No-Fault Case Law

A.B. Med. Servs. PLLC v Encompass Ins. (2005 NY Slip Op 51892(U))

The court considered whether the plaintiffs, A.B. Medical Services PLLC, D.A.V. Chiropractic P.C., and Daniel Kim's Acupuncture P.C., were entitled to summary judgment in their case against Encompass Insurance for failing to pay their no-fault benefits claims within the 30-day period. The court held that the plaintiffs established a prima facie entitlement to summary judgment, as it was uncontroverted that the defendant failed to pay or deny the claims within the required timeframe, precluding them from raising most defenses. The court also determined that the defendant's failure to seek verification of the assignments and to allege any deficiency in the assignments constituted a waiver of any defenses. However, the defendant could still assert a lack of coverage defense on the ground that the alleged injuries were not causally related to the accident, but their submissions were insufficient to demonstrate the insurer's defense was based on a "founded belief." Therefore, the motion for summary judgment by the plaintiffs was granted, and the matter was remanded for the calculation of statutory interest and attorney's fees. The appeal with respect to Somun Acupuncture P.C. was dismissed.
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Scotland v Allstate Ins. Co. (2005 NY Slip Op 51888(U))

The court considered the fact that the plaintiff, a New York resident, had been involved in an accident in Queens and sought to recover under the uninsured motorist endorsement of his automobile policy issued in Virginia. The main issue decided was whether the plaintiff was required to prove "serious injury" as defined by New York law, as the policy was issued in Virginia. The holding of the case was that the law of New York should be applied, and the plaintiff was required to demonstrate that he sustained a "serious injury." The court affirmed the denial of the plaintiff's motion to dismiss certain affirmative defenses, stating that the New York courts should apply the "serious injury" requirement, as strong policy considerations underlie it and the accident location and situs of the loss or injury were in New York.
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Elite Chiropractic Servs., PC v Travelers Ins. Co. (2005 NY Slip Op 51735(U))

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.
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Function Supply v Progressive Ins. Co. (2005 NY Slip Op 51755(U))

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.
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Stand-Up MRI of Bronx v General Assur. Ins. (2005 NY Slip Op 25453)

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.
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Matter of Green v Liberty Mut. Ins. Co. (2005 NY Slip Op 07961)

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.
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Ontaneda v Country-Wide Ins. Co. (2005 NY Slip Op 07938)

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.
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Ocean Diagnostic Imaging, P.C. v Utica Mut. Ins. Co. (2005 NY Slip Op 51747(U))

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.
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D.A.V. Chiropractic P.C. v GEICO Ins. (2005 NY Slip Op 51746(U))

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.
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Ocean Diagnostic Imaging, P.C. v Utica Mut. Ins. Co. (2005 NYSlipOp 51745(U))

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.
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