No-Fault Case Law

The relevant facts in the case involved an action to recover no-fault medical payments under insurance contracts, where New York and Presbyterian Hospital, as assignee of Jorge Peralta, New York Hospital Medical Center of Queens, as assignee of Christopher O'Neill, Mary Immaculate Hospital, as assignee of Racheal Castro, and Nyack Hospital, as assignee of Lourdes Veras, appealed from an order denying their motion for summary judgment on the first cause of action and granting the defendant's cross motion for summary judgment dismissing the first cause of action. The main issue decided by the court was whether the defendant was precluded from asserting the defense of the hospital's untimeliness in this action pursuant to Insurance Law § 5106 (a) for no-fault medical payments, and the holding was that the defendant is precluded from asserting the defense of the hospital's untimeliness in this action pursuant to Insurance Law § 5106 (a) based on the fact that despite the hospital's delay in providing verification of the claim, the defendant failed to either pay or deny the claim as required by 11 NYCRR 65.15 (g) (2) (iii). Therefore, the order denying the plaintiff's motion for summary judgment on the first cause of action was reversed, and the defendant was ordered to pay one bill of costs to the plaintiff New York and Presbyterian Hospital, as assignee of Jorge Peralta.

The relevant facts considered by the court included a health care provider submitting a claim for no-fault benefits for medical services rendered to its assignor, and the insurance company denying the claim more than two months after receiving it. The main issue decided was whether the insurance company's requests for examinations under oath tolled the 30-day claim determination period, and whether the insurance company could assert the defense that the collision was in furtherance of an insurance fraud scheme. The court held that the insurance company's requests for examinations under oath did not toll the claim determination period, but the company could still assert the defense of insurance fraud, despite its untimely denial of the claim, as the denial was based on a "founded belief that the alleged injuries do not arise out of an insured incident." Therefore, the court affirmed the denial of the health care provider's motion for summary judgment.

The court in this case considered whether a plaintiff, D.A.V. Chiropractic P.C., was entitled to recover first-party no-fault benefits for medical services rendered to its assignor, Latoya Jones, in the sum of $2,712.08. The main issue decided was whether the defendant insurance company's proof of mailing of letters scheduling independent medical examinations (IMEs) rebutted the presumption of medical necessity which ordinarily attaches to the plaintiff's claim forms, and raised a triable issue of fact as to the medical necessity of the services rendered. The court held that the defendant effectively rebutted the presumption of medical necessity and raised a triable issue of fact as to the medical necessity of the services rendered, and therefore the court properly denied both the plaintiff's motion for summary judgment and the defendant's cross motion for summary judgment. The appellate court affirmed the original decision without costs.

The court considered the facts of the case, where South Queens Imaging P.C. sought to recover first-party no-fault benefits for medical services provided to its assignor, Kadian Nicholson, from Nationwide Mutual Insurance Company. Plaintiff established a prima facie entitlement to summary judgment by proving that it submitted claim forms and that payment of no-fault benefits was overdue. In opposition, defendant submitted unsworn reports of an independent medical examination and a peer review report, which the court found to be insufficient to warrant denial of plaintiff's motion. The court reversed the order that denied plaintiff's motion for summary judgment, granted the motion, and remanded the matter for the calculation of statutory interest and attorney's fees. The main issue decided was whether the unsworn reports submitted by the defendant constituted competent proof in admissible form to warrant denial of plaintiff's motion for summary judgment. The holding of the case was that the unsworn reports were insufficient, and the plaintiff was granted summary judgment, with the matter remanded for the calculation of statutory interest and attorney's fees.

The relevant facts considered in this case included an action to recover first-party no-fault benefits for medical services rendered to the plaintiff’s assignor. The plaintiff health care provider established a prima facie entitlement to summary judgment by proving that it submitted a claim, the amount of the loss sustained, and that payment of no-fault benefits was overdue. The main issue decided by the court was whether the defendant was precluded from raising most defenses due to its failure to pay or deny the claim within the prescribed period, and whether the alleged injuries were causally unrelated to the accident. The holding of the court was that the defendant was precluded from raising most defenses due to its failure to pay or deny the claim within the 30-day prescribed period, but was not precluded from asserting the defense that the alleged injuries were causally unrelated to the accident. As a result, the plaintiff's motion for summary judgment was denied, and the matter was remanded for further proceedings.

In the case Ocean Diagnostic Imaging P.C. v New York Central Mutual Fire Insurance Company, the court considered whether the plaintiff health care provider was entitled to first-party no-fault benefits for medical services rendered to its assignor. The main issue decided was whether the defendant insurance company was precluded from raising defenses due to not paying or denying the claim within the prescribed 30-day period. The court held that the defendant was not precluded from asserting the defense that the alleged injuries were causally unrelated to the accident, despite the untimely denial of the claim. The court also found that the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, and therefore the plaintiff's motion for summary judgment was denied and the matter was remanded for further proceedings.

The relevant facts the court considered were that A.B. Medical Services PLLC, D.A.V. Chiropractic P.C., and Lvov Acupuncture P.C. submitted claims for payment of no-fault benefits which were denied by GMAC Insurance. The main issue decided was whether the injuries claimed by the plaintiffs' assignor were causally related to the subject motor vehicle accident. The holding of the case was that the motion for summary judgment by A.B. Medical Services PLLC, D.A.V. Chiropractic P.C. and Lvov Acupuncture P.C. was granted, and the matter was remanded to the court below for a calculation of statutory interest and an assessment of attorney's fees thereon. The claim by Square Synagogue Transportation Inc. was dismissed based on the revised insurance regulations that did not permit assignment of benefits for non-health-related services. The court also found that GMAC Insurance failed to raise any triable issue of fact in opposition to the plaintiffs' motion for summary judgment, and that their denial of the claims was not based upon a founded belief that the alleged injuries did not arise out of an insured incident. The dissenting opinion disagreed, finding that there was a sufficient basis to raise an issue of fact as to whether the defense of fraud was founded, and would have denied the plaintiffs' motion for summary judgment.

The court considered the case of Progressive Northern Insurance Company v. John Rafferty and Robert Carman. The main issue was whether Progressive had a duty to defend or indemnify Rafferty in an underlying personal injury action, and whether Carman was eligible for no-fault insurance benefits after being injured by Rafferty. The court held that Progressive had no duty to defend or indemnify Rafferty, and that Carman was not eligible for no-fault insurance benefits, due to the intentional nature of Rafferty's actions. The court noted that the intentional act exclusion of Rafferty's policy applied, despite his claim of only intending to scare Carman, and that Carman's injuries were inherent in Rafferty's actions and, thus, were not caused by an "accident". Therefore, Supreme Court properly granted summary judgment in plaintiff's favor.

The main issue in this case was whether the plaintiff was able to demonstrate a justifiable excuse for failing to file a notice of trial within ninety days of the defendant's demand, and a meritorious cause of action. The plaintiff, a health care provider, sought to recover first party no-fault benefits for medical services rendered to its assignor. The defendant cross-moved to dismiss the action for want of prosecution, for failure to provide proof of the claim, and because the services were provided by independent contractors hired by the plaintiff, a professional corporation. The court held that the plaintiff did not demonstrate a justifiable excuse for failing to file a notice of trial, and therefore dismissed the plaintiff's action. The decision was made by Randy Sue Marber, District Court Judge on April 20, 2005.

The main issue in this case was whether the decision of the Master Arbitration to affirm the initial arbitrator's decision to deny the disputed billing of $3947.96 was arbitrary, capricious, or incorrect as a matter of law. The petitioner, a medical provider, argued that it only needed to prove that it provided services, mailed a claim, and that the claim was not paid or denied within thirty days. The Master Arbitrator disagreed and confirmed the arbitration award, stating that the medical provider had to establish the necessity of its medical treatments. The court considered previous cases and found that the law with respect to the burden of proof in first party no-fault claims was established by the Court. Therefore, the court held that the decision of the Master Arbitrator was not arbitrary nor capricious and affirmed the award.