No-Fault Case Law

The relevant facts considered by the court in this case are that the plaintiffs initially submitted a Motion for Summary Judgment as providers of first party benefits under New York's No-Fault Insurance Law, which was denied due to insufficient support. The plaintiffs then submitted a second motion for summary judgment based on the same underlying claim, with new affidavits from treating physicians. The main issue decided by the court was whether a party may file a new Motion for Summary Judgment after an initial motion for the same relief on the same claim was denied. The court held that once a motion for summary judgment has been denied, subsequent motions seeking the same relief must be denied as res judicata, even if the original denial was based on a party's failure to come forward with evidentiary facts rather than on a full determination based on all relevant data. Therefore, the plaintiffs' Motion for Summary Judgment was denied as res judicata.

The relevant facts of the case included the plaintiff, a medical provider, initiating a claim for first party benefits under New York's No-Fault Insurance Law, and the defendant insurer denying the claim on the basis that the treatments provided were not medically necessary. The main issue decided by the court was the definition of "medical necessity" under the No-Fault statute, as it is not defined by the statute itself. The court considered several prior decisions attempting to define the term "medical necessity," including a definition adopted from the New Jersey courts and a modification of that definition based on pending legislation. Based on these decisions, the court held that an appropriate jury instruction on the definition of "medical necessity" is that for an expense to be considered medically necessary, the treatment, procedure, or service ordered by a qualified physician must be based on an objectively reasonable belief that it will assist in the patient's diagnosis and treatment and cannot be reasonably dispensed with. Such treatment, procedure, or service must be warranted by the circumstances as verified by a preponderance of credible and reliable evidence, and must be reasonable in light of the subjective and objective evidence of the patient's complaints.

The court considered whether the insurance carrier was entitled to disclaim coverage of plaintiff's late notice of the SUM claim in a declaratory judgment action. Plaintiff was rear-ended in an accident and filed a claim for no-fault benefits shortly after. After learning that the other driver, Bouyea, was underinsured and undergoing surgery for injuries from the accident, plaintiff notified State Farm and filed a lawsuit, but the insurance carrier disclaimed coverage based on the late notice of the SUM claim. The court ultimately held that the carrier must show prejudice before disclaiming coverage of a late notice of a SUM claim if the insured previously gave timely notice of the accident. Since the insured had given prompt notice of the accident, the carrier was required to demonstrate prejudice before disclaiming coverage. As a result, the court modified the decision of the Appellate Division and remitted the case to the trial court for the carrier to have an opportunity to demonstrate prejudice before further action could be taken.

The court considered the circumstances surrounding an automobile accident involving an employee of the URS Corporation, Mr. Wells, who sought workers' compensation, no-fault claim, disability benefits, and also filed a personal injury action. The main issue decided was whether Farmers New Century Insurance Company could seek reimbursement from National Union Fire Insurance Company, regarding the payment of first-party benefits to Mr. Wells. The court held that the dispute was not subject to mandatory arbitration pursuant to Workers Compensation Law 29 (1-a) and the loss transfer provisions of Insurance Law section 5105. The court granted National Union Fire Insurance Company's application to permanently stay the arbitration between the parties and denied Farmers New Century Insurance Company's cross-motion to dismiss the application.

The relevant facts of the case include a medical provider, T.S. Medical P.C., being denied no-fault benefits by an insurance company, Country Wide Insurance Co. After filing for arbitration, the arbitration award denied the petitioner's claim and was then reviewed by a Master Arbitrator, who upheld the lower arbitration award. The main issue at hand was whether the Master Arbitrator's decision should be vacated, as the award did not have a rational basis and did not comport with established principles of law. The court decided that the Master Arbitrator's award should be vacated, as it did not have a rational basis and did not correctly apply the law. Therefore, the court granted the petitioner's motion and vacated the Master Arbitrator's award.

The relevant facts considered by the court in this case involved a dispute over first-party no-fault benefits for medical services rendered to an assignor by plaintiff Daniel Kim's Acupuncture P.C. The main issue decided by the court was whether plaintiff Daniel Kim's Acupuncture P.C. was entitled to summary judgment, and whether the peer review report included by the defendant in its opposition was admissible. The holding of the case was that plaintiff Daniel Kim's Acupuncture P.C. established a prima facie entitlement to summary judgment and that the peer review report included by the defendant was unsworn and inadmissible. As a result, summary judgment was granted in favor of plaintiff Daniel Kim's Acupuncture P.C. The matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees. The appeal by the remaining appellants was dismissed.

The main issues decided in this case were whether the plaintiff was entitled to summary judgment in its action to recover assigned first-party no-fault benefits for medical supplies furnished its assignors, and whether the defendant's denial of the remaining claims was valid. The court held that the plaintiff was entitled to summary judgment as it established prima facie entitlement to summary judgment by proof that it submitted claim forms setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. Additionally, the court found that the defendant's denial of the remaining claims on the sole ground that plaintiff failed to produce the "initial narrative report[s] from the preparing physician" pursuant to a timely initial verification request was invalid. The matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees.

The relevant facts of the case are that King's Medical Supply Inc. was seeking to recover assigned first-party no-fault benefits from Kemper Auto & Home Ins. Co. King's Medical Supply Inc. was denied by Kemper Auto & Home Ins. Co. due to the eligible injured person's failure to attend the independent medical examinations as requested. However, Kemper Auto & Home Ins. Co. failed to follow up its initial verification request with a second IME request within the given time frame. Furthermore, Kemper Auto & Home Ins. Co. also asserted that King's Medical Supply Inc. failed to respond to two verification request letters regarding a separate claim. The main issues decided in the case were whether the denial form was effective to avoid preclusion and whether Kemper Auto & Home Ins. Co.'s proof of mailing sufficed to raise a triable issue of the timeliness of mailing. The court held that the denial form was ineffective to avoid preclusion as to all defenses to the $660 claim and that as to the $895 claim, Kemper Auto & Home Ins. Co.'s proof of mailing raised a triable issue of the timeliness of mailing. The court granted partial summary judgment in favor of King's Medical Supply Inc. in the principal sum of $660 and remanded the matter for the calculation of statutory interest and an assessment of attorney's fees, and remanded for all further proceedings on the remaining claim.

The court considered the fact that the plaintiff was seeking to recover first-party no-fault benefits for medical services rendered to an assignor. The main issue decided was whether the plaintiff had established a prima facie entitlement to summary judgment by offering proof that it submitted claims which set forth the fact and the amount of the loss sustained, and that the payment of no-fault benefits was overdue. The holding of the case was that the plaintiff failed to establish their prima facie case because they did not append the necessary claim forms to their motion papers, and the court appropriately denied their motion for partial summary judgment with leave to renew upon submission of proper papers.

The relevant facts that the court considered were that a medical provider submitted bills and an assignment of benefits form to an insurance company for medical services provided to someone involved in an automobile accident. The insurance company requested an additional assignment of benefits form, claiming that the original form was not properly executed. The main issue decided in the case was whether the medical provider had complied with the insurance company's request for additional verification, thus impacting the insurance company's time to pay or deny the claim. The holding of the case was that the medical provider failed to submit a properly executed assignment of benefits and did not comply with the insurance company's request for additional verification, therefore the insurance company's time to pay or deny the claim had not begun to run. As a result, the plaintiff's complaint was dismissed.