No-Fault Case Law

The court considered whether insurance carriers could withhold payment for medical services provided by fraudulently incorporated medical entities to which patients had assigned their claims. The main issue was whether a fraudulently incorporated medical corporation was entitled to be reimbursed by insurers for medical services rendered by licensed medical practitioners. The court held that insurance carriers may withhold payment for services provided by fraudulently incorporated medical entities, under the Superintendent of Insurance's regulation, even if the actual care received by patients was necessary and proper. The court concluded that if the allegations were true, the fraudulently incorporated medical corporations were disqualified from reimbursement due to noncompliance with licensing requirements. The court also upheld the regulation in deference to the Superintendent's authority, which excluded fraudulently licensed providers from reimbursement. The court also mentioned that if the corporation was fraudulently licensed, they are not eligible for reimbursement under the Insurance Law. The court declined to consider whether the insurers could recover payments already made under theories of fraud or unjust enrichment.

The court considered the facts that the medical supply company submitted bills for medical supplies to the insurance company but did not respond to the insurance company's request for verification of the necessity of the supplies. The main issue was whether the insurer can request verification of medical supplies from a claimant medical supplier that has no clinical expertise. The court held that the insurer has a duty to speedily process claims and can request verification of medical supplies, and claimants have a duty to cooperate in providing requested information to process the claim. The court ultimately found in favor of the defendant insurance company and dismissed the plaintiff's complaint.

The court considered the case of JSI Expert Service seeking payment of claims for services provided to James Percine and Antoine Wekson, which Liberty Mutual Insurance denied on the basis of potential fraud. The main issue decided was whether Liberty Mutual had met the burden of proving fraud by clear and convincing evidence. The court held that Liberty Mutual failed to meet this burden, stating that even if all evidence presented by the defendant's witness was credited, the insurer's "founded belief" that the accident was staged cannot be based upon "unsubstantiated hypotheses and supposition." Therefore, judgment was granted to JSI Expert Service for the payment of Mr. Percine's and Mr. Wekson's claims.

The court considered the fact that the plaintiff had failed to respond to the verification demands sent by the defendant insurance company, which led to the defendant not issuing a timely denial of no-fault benefits. The main issue decided was whether the plaintiff's action to recover no-fault benefits was premature due to failure to respond to verification requests. The holding of the case was that the plaintiff's action was filed prematurely because they failed to properly respond to the defendant's verification requests, and therefore the plaintiff's action was dismissed. The court cited previous cases as precedent to support their decision.

The court considered a case where plaintiffs were seeking to recover first-party no-fault benefits for medical services rendered to their assignors, who were injured in an automobile accident. The main issue was whether the plaintiffs were entitled to no-fault benefits under the Personal Injury Protection Endorsement in the automobile liability policy issued by the defendant to the car rental company, or whether the responsibility for payment of no-fault benefits fell on the insurance policy issued by First Beacon Insurance to plaintiffs' assignor. The holding of the court was that defendant was responsible for payment of no-fault benefits, as it was the first insurer to whom notice of claim was given, and any dispute in priority of payments as between insurers would have to be submitted for resolution by mandatory arbitration. Summary: The court considered a case regarding the responsibility for payment of no-fault benefits for medical services rendered to injured parties in an automobile accident. The main issue was whether the defendant was responsible for paying no-fault benefits under their insurance policy, or if the payment should have come from the insurance policy issued by First Beacon Insurance to plaintiffs' assignor. The holding of the court was that defendant was responsible for payment of no-fault benefits as the first insurer to whom notice of claim was given, and any dispute in priority of payments had to be submitted for resolution by mandatory arbitration in accordance with the law.

The relevant facts considered in the case were that the plaintiff provided medical treatment to Keith Elman and submitted forms to the defendant for payment, which the defendant did not pay or deny within 30 days. The main issues decided were whether the plaintiff's claim was premature due to requests for additional verification not responded to, whether the claim was improper due to a defective assignment of benefits, and whether there was failure of proof of medical necessity. The holding of the case was that the plaintiff's motion for summary judgment was granted, as the defendant failed to meet its burden of showing the existence of a triable issue of fact. The court found that the defendant waived any defects in the assignment by failing to timely object to them, and that the defendant's remaining contentions were without merit. The plaintiff was awarded judgment against the defendant for the amount of $5,567.67, plus interest, attorney's fees, and costs.

The court considered the case of Sunnyside Plus, Inc. v Allstate Ins. Co. Plaintiff Sunnyside, a medical supplies provider, was denied payment for medical supplies provided to the assignor Rene Attias, pursuant to a prescription from the insured's treating physician. Allstate, the defendant insurer, denied payment for the medical supplies based on lack of medical necessity. The issue was whether the court could consider the expert witness's opinion, which was based solely on out-of-court hearsay documents not in evidence, as a valid ground for denial of payment. The court held that expert's opinion must be based on facts personally known to the expert or facts or documents in evidence, and where the expert does not have personal knowledge of the facts upon which the opinion rests, the material upon which they rely must be derived from a witness subject to full cross-examination. Therefore, the court ruled that the defendant had failed to prove its defense of lack of medical necessity by a fair preponderance of the evidence and awarded judgment for the plaintiff, including interest and attorney's fees.

The court considered the action to recover no-fault insurance medical payments. Nyack Hospital, as Assignee of John Watson, was the respondent and Metropolitan Property & Casualty Insurance Company was the appellant. The court granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment dismissing the complaint. The plaintiff provided evidence that the prescribed statutory billing forms were mailed and received, and that payment of no-fault benefits was overdue. The defendant failed to raise a triable issue of fact in opposition. The court affirmed the order, with costs, based on the plaintiff's prima facie showing of entitlement to judgment as a matter of law.

The case involved a dispute between Patricia Simmons and State Farm Mutual Automobile Insurance Company. After State Farm refused to continue providing no-fault insurance benefits to Patricia Simmons, she and other plaintiffs commenced legal action against the insurance company. The main issue was whether State Farm had met its burden of showing lack of cooperation of its insured and had established that the plaintiff was able to return to work. The court decided that State Farm failed to meet its burden of showing lack of cooperation of its insured and was unable to establish that the plaintiff was able to return to work. Therefore, the court affirmed the lower court's decision to grant State Farm's motion only in part and denied it with respect to the first cause of action, ultimately dismissing the complaint.

The court considered a dispute between a health care provider and an insurance company over the refusal of the insurance company to pay for services rendered to a patient. The key issue in this case was the proper scope of an examination before trial (EBT) in an action by a health care provider for no-fault first-party benefits. The court had to decide whether the questioning at an EBT should be confined to the insurer's denial of claim form, the NF-10, or whether other matters should be allowed. The court also noted that the defendant's attorney had served the court with a motion four months late, without excuse or justification. The court held that the briefing schedules should be adhered to, and judges should scrupulously enforce deadlines set by fellow judges. Furthermore, the court would not consider papers that were untimely under a schedule.