No-Fault Case Law

Staten Is. Chiropractic Assoc., P.C. v Long Is. Ins. Co. (2006 NY Slip Op 50588(U))

The main issue in this case was whether the plaintiff, Staten Island Chiropractic Assoc., P.C., was entitled to recover $8,388.13 in first-party no-fault benefits for health care services provided to their assignor. Plaintiff had moved for summary judgment, but the court denied the motion. The court considered the fact that the defendant, Long Island Insurance Company, denied receiving the claims from the plaintiff. The plaintiff's only proof that it submitted its claims was a provider's statement that failed to prove a standard office practice or procedure designed to ensure that items are properly addressed and mailed. The court also considered that although plaintiff proved a claim denial form used by the defendant, the form admitted receipt of no specific claim and cannot be construed to concede that defendant received the specific claims at issue. In the end, the court affirmed the decision to deny plaintiff's motion for summary judgment.
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A.B. Med. Servs. PLLC v Utica Mut. Ins. Co. (2006 NY Slip Op 51334(U))

The case involved an action to recover $7,762.98 in assigned first-party no-fault benefits from a motor vehicle accident. The provider of health care services, the plaintiff, established their entitlement to summary judgment by submitting statutory claim forms indicating the fact and amounts of the losses sustained. The burden then shifted to the defendant to create a triable issue of fact. The claim denial form issued by the defendant was found to be untimely, except for a few claims, and was also found to be fatally defective due to the omission of numerous items of requested information, making it incomplete. As a result, the court granted the plaintiffs' motion for summary judgment and remanded the matter to the court for a calculation of statutory interest and an assessment of attorney's fees.
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Rigid Med. of Flatbush, P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 50582(U))

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.
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Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2006 NY Slip Op 50581(U))

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.
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SK Med. Servs., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 50721(U))

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.
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New York & Presbyt. Hosp. v Auto One Ins. Co. (2006 NY Slip Op 02509)

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.
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Better Health Med. PLLC v Empire/Allcity Ins. Co. (2006 NY Slip Op 50571(U))

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.
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Capri Med., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 50538(U))

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.
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Craig Antell, D.O., P.C. v New York Cent. Mut. Fire Ins. Co. (2006 NY Slip Op 50521(U))

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.
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New York Craniofacial Care, P.C. v Allstate Ins. Co. (2006 NY Slip Op 50500(U))

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.
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