No-Fault Case Law

The main issue in this case was whether the insurer was justified in denying a claim for no-fault benefits for medical services provided to the plaintiff's assignor based on lack of medical necessity. The court considered the fact that the insurer denied the claim on the ground of lack of medical necessity based on a peer review report that concluded there was no medical necessity due to the lack of sufficient information. The court held that the insurer's denial was deficient, as it failed to set forth an adequate factual basis and medical rationale. The court also held that the insurer was not obligated to seek further verification if the peer review report clearly indicated that the pertinent physician's reports and other documentation had been requested and provided for the purpose of conducting a peer review. Therefore, the court reversed the order denying summary judgment, granted plaintiff's motion for summary judgment, and remanded the matter for the calculation of statutory interest and an assessment of attorney's fees.

The relevant facts considered by the court included the failure of the plaintiff to adequately establish that they submitted the claim forms to the defendant. The main issue decided was whether the plaintiff demonstrated an entitlement to summary judgment on the first cause of action regarding the assignor Robert Gevorkov. The court held that the plaintiff did not provide proof of proper mailing of the claim forms regarding assignor Robert Gevorkov, and therefore, the lower court's order granting the plaintiff's motion for summary judgment was reversed and denied.

The court considered the fact that the plaintiff, Dr. Patil, sought to recover first-party no-fault benefits from Countrywide Insurance Company. The main issue decided was whether the plaintiff had established a prima facie entitlement to summary judgment by submitting statutory claim forms showing the amount of losses sustained and that the payment of benefits was overdue, as required by Insurance Law § 5106(a). The court held that the plaintiff's motion for summary judgment was properly denied because the necessary claim forms were not properly appended to the motion papers, and the affirmation by the plaintiff's attorney without personal knowledge did not constitute a proper vehicle for the admissibility of the claim forms. The court also noted that a nurse's peer review may be competent to establish the admissibility of medical opinions and conclusions, but the plaintiff's motion was properly denied with leave to renew upon submission of proper papers.

The relevant facts of the case are that V.S. Medical Services, P.C. sought to recover $10,811.67 in first-party no-fault benefits for medical services rendered to its assignor, Rafael Rodrigues, who was allegedly injured in a motor vehicle accident. State Farm Mutual Insurance Co. denied the claim, arguing that the injuries did not arise out of an insured incident. The main issue decided was whether defendant's denial of the claim was based on a founded belief that the injuries did not arise out of an insured incident. The holding of the case was that the affidavit submitted by defendant's investigator was sufficient to demonstrate that defendant's denial was based on a founded belief, and plaintiff's motion for summary judgment was denied. The dissenting opinion argued that the plaintiff lacked standing to prosecute the claim and failed to submit the requisite documents in accordance with statutory billing forms, and therefore did not make out a prima facie entitlement to summary judgment.

The relevant facts that the court considered in this case were that A.R. Medical Art, P.C. sought to recover fees for EMG/NCV tests performed on a patient, Nato Seselia. State Farm Mutual Automobile Insurance Company denied payment, claiming the tests were medically unnecessary. The main issue decided by the court was whether the EMG/NCV tests were necessary, with State Farm bearing the burden of proof. The holding of the case was that the insurer failed to show that the tests were inconsistent with generally accepted medical practices and were therefore medically unnecessary. As a result, the court rendered judgment in favor of the plaintiff and against the defendant in the sum of $2,143.90.

The relevant facts the court considered were that the plaintiff had failed to respond to certain discovery demands, resulting in the dismissal of the complaint in February 2005. The main issue decided was whether Supreme Court erred in granting relief to the plaintiff after she failed to appeal the dismissal of the complaint, and whether a motion to vacate pursuant to CPLR 5015 (a) (1) was appropriate. The holding of the court was that the default that the plaintiff sought to vacate was her default in opposing the defendant's motion to preclude in the first instance, and therefore, Supreme Court did not err in entertaining her motion to vacate. The court affirmed the order with costs.

The court considered an action to recover first-party no-fault benefits for medical services rendered to the plaintiffs' assignor. The main issues decided were whether the plaintiffs were entitled to partial summary judgment for their claim, and whether the defendant's discovery demands should be granted. The court held that the plaintiffs were entitled to partial summary judgment, as they established their entitlement to the benefits, and the defendant's assertion that it timely denied the claims lacked merit. However, the court also ordered a hearing to determine the plaintiffs' compliance with licensing requirements, as the defendant was entitled to information regarding the corporate structure and licensing status of the plaintiffs. The court also granted the defendant's cross motion to determine the genuineness of the signature of the plaintiffs' counsel on various papers submitted in the case.

The court considered the fact that plaintiff PDG Psychological P.C. was seeking to recover first-party no-fault benefits for health care services rendered to its assignor, Gloria Jones. Defendant Utica Mutual Insurance Company moved for summary judgment dismissing the complaint, while plaintiff cross-moved for summary judgment. The main issue decided was whether plaintiff was entitled to rely upon defendant's denial of claim forms to establish the dates of defendant's receipt of the claim forms, and whether defendant mailed the denial of claim forms to plaintiff within the prescribed 30-day claim determination period. The holding was that plaintiff established a prima facie entitlement to summary judgment, and since defendant failed to establish that it mailed the denial of claim forms to plaintiff within the prescribed 30-day claim determination period, it was precluded from raising its defenses and the court properly granted plaintiff's cross motion for summary judgment.

The court considered the case of Star Medical Services, P.C. v Allstate Insurance Company, pertaining to the recovery of first-party no-fault benefits for medical services that were rendered. The main issue was whether the plaintiff health care provider had established a prima facie entitlement to summary judgment through proof of submitting claims and the overdue payment of no-fault benefits. The decision held that plaintiff was entitled to summary judgment in the principal sum of $1,791 with respect to the claims submitted on behalf of Naika Gousse. The matter was remanded to the court for calculation of statutory interest and attorney's fees due on those claims, as well as for all further proceedings on the remaining claims submitted on behalf of Jimmy Cadet. Additionally, the court concluded that the defendant failed to follow the requisite follow-up verification procedures and that claim denials based upon nonattendance for examinations under oath were ineffective. Finally, it was determined that the defendant's submissions were legally sufficient to support the allegations that the injuries did not arise out of an insured incident for the claims submitted on behalf of Jimmy Cadet.

The court considered a motion to vacate a default judgment entered against Allstate Insurance Company in an action to recover first-party no-fault benefits for medical services rendered to the plaintiffs' assignor. The main issues decided were whether the defendant established a reasonable excuse for the default and a meritorious defense to the action. The court held that the lower court had improvidently exercised its discretion in granting defendant's motion to vacate the default judgment. It was determined that the defendant did not show a reasonable excuse for the default and failed to sufficiently establish a meritorious defense. The court found that the defendant's moving papers did not include an affidavit by someone with personal knowledge of the underlying circumstances, and therefore did not meet the necessary burden of proof.