by the court was whether the case should be certified as a class action, and the court held that it should not. The court found that Globe did not meet the prerequisites for class action certification under CPLR 901 and did not adequately establish compliance with the statutory requirements. The court also found that a class action was not superior to other available methods for fair and efficient adjudication of the controversy and that individual transactions would need to be examined separately. Therefore, the holding of the case was that the plaintiff's application for class action certification was denied.

The case involved a dispute between Delta Diagnostic Radiology, P.C. and American Manufacturers Mutual Insurance Co. regarding the payment of first-party no-fault benefits for medical services rendered to an assignor. Delta Diagnostic Radiology, P.C. moved for summary judgment, which was granted in March 2005, but American Manufacturers Mutual Insurance Co. moved for reargument and, in July 2005, the court granted reargument and denied Delta Diagnostic Radiology, P.C.'s motion for summary judgment. The main issue decided by the court was whether or not Delta Diagnostic Radiology, P.C. had provided sufficient proof of its submission of the claims to American Manufacturers Mutual Insurance Co., and whether or not American Manufacturers Mutual Insurance Co. had timely requested verification and made the requisite follow-up requests as well as timely denied the claims based on lack of medical necessity. The court determined that the affidavit submitted by Delta Diagnostic Radiology, P.C. was sufficient to allow the annexed claim forms to be considered, but that American Manufacturers Mutual Insurance Co. had raised a triable issue of fact by showing that it timely requested verification and made follow-up requests, and timely denied the claims based on lack of medical necessity. Therefore, the court held that Delta Diagnostic Radiology, P.C.'s motion for summary judgment was properly denied.

The plaintiff in this case sought to recover $1222.95 in first-party no-fault benefits for medical supplies provided to its assignor and subsequently moved for summary judgment. The defendant's attorney argued that the plaintiff failed to make a case for summary judgment. However, the court ruled that the deficiency in the plaintiff's papers was cured by a denial of claim form annexed to the plaintiff's motion, which proved the submission of the claim to the defendant. The court also determined that the defendant did not establish that it timely mailed its denial of claim form, and thus failed to raise an issue of fact regarding whether it paid or denied the claim within the prescribed period. As a result, the plaintiff's motion for summary judgment was granted, and the case was remanded for the calculation of interest and an assessment of attorney's fees. Ultimately, the Court reversed the order denying plaintiff's motion and held in favor of the plaintiff.

The main issues in this case were whether the plaintiff established a prima facie entitlement to summary judgment for first-party no-fault benefits and whether the defendant timely made verification requests to toll the 30-day payment period. The court considered the fact that the plaintiff did not establish proof of proper mailing of the claim forms, but the defendant's opposition papers adequately established that the claims were sent and received. The court also considered whether the defendant timely made verification requests to toll the 30-day payment period and the defendant's assertion that the alleged injuries were not causally related to the accident. The holding of the case was that the order granting plaintiffs' motion for summary judgment was reversed, and the plaintiff's motion for summary judgment was denied. The defendant was precluded from raising most defenses due to not paying or denying the claims within the prescribed period, but was not precluded from asserting the defense that the alleged injuries were not causally related to the accident. Therefore, the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, so the plaintiff's motion for summary judgment should have been denied.

The court considered whether a plaintiff health care provider was entitled to summary judgment to recover first-party no-fault benefits for health care services rendered to the assignor, for the principal sum of $1,125.01. The main issue was whether the health care provider submitted a claim and if the payment of no-fault benefits were overdue. The court decided that the plaintiff had established a prima facie entitlement to summary judgment on its claim for $1,125.01 by providing proof of the submission of the claim and that payment was overdue. The defendant failed to establish that the denial for the claim was mailed within the prescribed 30-day period, and is precluded from raising its proffered defense of lack of medical necessity. Plaintiff's motion was insufficient for the claims in the amounts of $1,200.92 and $540.56, and the matter was remanded for further proceedings on the remaining claims. The holding of the case was that plaintiff's cross motion for summary judgment was granted to the extent of awarding partial summary judgment in the principal sum of $1,125.01 and the award of $50 costs to the defendant was stricken.

The relevant facts considered by the court in this case were that the plaintiff, Doshi Diagnostic Imaging Services, sought to recover no-fault benefits for medical services rendered to its assignor. Plaintiff had provided the defendant, Progressive Insurance Company, with an assignment of benefits form, but the form did not contain the signature of the medical provider, as required by New York regulations. Defendant objected to the incomplete form and requested an assignment containing the provider's signature, but plaintiff failed to provide the requested verification. The main issues decided in this case were whether the defendant had established that payment of no-fault benefits was not overdue due to the incomplete assignment of benefits form provided by the plaintiff, and whether the court should grant defendant's motion for summary judgment dismissing the complaint and deny plaintiff's cross motion for summary judgment. The holding of the case was that the court affirmed the order without costs, finding that since the plaintiff had failed to provide the requested verification consisting of an assignment with the provider's signature, the statutory period in which the defendant had to pay or deny the claim had been tolled, and therefore, the defendant had established that payment of no-fault benefits was not overdue. As a result, the court properly granted defendant's motion for summary judgment dismissing the complaint and denied plaintiff's cross motion for summary judgment.

The relevant facts considered in this case involved a health care provider seeking to recover first-party no-fault benefits for medical services rendered to its assignor. The provider submitted all required claim forms but was denied payment by the insurance company due to a determination that the treatment was not medically necessary. The main issue decided was whether the denial of claim by the insurance company was valid, and whether the health care provider was entitled to summary judgment. The court ultimately held in favor of the health care provider, reversing the previous order denying summary judgment, and remanded the case for the calculation of statutory interest and an assessment of attorney's fees. The court determined that there was no evidence that the peer review report was sent to the provider within the 30-day claim determination period, and that the denial of claim was devoid of any factual basis or medical rationale, and therefore the insurance company was precluded from asserting lack of medical necessity as a defense.

The court considered an appeal from a lower court order granting plaintiff's motion for summary judgment in the sum of $2,941.01 in a case to recover assigned first-party no-fault benefits for medical services. Plaintiff submitted claims and proved that payment of a portion of the claims was overdue. The court determined that the denial of the initial claim was untimely on its face, thereby precluding the defenses based on the application of the fee schedules to the specific services provided. However, the court held that the denial forms that were timely set forth in detail the specific grounds for the denials, but some of these denials were factually insufficient, conclusory, and vague. The court decided to modify the order by granting plaintiff partial summary judgment in the principal sum of $2,595.42.

The court considered whether the plaintiff, a healthcare provider, had submitted sufficient evidence to establish its entitlement to first-party no-fault benefits for medical services rendered to its assignor. The main issues decided were whether plaintiff's claims were properly denied by the defendant, and whether plaintiff was entitled to summary judgment. The holding of the case was that the denial of the plaintiff's claim forms by the defendant were insufficient to assert the defense of lack of medical necessity, and therefore the plaintiff was entitled to partial summary judgment in the sum of $3,935.24. The case was remanded to the lower court for the calculation of statutory interest and an assessment of attorney's fees on said amount and for further proceedings on the remaining $687 claim.

The court considered the fact that the plaintiff's assignor had withdrawn her claim for medical services, and that the driver of the vehicle involved in the collision had also withdrawn his claim, both due to suspicions about insurance fraud. The main issue decided was whether the defendant's refusal to pay the claim was justified based on a "founded belief that the alleged injur[ies] do[] not arise out of an insured incident." The holding of the case was that the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and that there was an issue of fact as to whether there was a lack of coverage. The court also ordered a hearing to address whether the prosecution of the appeal seeking summary judgment in favor of the plaintiff was frivolous and subject to sanctions.