No-Fault Case Law

The court considered the fact that plaintiff provided medical services to its assignor and submitted claims to the defendant insurer seeking first-party no-fault benefits. The main issue decided was whether the defendant insurer was obligated to pay or deny a claim when the plaintiff and its assignor failed to respond to timely requests for additional verification. The holding of the court was that the defendant insurer established its entitlement to summary judgment dismissing the complaint, as it was not obligated to pay or deny a claim until requested verifications were provided. The court found that the plaintiff and its assignor failed to respond to the defendant's timely requests for additional verification, making any claim for payment premature. Therefore, the defendant was not required to respond to the plaintiff's claims, and the claim for payment was not valid.

The court considered the plaintiff's action to recover first-party no-fault benefits for medical services rendered to its assignor, as well as the defendant's motion for summary judgment on the grounds that the claims were not overdue and the action was premature. The main issues decided were whether the defendant failed to pay or deny the claims within the statutory 30-day period as required by Insurance Law section 5106(a), and whether the defendant's verification requests were timely sent to the plaintiff. The court held that the defendant's motion for summary judgment was denied, and that the plaintiff's cross-motion for summary judgment was granted, awarding judgment in favor of the plaintiff in the amount of $759.00, together with statutory interest and attorney's fees.

The court considered the fact that plaintiff is the assignee of a person involved in an automobile accident who was entitled to health service expenses under an insurance policy, specifically MRIs of her lumbar and cervical spine. Plaintiff timely submitted a bill for these MRIs to the defendant, who denied payment based on a defense of no medical necessity. However, at trial, the defendant for the first time raised an objection to the referral as an improper self-referral as prohibited by section 238-a of the Public Health Law. The issue was one of first impression in the court. The court found the referral to be in violation of section 238-a and dismissed the case. Issues Decided: Whether a medical referral was proper and legal according to the Public Health Law. Whether this concern had been properly raised and addressed by the parties. Holding: This case was dismissed based on the court's finding that the referral in question was improper and in violation of section 238-a of the Public Health Law.

The court considered whether a master arbitrator's award, affirming an original award of an arbitrator, should be vacated. The main issues were whether there were grounds specified in CPLR 7511 for vacating or modifying a no-fault arbitration award and whether the arbitrator acted within his discretionary authority in refusing to entertain late submissions from the parties. The court held that consistent with the public policy in favor of arbitration, the grounds specified in CPLR 7511 for vacating or modifying a no-fault arbitration award are few in number and narrowly applied. The court also held that the petitioner failed to demonstrate the existence of any of the statutory grounds for vacating the master arbitrator's award, and the arbitrator acted within his discretionary authority in refusing to entertain late submissions from each of the parties. The determination of the master arbitrator affirming the original award had a rational basis.

The court considered that the plaintiff had sustained personal injuries in an automobile accident and pursued multiple actions and arbitration to recover benefits from her insurance company. The main issue decided was whether the general release the plaintiff signed in connection with the settlement of her second action barred her from bringing the instant action seeking damages for breach of contract. The holding of the court was that the general release signed by the plaintiff barred the instant action. The court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint, stating that the general release signed by the plaintiff barred her from seeking damages for breach of contract based on the delay in processing her insurance claims.

The relevant facts considered by the court involved a health care provider seeking to recover no-fault benefits, and the insurance company's failure to deny the claim within the statutory 30-day period. The main issue decided was whether the insurance company's failure to deny the claim within the 30-day period precluded it from interposing defenses other than a claim that the incident was staged to defraud. The holding of the case was that the insurance company's failure to deny the claim within the 30-day period, as well as its untimely requests for examinations under oath, violated the statutory time frames and precluded it from interposing defenses aside from the fraud claim. The court also concluded that the insurance company's proof of fraud was not submitted in admissible form, failing to raise a triable issue of fraud. The court affirmed the order without costs.

The court considered the plaintiff's motion for partial summary judgment in a case where D.A.V. Chiropractic P.C. sought first-party no-fault benefits for medical supplies furnished to its assignor. The main issue was whether the plaintiff had established a prima facie entitlement to summary judgment and whether the defendant's denial of claim forms, with unaffirmed peer reviews attached, raised a triable issue of fact regarding medical necessity. The court held that while the plaintiff had established a prima facie entitlement to summary judgment, the defendant's reliance on unaffirmed peer reviews which contained a sufficient factual basis and medical rationale raised a triable issue of fact regarding medical necessity, warranting the denial of the plaintiff's motion for partial summary judgment. The appeal made by plaintiff Daniel Kim's Acupuncture P.C. was dismissed.

The main issues were whether defendant established a tolling of the statutory time and whether plaintiff health care provider established its prima facie entitlement to summary judgment by proof that it submitted a statutory claim form setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. The court held that the district court was right to grant plaintiff's motion for summary judgment and deny defendant's cross motion for summary judgment or an order compelling discovery. Defendant's conceded failure to deny the claim on time precluded most defenses unless it established a tolling of the statutory time. Also, the verification requests by the defendant failed to toll the claim determination period. Lastly, the defense that the incident was staged to defraud did not survive the preclusion sanction as plaintiff's proof offered to establish the defense was inadmissible form.

The court considered the case of A.B. Medical Services PLLC et al. as assignee of Sahara Abbott, who were appealing against Utica Mutual Insurance Company. The claimants were seeking partial summary judgment in the sums of $6,765.47 and $1,690.56 respectively. The main issues decided by the court were whether the defendant violated the 30-day claim determination period and precluded itself from interposing most defenses as to all claims mailed on or before November 2, 2002, and whether they demonstrated a tolling via proof that one or more of the notice of physical examination letters were issued and the plaintiffs failed to appear. The holding of the court includes the modification of the order by granting the plaintiffs' partial summary judgment in the declared sums and remanding other claims to the court below for a calculation of statutory interest and an assessment of attorney's fees. The appeal as taken by plaintiff Square Synagogue Transportation Inc. was unanimously dismissed. The court determined that the defendant failed to establish a triable issue of fraud and proper verification requests with respect to its letters, and that the letters issued were ineffective to toll the 30-day claim determination period.

The relevant facts considered by the court were that plaintiff, a healthcare provider, submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that defendant insurance company failed to pay or deny the claim within the prescribed period. The main issue decided was whether defendant was precluded from raising certain defenses due to the untimely denial of the claim, and whether the defense of insurance fraud scheme could be asserted. The holding of the case was that plaintiff was not entitled to summary judgment because defendant raised a triable issue of fact as to whether there was a lack of coverage, and the court erred in granting plaintiff's motion for summary judgment.