No-Fault Case Law

The relevant facts in the case included a timely denial of claims submitted by A.B. Medical Services PLLC by American Manufacturers Mutual Insurance Company (American). American's denials were based on a peer review that concluded there was no medical necessity for the procedures performed, due to the reviewer lacking sufficient information to make such a determination. However, the court found that the reviewer's lack of information alone did not demonstrate the existence of a triable issue of fact, as American failed to seek the necessary information through verification procedures. Therefore, the court held that American was precluded from asserting the defense of lack of medical necessity, and granted summary judgment in favor of A.B. Medical Services PLLC. The main issue decided was whether American's defense of lack of medical necessity was valid, and the court held that it was not, granting summary judgment in favor of A.B. Medical Services PLLC.

The court considered an action to recover $8,205.98 in assigned first-party no-fault benefits, in which defendant's denials of plaintiff's claims for $151.28, $67.40, and $180.00 in no-fault benefits were found to be untimely. The main issue was whether the defendant's failure to attend independent medical examinations (IMEs) prior to the submission of statutory claim forms precluded the defendant from defending its denials. The holding of the court was that while the failure of the plaintiff's assignor to attend the IMEs did not afford the insurer a defense to the action, it did rebut the presumption of medical necessity that attaches to the claim forms. The court modified the order to grant the plaintiff partial summary judgment in the sum of $398.68 and remanded the matter for the calculation of statutory interest and attorney's fees thereon.

The court considered the evidence submitted by the plaintiffs, including claim forms and medical reports, in a case to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiffs had established a prima facie entitlement to summary judgment by proving that payment of the benefits was overdue. The court held that in order to establish that payment on the claims was overdue, the plaintiffs had to demonstrate that the 30 calendar days had elapsed from the time the insurer received proof of the claim. Since there was no evidence as to when the claim forms were submitted to the defendant and the defendant's letters did not specify which claims were received, the court found that the plaintiffs were unable to establish whether payments on any of the claims were overdue. Therefore, the plaintiffs' motion for summary judgment was properly denied.

The main issue in A & S Medical P.C. v Allstate Insurance Company was whether a no-fault insurer was able to defend against a claim for services provided after a certain date based on an earlier blanket denial issued to the insured. Plaintiff submitted a claim to defendant for orthopedic services it had provided, and defendant had previously denied all further orthopedic benefits. However, defendant rejected a portion of the claim more than 30 days later. The Court held that the No-Fault Law and regulations required the insurer to respond to the claim within the statutory 30-day time limit, and that it was not sufficient for the insurer to rely silently on an earlier denial issued to the insured. The Appellate Division ultimately affirmed the lower court's decision, granting summary judgment in favor of the plaintiff.

The court considered the facts presented in the case of Ocean Diagnostic Imaging, Inc. v Utica Mut. Ins. Co., where the plaintiff sought to recover no-fault benefits for medical services provided to an assignor. The main issue decided was whether the plaintiff was entitled to summary judgment, and whether the defendant's cross motion for summary judgment should be denied. The court held that the plaintiff had established a prima facie entitlement to summary judgment by providing evidence that it mailed the claim forms and that the defendant failed to pay or deny the claims within the prescribed 30-day period. However, the defendant was not precluded from asserting the defense of insurance fraud, despite the untimely denial of the claims. The court ultimately modified the order to deny the plaintiff's motion for summary judgment, and affirmed that the defendant's cross motion for summary judgment was properly denied.

The court in A.B. Medical Services PLLC v Prudential Property & Casualty Insurance Company considered the failure of the insurer to timely pay or deny the claim within the 30-day statutory period, and the sufficiency of proof submitted to rebut a plaintiff's prima facie case for entitlement to no-fault benefits. The main issue decided was whether a timely denial relieves the insurer from the necessity of submitting proof in admissible form to rebut the plaintiff's prima facie case, and the validity of assignments to health care providers of benefits for non-health-related services. The holding of the court was that defendant's failure to seek verification of the assignments or to allege any deficiency in the assignments in its denial of claim forms constituted a waiver of any defenses with respect thereto, and that despite its untimely denial of certain of plaintiff's claims, defendant was not precluded from asserting the defense that the alleged injuries do not arise out of a covered accident. Furthermore, the court held that renewal of plaintiffs' motion for summary judgment would be unwarranted.

The court considered the motion made by defendant State Farm Insurance Company to sever the action brought by plaintiff Midwood Acupuncture, P.C. into separate actions on behalf of individual assignors. In this action, the plaintiff sought to recover first party No-Fault benefits with interest and statutory attorney's fees from the defendant for alleged medical services provided to its assignors. The main issue decided was whether the claims should be severed into separate actions, and the court held that severance was not necessary. The court found that even if the claims involved separate accidents and individuals, they did not lose their character as a series of transactions because they occurred at different places and times, and if they involved a common question of law, joinder was proper. Therefore, the court denied the defendant's motion to sever the action.

Plaintiffs were healthcare providers seeking first-party no-fault benefits for medical services offered to their assignor. They established that they sent the statutory claim forms and that payment of no-fault benefits was overdue. The court considered the defendant's delay letters acknowledging the bills submitted, causing them to establish reception of the respective claims. The court also noted that an insurer's failure to timely pay or deny claims within the statutory period precludes it from asserting most defenses. The primary issue decided was whether the defendant effectively demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage. The holding was that despite the defendant's untimely denial of most claims, a triable issue of fact existed on whether there was a lack of coverage, so the plaintiffs' motion for summary judgment was properly denied.

The relevant facts considered by the court in this case involve a medical provider, Plaintiff, seeking to recover first party no-fault benefits from Defendant insurer. Plaintiff moved for summary judgment, alleging that Defendant did not pay or deny the claim within the required thirty-day period. In response, Defendant claimed the denials were timely, but Plaintiff argued that Defendant failed to provide legally sufficient proof of mailing the denials within the thirty-day period. The main issue decided in this case was the information required on an affidavit of mailing to meet the requirements of New York's no-fault law for a proper proof of mailing. The holding of the court was that the Defendant failed to meet its burden of proving that the denials were mailed within the thirty-day period, and therefore, summary judgment was awarded to Plaintiff. As a result, the court ordered the entry of judgment in favor of Plaintiff in the amount of $1,181.63, plus interest, costs, and attorney fees.

The court considered the correspondence between the claimant's attorney and the insurance company, as well as the submission of an application for no-fault benefits. The main issue was whether this correspondence provided the insurance company with notice of the claim for uninsured motorist benefits as required by the insurance policy. The court found that the correspondence did not constitute the requisite notice, and the claimant failed to offer a valid excuse for her failure to give the insurance company timely notice. As a result, the Supreme Court properly granted the petition to stay arbitration, and the order was affirmed on appeal. The main holding was that the failure to satisfy the notice requirement specified in the insurance policy vitiates coverage for uninsured motorist benefits.