No-Fault Case Law
Gribenko v Allstate Ins. Co. (2005 NYSlipOp 52201(U))
December 30, 2005
The relevant fact that the court considered was that a health care provider submitted a claim for payment of no-fault benefits and that there was a dispute over whether the claim forms were actually mailed to the insurance company. The main issue decided was whether the health care provider had established a prima facie case that the claim forms were properly sent and that the insurance company failed to pay or deny the claims within the required time period. The holding of the case was that the health care provider had failed to provide competent proof that the claim forms were submitted to the insurance company, and therefore, they did not make the requisite showing to establish a prima facie entitlement to summary judgment. As a result, the order granting the motion for summary judgment was reversed, and the insurance company's motion for summary judgment was denied.
Ocean Diagnostic Imaging P.C. v AIU Ins. Co. (2005 NY Slip Op 52200(U))
December 30, 2005
The relevant facts considered by the court in this case were that Ocean Diagnostic Imaging P.C. sought to recover first-party no-fault benefits for medical services rendered to its assignor. The plaintiff established a prima facie entitlement to summary judgment by demonstrating that it had submitted claims for the losses sustained and that the payment of benefits was overdue. The main issue decided by the court was whether the defendant, AIU Insurance Company, was precluded from raising defenses due to its failure to pay or deny the claims within the prescribed 30-day period. The holding of the court was that while the defendant was precluded from raising most defenses, it could assert the defense that the alleged injuries did not arise out of a covered accident. The court found that the defendant had demonstrated the existence of a triable issue of fact as to the lack of coverage, and therefore, the plaintiff's motion for summary judgment was properly denied.
Mega Supply & Billing Inc. v Allstate Ins. Co. (2005 NY Slip Op 52168(U))
December 30, 2005
The relevant facts considered by the court included the plaintiff's motion for summary judgment to recover no-fault benefits from the defendant in the amount of $540.00, which the defendant failed to pay or deny within the required 30-day period. The main issue decided by the court was whether the defendant had a valid basis to toll the 30-day period for payment of benefits. The court also considered the defense of lack of medical necessity and the assertion by the defendant that the accident was staged in order to deny the claim. The holding of the case was that the plaintiff's motion for summary judgment was granted, and the court directed the clerk to enter judgment in favor of the plaintiff in the sum of $540.00, statutory interest, and attorney's fees.
St. Vincent’s Hosp. & Med. Ctr. v County Wide Ins. Co. (2005 NY Slip Op 10114)
December 27, 2005
The court considered an action to recover no-fault medical payments under an insurance contract. The main issue was whether the plaintiffs were entitled to summary judgment on their first and second causes of action, and whether the defendant's cross motion for summary judgment dismissing those actions should be granted. The holding was that the Supreme Court correctly granted the defendant insurer's cross motion for summary judgment dismissing the first cause of action, but erred in granting summary judgment dismissing the second cause of action. The second cause of action was reinstated, as numerous questions of fact existed as to how the claim was processed and whether it should be paid by a workers' compensation carrier. Neither party demonstrated its prima facie entitlement to judgment as a matter of law, and the remaining contentions were deemed without merit.
Lamed Med. P.C. v Travelers Ins. Co. (2005 NY Slip Op 52142(U))
December 22, 2005
The court case involved Lamed Medical P.C., a medical services provider, seeking to vacate a master arbitration award after the lower arbitrator denied its claim, and the master arbitrator subsequently denied the request for review on the basis that the appeal was untimely. The main issue decided was whether the request for review was timely made, and if not, whether the Master Arbitrator had the authority to deny the request for review. The court held that the petitioner failed to demonstrate a ground to vacate the Master Arbitrator's decision and that the determination that petitioner failed to timely appeal the lower arbitration award was not arbitrary or a violation of petitioner's due process rights. The court dismissed the petition to vacate the Master Arbitrator's award, stating that the petition would be denied even if it had complied with statutory requirements.
Multiquest, P.L.L.C. v Allstate Ins. Co. (2005 NY Slip Op 52071(U))
December 20, 2005
The court considered a series of 12 actions seeking no fault first class benefits, which involved motions for summary judgment from plaintiff Multiquest, P.L.L.C., and cross-motions. The main issue decided was whether the decision of the New York Court of Appeals in State Farm v. Mallela should be applied to the cases at hand. The holding of the case was that the decision in State Farm v. Mallela should be applied, and that under the facts of the case, Multiquest, P.L.L.C. was entitled to summary judgment on its claim.
Multiquest PLLC v Allstate Ins. Co. (2005 NY Slip Op 52209(U))
December 19, 2005
The court considered whether Multiquest PLLC was entitled to summary judgment in its action against Allstate Insurance Company to recover the cost of health care services, according to the Insurance Law and regulations of the New York State Insurance Department. The main issue at hand was whether the evidence provided by Multiquest was sufficient to warrant summary judgment, and whether Allstate was entitled to summary judgment to deny payment to Multiquest based on allegations of fraudulent billing practices. The court held that Multiquest's motion for summary judgment was denied, and Allstate's motion for summary judgment was granted. The complaint filed by Multiquest was dismissed. Despite Multiquest's failure to establish evidence supporting their claim, the court also noted that recent Court of Appeals decisions involving No-Fault Law have addressed the issue of insurance fraud, which has undermined the goals of the law.
Multiquest, P.L.L.C. v Allstate Ins. Co. (2005 NY Slip Op 52069(U))
December 19, 2005
The court considered the motion for summary judgment from both parties, who were involved in a case concerning the Comprehensive Motor Vehicle Reparations Act for reimbursement of psychological injury treatments following an automobile accident. The critical issue was whether the plaintiff could receive payment for the psychological treatments due to a timely denial from the defendant. The court holding is that the defendant's failure to issue a timely denial of claim rendered the no-fault benefits overdue according to the law. The defendant argued that the plaintiff did not have a psychologist as an "owner" at the time of billing for services, and the corporate structure of the plaintiff was defective. However, the court did not take these arguments into account. Furthermore, the court determined that the regulation does not apply retroactively to bar recovery of the no-fault claim.
JSI Expert Servs. Inc. v Firemans Fund Ins. Co. (2005 NY Slip Op 52058(U))
December 16, 2005
The court considered a case in which JSI Expert Services Inc., sought to recover first party no-fault benefits for medical equipment provided to treat its assignor. The main issue was whether the insurance company had the right to raise a defense at the arbitration hearing that the assignor was working at the time of the accident, despite failing to deny the claim in a timely manner. The court concluded that the defense raised by the insurance company was a denial of coverage defense and was not precluded by the fact that it failed to timely deny the claim. The holding of the court was that the arbitrator's award was rational and not arbitrary or capricious, so the petition was dismissed and the insurance company's motion to dismiss the petition was granted.
Careplus Med. Supply Inc. v State-Wide Ins. Co. (2005 NY Slip Op 25545)
December 15, 2005
The relevant facts of the case were that Careplus Medical Supply was seeking to recover first-party no-fault benefits for medical supplies it provided, while State-Wide Insurance Company had submitted a properly completed denial of claim form covering all the claims involved in the lawsuit. The main issue was whether the denial of claim form submitted by State-Wide Insurance Company established that the claims were sent and received. The court held that the denial of claim form submitted by State-Wide Insurance Company sufficiently established that the plaintiff sent and the defendant received the claims. Therefore, the court unanimously reversed the previous order without costs, granted plaintiff's motion for summary judgment, and remanded the matter to the court below for a calculation of statutory interest and an assessment of attorney's fees.