No-Fault Case Law

The main issue in this legal case was whether first-party no-fault benefits could be denied by an insurer for lack of medical necessity, when the provider had submitted proper proof of claim for the services. American Transit Insurance Company had denied payment for medical and rehabilitation services provided to Sandra Berger, citing lack of medical necessity based upon a medical examination conducted by Dr. Irving Liebman, a board-certified orthopedic surgeon. The court considered whether Dr. Liebman's findings provided sufficient evidence to establish prima facie that the subsequent treatment was not medically necessary. The court ultimately held that Dr. Liebman's report did not establish prima facie the absence of "serious injury" and therefore denied the plaintiff's motion for summary judgment and the defendant's cross-motion for summary judgment. The court ruled that the "presumption of medical necessity" that attaches to the provider's claim forms was not sufficiently rebutted to establish that the insurer was entitled to judgment as a matter of law.

The court considered a motion for summary judgment in a case involving a claim for first-party no-fault benefits for medical supplies provided to an assignor. The plaintiff established a prima facie case for summary judgment by demonstrating that it submitted claims and that payment of the benefits was overdue. In response, the defendant submitted peer reviews that raised a triable issue as to the medical necessity of the equipment. The main issue decided in the case was whether the plaintiff was entitled to summary judgment for the recovery of first-party no-fault benefits. The court held that the order denying the plaintiff's motion for summary judgment was affirmed without costs, indicating that there was a genuine issue as to the medical necessity of the equipment, and therefore summary judgment was not appropriate.

The court considered a billing dispute between a psychiatric services provider and an insurance company. The main issue in the case was whether the services provided were medically necessary. The court decided that based on the testimony of the expert witnesses and the evidence presented, the comprehensive intake interview was never performed, and therefore the payment for certain services was denied. The court found that a comprehensive intake interview was necessary to determine the medical necessity and appropriateness of the various tests performed, which was not done in this case. Based on this, the court denied payment for the psychological testing and for the explanation and interpretation of results to the primary physician. However, the court did award payment for the review of records for medical diagnosis, as the insurance company had failed to prove that it was not medically necessary. Therefore, judgment was entered in favor of the plaintiff for the amount of $67.24, along with statutory interest and attorney's fees and costs.

The case revolves around an action taken by Hospital for Joint Diseases to recover unpaid no-fault benefits. The Supreme Court decided on an order that granted the defendant's cross motion for summary judgment dismissing the first and second causes of action and denied the plaintiff's motion for summary judgment. The Appellate Division of the Supreme Court ordered that this decision be modified. They decided that the Supreme Court erred in concluding that the plaintiff lacked standing to bring the action absent proof of a valid assignment from each claimant. They also found that the defendant failed to raise a triable issue of fact as to whether the insured's 2002 medical expenses were for injuries for which expenses for treatment had not been submitted within one year of his accident. The holding of the case was that the Supreme Court's order was modified to deny the defendant's motion for summary judgment, reinstate the first and second causes of action, and grant the plaintiff's motion for summary judgment on the first cause of action. Both parties were denied summary judgment on the second cause of action.

The court considered the case of A.B. Medical Services PLLC, D.A.V. Chiropractic P.C., and Lvov Acupuncture P.C. suing Allstate Insurance Company for $6,523.32 in first-party no-fault benefits for medical services rendered to their assignor. The health care providers moved for partial summary judgment in the sum of $6,326.52, which was comprised of various claims for each provider. The main issue decided was whether the health care providers were entitled to the requested sum, and the court held that the providers were entitled to partial summary judgment in the aggregate amount of $6,334.98. The court found that the providers established a prima facie entitlement to partial summary judgment by showing that they submitted claims setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. The burden then shifted to the defendant to show a triable issue of fact, but the defendant failed to establish by competent evidence that its denial of claim forms were timely mailed within the requisite 30-day period to pay or deny the claims. Therefore, the court granted the provider's motion for partial summary judgment and remanded the case for a calculation of statutory interest and an assessment of attorney's fees on the aggregate sum of $6,334.98.

The relevant facts were that the plaintiff, Great Wall Acupuncture, P.C., sought to recover $789.10 in first-party No-Fault benefits from defendant GEICO General Insurance Co. for acupuncture treatment provided to June Jackson. The defendant had reimbursed only $380.90 for the treatment, arguing that the fee billed exceeded the permissible charges for similar procedures under existing fee schedules. The main issue was whether acupuncture performed by a licensed acupuncturist should be reimbursed at a rate higher than what was considered permissible for chiropractors. The court held that plaintiff's motion for summary judgment was denied, as they failed to establish that a licensed acupuncturist should receive higher fees, and the fact that a licensed acupuncturist's services are similar to that of a chiropractor was not resolved. The only remaining issue for trial was whether the defendant had properly reduced the amount billed.

The court considered that defendant insurer had moved for summary judgment dismissing the complaint. The main issue was whether the record established, as a matter of law, that the plaintiff failed to submit proof of his claims for medical expenses and lost wages within the applicable time limitations. The court held that the Supreme Court erred in granting the defendant insurer's motion for summary judgment dismissing the complaint. The record did not establish, as a matter of law, that plaintiff failed to submit proof of his claims for medical expenses and lost wages within the applicable time limitations. The existing record also did not establish the defense of seeking a double recovery as a matter of law. Finally, the plaintiff was not precluded from asserting the claims at bar based on an assignment of benefits executed more than six years prior to the accident.

The court considered a case where Ocean Diagnostic Imaging P.C. sought summary judgment in a dispute with Allstate Insurance Company over the payment of a claim for diagnostic imaging services. The main issue decided was whether the court erred in ordering an assessment of damages after awarding summary judgment in favor of the plaintiff. The holding of the case was that the court did err in setting the matter down for an assessment of damages, as the plaintiff had met the burden of proof for their claim and the calculation of interest and attorney's fees was prescribed by statute. The court remanded the matter for a calculation of statutory interest and an assessment of attorney's fees in accordance with the relevant laws and regulations, and did not address any other issues.

The court considered the fact that plaintiff commenced the action to recover no-fault benefits as the assignee of 11 injured individuals, with claims arising from separate accidents. Defendant moved to sever the assigned claims into separate actions, which the court previously denied. The main issue decided was whether the claims of each assignor should be severed into separate actions. The holding of the case was that the appellate court reversed the previous denial, granted the defendant's motion to sever the claims of each assignor into separate actions, and found that the particular facts relating to each claim are likely to raise few, if any, common issues of law or fact, even if the assignors' insurance policies are identical.

The main issue in this case was whether the trial court properly denied the motion to sever the 47 causes of action to recover unpaid no-fault benefits asserted by the plaintiff. The defendant insurer contended that the claims at issue were being prosecuted by a single assignee against a single insurer but arose from 47 different automobile accidents on various dates and involved unrelated assignors with diverse injuries and medical treatment, as well as different reasons for the denial of benefits and varied defenses. The court ultimately held that it was an improvident exercise of discretion to deny the motion to sever, as a single trial of all the claims would be unwieldy and potentially confuse the trier of fact. Therefore, the appellate division reversed the order, granted the motion, and severed the causes of action to recover no-fault benefits.