No-Fault Case Law

The relevant facts considered by the court were that the plaintiffs submitted claims for first-party no-fault benefits for medical services rendered to their assignor, and that the payment of these benefits was overdue. The main issue decided by the court was whether the defendant's denial of coverage was based on a "founded belief that the alleged injuries do not arise out of an insured incident." The holding of the court was that the defendant failed to demonstrate the existence of a triable issue of fact as to whether there was a lack of coverage, and as a result, the plaintiffs' motion for summary judgment was granted, and the matter was remanded for the calculation of statutory interest and attorney's fees. The dissenting judge argued that the defendant presented sufficient facts to establish that its denial was based on a "founded belief," and that the report annexed to the motion papers was sufficient to raise a triable issue of fact.

The court considered the plaintiff's action to recover first-party no-fault benefits as the assignee of 11 alleged injured persons, arising from 11 separate accidents. The defendant failed to timely answer, and a default judgment was entered, after which the defendant moved to vacate the default judgment and sever the causes of action. Plaintiff also cross-moved for summary judgment. The main issue decided was whether the court below properly exercised its discretion in granting defendant's motion to sever plaintiff's causes of action and in denying plaintiff's cross motion for summary judgment. The holding of the case was that the court below properly exercised its discretion in granting defendant's motion to sever plaintiff's causes of action, as the defenses raised by the defendant were likely to raise few, if any, common issues of law or fact, even if the assignors' insurance policies were identical, and the plaintiff's cross motion for summary judgment was properly denied.

The court considered whether the plaintiff, Amaze Medical Supply Inc., was entitled to summary judgment in a case to recover first-party no-fault benefits for medical supplies furnished to its assignor, Marta Yepes. Although the plaintiff established a prima facie entitlement to summary judgment by showing that it submitted a claim and the payment of benefits was overdue, the defendant, Allstate Insurance Company, provided evidence demonstrating the timely mailing of its denial of claim based on the assignor's failure to appear for a pre-claim independent medical examination (IME). In addition, the record showed that the assignor failed to appear for the scheduled IME. The court held that the plaintiff's motion for summary judgment was properly denied, affirming the order without costs. Golia, J.P., concurred with the result only, expressing disagreement with certain propositions of law set forth in the majority's decision.

The court considered that the plaintiff provided proof that it submitted claims for first-party no-fault benefits for medical supplies, and that payment of these benefits was overdue. The plaintiff established that it mailed these claims to the defendant via certified mail, and a corporate officer attested to the usual procedure for sending billing by certified mail. The defendant failed to provide a timely denial of the claim within the 30-day statutory period, and their requests for examinations under oath did not toll the 30-day claim determination period. As a result, the defendant failed to show that its time to deny the claims was tolled and is precluded from raising most defenses. Therefore, the plaintiff was entitled to partial summary judgment in the sum of $1,997. The main issues decided were whether the plaintiff was entitled to summary judgment on the claims for first-party no-fault benefits for medical supplies, and whether the defendant's requests for examinations under oath tolled the 30-day claim determination period. The holding of the case was that the plaintiff was entitled to partial summary judgment in the sum of $1,997 due to the defendant's failure to provide a timely denial of the claim within the 30-day statutory period.

The case involved SZ Medical, as well as other medical practices, bringing a lawsuit against Country-Wide Insurance to recover no-fault benefits for medical treatments rendered. The medical practices showed that they submitted claims and that the payments for the no-fault benefits were overdue. Country-Wide Insurance then needed to prove there were any material factual issues in question. In its claim denial form, the insurance company considered and adjusted amounts for several of the claims submitted. The Supreme Court decided that the medical practices were entitled to receive summary judgment after sufficiently showing that payments for no-fault benefits were overdue, and that the insurance company's denials based on lack of medical necessity were insufficient. The matter was then sent back to the lower court for calculation of statutory interest and assessment of attorney's fees.

The court considered the medical supplies provided by the plaintiff to its assignor after an auto accident, and the defendant's defense that the supplies were not medically necessary. The main issue decided was whether the medical supplies provided were necessary for the treatment of the injuries sustained in the auto accident. The holding of the court was that after reviewing the evidence presented, including invoices and prescriptions, the medical supplies provided were found to be medically necessary. Therefore, the court ruled in favor of the plaintiff, Expo Medical Supplies, Inc., ordering the defendant, Clarendon Insurance Company, to pay $2,882.85 for the medical supplies provided.

The relevant facts the court considered in State Farm Mut. Auto. Ins. Co. v Baltz Concrete Constr., Inc. were that State Farm Mutual Automobile Insurance Company sought to recover insurance benefits paid to its insured from Baltz Concrete Construction, Inc. The main issue decided by the court was whether the Insurance Law prohibited State Farm from seeking recovery of benefits it had paid to its insured for "extended economic loss" pursuant to an "additional personal injury protection" endorsement. The holding of the case was that the defendants were entitled to judgment as a matter of law because the plaintiff's subrogor had unsuccessfully sought to recover damages for his extended economic loss from them in a prior action, and the jury verdict in that action had preclusive effect on the issue of the plaintiff's entitlement to recoup the benefits it had paid to its subrogor for extended economic loss. Therefore, the motion for summary judgment dismissing the complaint was properly granted.

The civil court case of Universal Open MRI of the Bronx, P.C. v State Farm Mut. Auto Ins. involved the plaintiff seeking to recover first-party no-fault benefits for health care services rendered to an assignor allegedly injured in an automobile accident. The defendant denied the claims on the basis that the injuries did not arise out of an insured incident, and presented evidence that the accident was deliberate and staged. The main issue decided was whether the defendant's evidence was admissible and sufficient to prove that the injuries were not covered by no-fault insurance, and the court held that the defendant failed to come forward with admissible evidence to establish intentional collision, and thus ruled in favor of the plaintiff for the recovery of the benefits. In summary, the relevant facts considered by the court included the defendant's evidence based on its investigation of the accident, and the main issue decided was whether the defendant had provided sufficient admissible evidence to prove lack of coverage under the insurance policy. The holding of the court was in favor of the plaintiff, as it ruled that the defendant failed to provide admissible evidence to establish intentional collision, and judgment was granted for the plaintiff in the amount of $1,842.26.

The court considered the fact that the action was commenced by a summons and complaint in July, 2002 for unpaid medical bills submitted to defendant no-fault carrier on behalf of its assignor in the amount of $3,389.72. An Answer was interposed in August, 2002, together with various discovery demands. Plaintiff failed to respond to defendant's demands, and a stipulation was agreed upon, in which plaintiff agreed to respond to defendant's discovery demands within sixty (60) days or be precluded from offering evidence at trial. Plaintiff failed to respond within the sixty days, and defendant brought a motion to dismiss the case. The main issue decided in the case was whether plaintiff's failure to comply with the discovery stipulation warranted summary judgment in favor of defendant. The court held that the plaintiff's failure to produce evidentiary proof in admissible form, and its failure to oppose the defendant's motion, warranted granting summary judgment in favor of the defendant. Therefore, the court dismissed the action.

The relevant facts considered by the court were that the plaintiff had rendered medical services to the defendant's insured, who had been in an automobile accident, and had submitted three claims for payment of first-party no-fault benefits, all of which were timely denied by the defendant. The main issues decided were whether the defendant had provided sufficient evidence to rebut the plaintiff's prima facie showing and whether interest on the judgment should accrue from the date of claim denial or filing of a lawsuit. The holding of the court was that the defendant had failed to provide admissible proof to oppose the motion for summary judgment, so the motion was granted in favor of the plaintiff. Additionally, interest was to accrue at two percent per month from the date the lawsuit was filed, and the plaintiff was entitled to attorneys' fees.