No-Fault Case Law

The relevant facts that the court considered in Rigid Med. of Flatbush, P.C. v New York Cent. Mut. Fire Ins. Co. were that the plaintiff health care provider sought to recover no-fault benefits for medical services rendered to its assignor, and established a prima facie entitlement to summary judgment by proving that it submitted the statutory claim form and that payment was overdue. The main issue in this case was whether the defendant's denial based on the assignor's failure to attend examinations under oath was proper and timely. The holding of the case was that the defendant failed to establish that the insurance policy contained an endorsement authorizing examinations under oath, and therefore any post-claim examination under oath request could not toll the 30-day period within which the defendant was required to pay or deny the claim. As a result, the plaintiff's motion for summary judgment was properly granted.

The court considered the motion by State Farm Mutual Automobile Insurance Company to vacate a default judgment in an action to recover assigned first-party no-fault benefits. The main issue decided was whether State Farm Mutual Automobile Insurance Company had established a reasonable excuse for its default and a meritorious defense to the action. The holding of the court was that upon a review of the record, there was no basis to disturb the lower court's finding that the defendant had indeed established both a reasonable excuse for its default and a meritorious defense to the action. Therefore, the lower court's order granting the defendant's motion to vacate the default judgment was affirmed.

The main issue decided in this case was whether the defendant was entitled to discovery regarding plaintiff's corporate structure and licensing status before summary judgment could be granted. The court considered that the defendant was entitled to compliance with its various discovery demands which sought information regarding plaintiff's corporate structure and licensing status. Until such discovery was provided, the plaintiff's cross-motion for summary judgment was to be denied as premature. The court held that the plaintiff's cross-motion for summary judgment was denied without prejudice to renewal upon completion of discovery. Additionally, the defendant's motion to strike plaintiff's complaint was granted unless plaintiff complied with the defendant's discovery demands within 60 days. Furthermore, the defendant's discovery demands to the extent they sought information regarding defenses defendant was precluded from raising due to its untimely denial of the claim were struck down.

The Supreme Court in this case granted the defendant's motion to vacate its default in answering and for an extension of time to answer pursuant to CPLR 3012 (d). The defendant demonstrated a reasonable excuse for its brief delay in serving an answer and potentially meritorious defenses. The default was not willful, nor was there a showing of prejudice to the plaintiffs. Therefore, the Court held that the default was properly vacated. Furthermore, the Court also granted the defendant's separate motion to quash an information subpoena, finding that this was also properly granted. As a result, the order of the Supreme Court was affirmed with costs.

The relevant facts considered in the case were that Better Health Medical PLLC, a provider of medical services, sought to recover first-party no-fault benefits for medical services provided to its assignor, totaling $1,764.62, with partial payments made in the amount of $849.84. The arbitrator's conclusion was that the company was dissolved and unlicensed and therefore ineligible to claim for no-fault benefits. The main issue decided was whether the Master Arbitrator's decision to deny payment to the provider was arbitrary, capricious, or an error of law. The holding of the court was that the arbitrator’s determination was not arbitrary or capricious, concluding that the fraud denial of the claim had a rational basis and was not incorrect as a matter of law. Therefore, the petition to vacate the arbitration award was dismissed.

The court considered the evidence provided by the plaintiff, including an assignment of benefits form, denial of claim forms, and an affidavit from the defendant's billing manager. The main issue decided here was whether the plaintiff had established a prima facie entitlement to summary judgment under the No-Fault Law. The court held that plaintiff had indeed established its entitlement to summary judgment, as the defendant did not present enough evidence to support its defense that the injuries were not related to the accident. Therefore, the court granted the plaintiff's motion for summary judgment in the amount of $3,383.38, plus interest and attorney's fees.

The court considered whether an insurance company was required to pay no-fault benefits directly to a medical provider or its assigned assignee, when the services were performed by an independent contractor. The main issue was whether the health care services were provided by the plaintiff or its employees, or by an independent contractor. The court held that under Insurance Department regulation 11 NYCRR 65-3.11, if the services were not performed by the billing provider or its employees, but by a treating provider who is an independent contractor, the billing provider is not entitled to direct payment of assigned no-fault benefits. Therefore, the court affirmed the grant of summary judgment to the defendant insurance company, as the plaintiff was not properly considered a "provider" authorized to bill under the no-fault law.

The case between New York Craniofacial Care, P.C. and Allstate Ins. Co. was decided on March 29, 2006, in the Civil Court of New York, Kings County. The main issue decided in the case was whether a first-party No-Fault plaintiff, in this instance New York Craniofacial Care, P.C., needs to state in an affidavit that bills have not been paid, or if it also needs to state they have not been properly denied. The court found that a No-Fault plaintiff must establish that the claims were neither paid nor properly denied within 30 days. The court further held that to move for summary judgment, a plaintiff must submit an affidavit stating the basis of its entitlement to summary judgment and addressing known defenses. Since the plaintiff in this case failed to do so, the motion was denied.

The relevant facts in New York and Presbyterian Hospital v Travelers Property Casualty Insurance Company, include an action to recover no-fault medical payments, in which New York and Presbyterian Hospital, as the assignee of William Browne, and New York Hospital Medical Center of Queens, as assignee of Amy Kazane, were the plaintiffs. The main issue decided was whether the defendant's motion to vacate a judgment entered upon its failure to appear or answer the complaint, and for leave to serve a late answer, should be granted. The holding of the case was that the defendant was required to demonstrate both a reasonable excuse for the default and a meritorious defense, and the defendant made that showing. Therefore, the Supreme Court granted the defendant's motion to vacate the judgment and for leave to serve a late answer.

The relevant facts considered by the court in this case was an action to recover assigned first-party no-fault benefits. The plaintiff health care provider moved for summary judgment, while the defendant argued that the assignor failed to attend examinations under oath (EUOs) and that the accident was in furtherance of an insurance fraud scheme. The main issues decided were whether the EUO requests tolled the 30-day claim determination period, rendering the denial untimely, and whether the defendant failed to establish a triable issue of fraud regarding the accident being staged for a scheme to defraud. The holding of the case was that the order denying plaintiff's motion for summary judgment was reversed, and the matter was remanded to the court below for a calculation of the statutory interest and an assessment of attorney's fees. The dissenting opinion disagreed with the majority's finding, stating that the defendant should not have been required to produce a copy of the insurance policy, and would have affirmed the lower court's denial of the plaintiff's motion for summary judgment.