No-Fault Case Law
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2005 NY Slip Op 25336)
March 1, 2005
In the legal case of Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co., the plaintiff sought to recover first-party no-fault benefits for medical treatment. Plaintiff established its prima facie case for summary judgment by proving the statutory billing forms had been received and that payment was overdue. Defendant was allowed to assert a defense that the collision was in furtherance of an insurance fraud scheme. The court found that the affidavit submitted by defendant's special investigator was sufficient to demonstrate that defendant's denial was based upon a well-founded belief that the alleged injuries did not arise out of an insured incident. Plaintiff's motion for summary judgment was properly denied as defendant demonstrated a triable issue of fact as to whether there was a lack of coverage. The court also found that defendant's opposition to plaintiff's motion for summary judgment based on the assignor’s failure to attend examinations under oath was without merit.
Nir v Allstate Ins. Co. (2005 NY Slip Op 25090)
February 28, 2005
The main issues in this case were whether the diagnostic testing performed by Dr. Nir on the patient, Josapphat Etienne, was medically necessary and if the insurer, Allstate, properly denied payment for these services. The court considered the evidence presented by both parties, including testimony from medical professionals from both sides. The defendant's expert testified that the tests were not medically necessary as they were performed too soon after the accident, while the plaintiff's expert testified that the tests were necessary based on the patient's symptoms and consistent with medical standards. The court found that the burden of proof fell on the insurer to prove that the diagnostic testing was medically unnecessary, and held that the tests were indeed medically necessary and ordered Allstate to pay the remaining balance of the claim to Dr. Nir.
New York Univ. Hosp. Tisch Inst. v Merchants Mut. Ins. Co. (2005 NY Slip Op 01332)
February 22, 2005
The New York Supreme Court, Appellate Division, Second Department reversed an order denying a motion to vacate a judgment in a case brought by New York University Hospital Tisch Institute to recover unpaid no-fault benefits from Merchants Mutual Insurance Co. The court ruled that the denial of the motion was an unwise exercise of discretion. The defendant's default was found to be reasonable due to an inexperienced claims adjuster's belief that advising opposing counsel that no-fault benefits had been exhausted would be sufficient. The court also found that the defendant demonstrated a reasonable excuse for the default and a meritorious defense, and that there was a lack of prejudice to the plaintiff. Therefore, the judgment entered upon the defendant's default was vacated, and the case was remitted for further proceedings.
Mount Sinai Hosp. v Zurich Am. Ins. Co. (2005 NY Slip Op 01329)
February 22, 2005
The court considered whether the plaintiffs were entitled to recover no-fault insurance medical payments. Mount Sinai Hospital demonstrated that it submitted the required documents to recover payment for medical services, but Zurich American Insurance Company neither paid nor denied the claims. However, an insurer is not required to pay a claim where the policy limits have been exhausted. In opposition to Mount Sinai's motion, Zurich demonstrated that there were issues of fact as to whether it exhausted the coverage limits of the policy by other "no-fault" payments and whether such payments were in compliance with 11 NYCRR 65.15. The main issue decided was whether Mount Sinai and Wyckoff Heights Medical Center, as assignee of Juan Picardo, were entitled to judgment as a matter of law on their first and third cause of actions. The holding of the case was that Mount Sinai's motion for summary judgment on the first cause of action was denied, while Wyckoff Heights Medical Center was granted summary judgment on the third cause of action.
Pueblo Med. Treatment v Progressive Cas. Ins. Co . (2005 NY Slip Op 50287(U))
February 18, 2005
The court considered whether a defendant was required to attempt to conduct a deposition before moving for preclusion in a no-fault first party benefits case. The plaintiff did not dispute that it did not attend the deposition session as ordered, but argued that the defendant should have made a specific statement on the record of an attempted examination before trial in order to secure preclusion. The court held that the defendant was not required to undergo the expense and trouble of arranging for a deposition before moving for preclusion. Therefore, the defendant's motion was granted, and full preclusion was accorded against the plaintiff, resulting in the dismissal of the complaint.
Amaze Med. Supply Inc. v GEICO Ins. (2005 NYSlipOp 51053(U))
February 17, 2005
The relevant facts in this case were that the plaintiff, Amaze Medical Supply Inc., sought to recover first-party no-fault benefits for medical supplies furnished to its assignor. The plaintiff established a prima facie entitlement to summary judgment by showing that it submitted a claim, setting forth the fact and amount of the loss sustained, and that payment of no-fault benefits was overdue. The defendant, GEICO Insurance, timely denied the claims but failed to submit proof in admissible form in opposition to the plaintiff's motion to rebut the prima facie showing. The defendant's submission, an unsworn peer review report, was deemed insufficient to warrant the denial of the plaintiff's motion for summary judgment. Therefore, the appellate court reversed the order denying the plaintiff's motion for summary judgment, granted the motion, and remanded the matter for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106(a) and the regulations promulgated thereunder.
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2005 NYSlipOp 50454(U))
February 17, 2005
The court considered the fact that the plaintiff had submitted a claim for first-party no-fault benefits for medical services and that payment was overdue. The main issue decided was whether the defendant's defense of insurance fraud could be raised, despite the untimely denial of the claim. The court held that the defendant was precluded from raising most defenses due to the untimely denial of the claim, but was not precluded from asserting the defense of insurance fraud. The court found that the affidavit submitted by the defendant's special investigator was sufficient to demonstrate the existence of a triable issue of fact, and therefore the plaintiff's motion for summary judgment was properly denied.
Metro Med. Diagnostics, P.C. v Allstate Ins. Co. (2005 NY Slip Op 50327(U))
February 17, 2005
The relevant facts considered by the court in this case include the denial of claims for medical services by an insurance company, the timing of the denials, and the issue of standing for the plaintiff to bring the action. The main issues decided by the court were whether the insurance company's denials of the claims were timely, the propriety of denial based on pending investigation, the authentication of assignment of benefits, and the standing of the plaintiff to bring the action. The holding of the case was that defendant's defenses were waived due to untimely denials and that further discovery was necessary to determine the plaintiff's standing to bring the action. The court extended the discovery period for this purpose and granted plaintiff summary judgment on claims that had not already been paid if they were found to have standing.
Ocean Diagnostic Imaging P.C. v Allstate Ins. Co. (2005 NY Slip Op 50189(U))
February 17, 2005
The court considered whether the plaintiff, a healthcare provider, was entitled to summary judgment to recover $2,670.40 in assigned first-party no-fault benefits for medical services rendered to its assignor. The main issue was whether the plaintiff had demonstrated a prima facie case for entitlement to this sum. The court held that the plaintiff had established a prima facie entitlement to summary judgment by proving that it submitted a claim form, and that payment of no-fault benefits was overdue, precluding the defendant from interposing most defenses to the action. The defendant was not precluded from asserting the defense that the alleged injuries did not arise out of a covered accident, which would constitute a complete defense to the action, but the defendant failed to sufficiently raise a triable issue of fraud in alleging staged-accident fraud. Therefore, the order granting plaintiff's motion for summary judgment was affirmed.
Ocean Diagnostic Imaging P.C. v AIU Ins. Co. (2005 NY Slip Op 50188(U))
February 17, 2005
The court considered the facts that plaintiff health care provider submitted a claim for first-party no-fault benefits for medical services rendered to its assignor, and that the defendant insurance company failed to pay or deny the claim within the 30-day prescribed period. The main issue decided was whether the defendant was precluded from raising defenses due to the untimely denial of the claim, and whether the defendant's assertion that the accident was fraudulent was supported by admissible evidence. The holding was that the plaintiff's motion for summary judgment was granted in the principal sum of $1,791.73, and the matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder. The court also ruled that the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, but failed to submit proof in admissible form to rebut the plaintiff's prima facie showing.