No-Fault Case Law

The court considered the facts of an action to recover assigned first-party no-fault benefits, in which the defendant moved to strike the complaint, or alternatively, to preclude the plaintiff from offering testimony at trial or compel plaintiff to respond to its demand for a bill of particulars and demand for discovery and inspection. The plaintiff also cross-moved for summary judgment, which the defendant opposed. The main issue decided was whether the plaintiff had established its prima facie entitlement to summary judgment, and whether the defendant's motion should be granted on default. The court held that the plaintiff failed to establish its entitlement to summary judgment as the claim forms indicated that the named treating providers were independent contractors, and plaintiff did not cure this defect by providing evidence that the providers were employed by the plaintiff on the date the services were rendered. Additionally, the defendant's motion was granted on default and therefore no appeal lies therefrom. The court dismissed the appeal from the portion of the order that conditionally granted the defendant's motion and awarded costs.

The court considered the fact that First Help Acupuncture P.C. was seeking to recover no-fault benefits from State Farm Ins. Co. The main issue decided was whether the defendant demonstrated the existence of a triable issue of fact as to whether the plaintiff was a fraudulently licensed medical corporation. The court held that the defendant's submissions raised an issue of fact as to whether the plaintiff was a fraudulently incorporated medical corporation, and as a result, the plaintiff's motion for summary judgment was denied. This was based on the nonwaivable defense that a provider is fraudulently licensed and hence ineligible for reimbursement of no-fault benefits under 11 NYCRR 65-3.16 (a) (12).

The court considered the facts of the case in which the plaintiff sought unpaid medical bills for services rendered to the plaintiff's assignor that were submitted to the defendant no-fault carrier. The defendant acknowledged receipt of the plaintiff's bill but issued a denial for the services rendered due to lack of substantiation for the medical necessity. A stipulation was entered into by both parties, which required the defendant to produce all outstanding discovery within 60 days, and failure to do so would result in preclusion of evidence at trial. The main issue decided was the failure of the defendant to comply with the discovery stipulation and whether the plaintiff was entitled to summary judgment based on this failure. The holding of the court was that the defendant's failure to comply with the discovery stipulation resulted in the preclusion of any evidence not provided in the outstanding discovery notices, and the plaintiff was not entitled to summary judgment because they failed to prove that payment of no-fault benefits was overdue. Therefore, that portion of the motion was not granted, and trial would proceed with the available documentation.

The relevant facts that the court considered included an action to recover no-fault insurance benefits under certain insurance contracts. The plaintiffs appealed from an order of the Supreme Court, Nassau County which granted the defendant's motion to vacate a judgment in favor of the plaintiffs and against it and to extend its time to answer. The main issue decided was whether the defendant had received actual notice of the summons in time to defend and if the defendant's defenses were meritorious. The holding of the case was that the defendant did not receive actual notice of the summons in time to defend and that its defenses were meritorious, therefore the Supreme Court rightly exercised its discretion in vacating the default judgment and extending the defendant's time to answer.

The court considered that the plaintiff had submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that the defendant failed to pay or deny the claim within the 30-day prescribed period. The main issue decided was whether the defendant was precluded from raising certain defenses due to the untimely denial of the claim, and whether there was a lack of coverage. The holding of the case was that plaintiff's motion and defendant's cross motion for summary judgment should have been denied, as the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and an issue of fact existed as to whether there was a lack of coverage.

In this case, Dilon Medical Supply Corp. appealed the Civil Court of the City of New York, Kings County's denial of their motion for summary judgment in an action to recover assigned first-party no-fault benefits from State Farm Mutual Insurance Company. Dilon Medical Supply Corp. argued that they had mailed a statutory claim form to State Farm, and the State Farm employee's affidavit and denial of claim form established that the form was received, thereby establishing Dilon's prima facie entitlement to summary judgment. The court found that Dilon's motion for summary judgment was granted and the matter was remanded to the lower court for a calculation of statutory interest and an assessment of attorney's fees. State Farm attempted to raise issues related to a fraudulent scheme involving Dilon and medical equipment wholesalers, but the court found these defenses were precluded due to an untimely denial of the claim. The court also ruled that letters from State Farm to Dilon regarding payment delays did not toll the statutorily prescribed 30-day period within which to pay or deny the claim. The main issue decided in this case was whether Dilon was entitled to summary judgment on their claim for no-fault benefits, which the court ultimately decided in favor of Dilon.

The court considered whether the defendant was entitled to partial summary judgment upon the claims which it denied due to an alleged lack of medical necessity. The defendant argued that the affirmed peer review reports established its entitlement to judgment as a matter of law upon the issue of medical necessity and that the plaintiff failed to present evidence to demonstrate the existence of an issue of fact with regard to medical necessity. The court held that where a denial of claim form fails to set forth with sufficient particularity the factual basis and medical rationale for its denial based upon lack of medical necessity, the defendant is precluded from asserting said defense. The denial of claim forms submitted in this case were insufficient on their face for vagueness, and therefore, the defendant was not entitled to partial summary judgment as a matter of law.

The relevant facts the court considered were that Ultra Diagnostics Imaging was seeking to recover first-party no-fault benefits for medical services rendered to its assignor, David Pyon. The main issue decided was whether Ultra Diagnostics Imaging established a prima facie entitlement to summary judgment by proving that it submitted the claim, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. The holding of the case was that plaintiff's motion for summary judgment was granted because they established a prima facie entitlement, and the matter was remanded to the court below for a calculation of statutory interest and an assessment of attorney's fees. The burden then shifted to the defendant to demonstrate a triable issue of fact, which they failed to do. Consequently, the court reversed the order, granted plaintiff's motion for summary judgment, and remanded the case for further proceedings.

The relevant facts of the case involved Amaze Medical Supply Inc. seeking to recover first-party no-fault benefits for medical supplies provided to its assignor. The plaintiff, Amaze Medical Supply Inc., moved for summary judgment, but the court denied the motion, finding an issue of fact with regard to medical necessity. The main issue decided was whether defendant's affirmed peer review report, which referred to unaffirmed reports prepared by doctors who treated the plaintiff's assignor, was admissible as evidence. The holding of the case was that the affirmed medical reports prepared by the defendant's doctors, which referred to unaffirmed reports prepared by plaintiff’s doctor, were sufficient to raise a triable issue of fact and were admissible in opposition to a motion for summary judgment. As a result, the court affirmed the order denying plaintiff's motion for summary judgment.

The relevant facts of the case Vista Surgical Supplies, Inc. v Statewide Ins. Co. involved a plaintiff provider seeking to recover assigned first-party no-fault benefits. The plaintiff moved for summary judgment, but in order to establish a prima facie entitlement to summary judgment, they were required to prove that they submitted the claims and that payment of no-fault benefits was overdue. The plaintiff submitted an affidavit and copies of certified mail receipts and return receipt cards but failed to establish that the claims were actually mailed to the defendant or that the defendant received them. The court found that there was no competent evidence establishing the plaintiff's mailing of the claims or the defendant's receipt of them, and therefore, the plaintiff did not make the requisite showing to establish a prima facie entitlement to summary judgment. As a result, the court affirmed the order denying the plaintiff's motion for summary judgment.