No-Fault Case Law

The case NYC Med. & Neurodiagnostic, P.C. v Republic W. Ins. Co. involved a dispute over first-party no-fault benefits for medical services provided in an automobile accident. The insurance company, Republic Western Ins. Co. denied the claim, arguing that the court lacked jurisdiction over them. The court considered evidence regarding the defendant's business activities, insurance policies, and involvement in New York City. The main issues were whether the defendant was authorized to do business in New York and whether the court had jurisdiction over the case. The holding of the case was that the court erred in denying the defendant's motion to dismiss and that it was found that the defendant had been authorized to do insurance business in New York, therefore service of process on the Superintendent of Insurance was proper, and jurisdiction was granted over the defendant.

The court considered whether an assignment of benefits is an essential element of a claim for no-fault benefits, and whether the failure to include it is a waivable defect. Plaintiff, who was the assignee of Melvin Reyes, brought this action to recover $3,080 in first-party no-fault benefits, alleging that he was injured in a car accident and received treatment from the plaintiff who was assigned rights to benefits. The main issue was whether the absence of an assignment in a no-fault case could be waived, and whether its absence prevented an insurer from objecting to the claim. The court held that an assignment is an essential element of a claim for no-fault benefits, which cannot be waived even if the insurance company failed to assert it in the denial of claim form. The court also concluded that the insurer has no contractual obligation if an assignment is not present and thus plaintiff's motion for summary judgment was denied.

The plaintiffs appealed from the Supreme Court's order which granted the defendant's motion for summary judgment and denied the plaintiffs' cross motion. The plaintiffs had submitted a claim for no-fault benefits to the defendant's insurance company after the injured plaintiff was injured in a motor vehicle accident. The defendant sought to examine the injured plaintiff under oath, to which the plaintiffs refused unless both of them could be present. After this requested was denied, the defendant denied the plaintiffs' claim for no-fault benefits. The Supreme Court concluded that the plaintiffs' failure to cooperate with the insurer constituted a material breach of the policy. The Appellate Court disagreed and held that the defendant failed to demonstrate the plaintiffs engaged in a pattern of unreasonable and willful noncooperation, so the defendant's denial of no-fault insurance benefits on the ground of the plaintiffs' noncooperation was improper. The matter was remitted to the Supreme Court for the entry of a judgment declaring such.

The relevant facts the court considered in this case were that Ultimate Medical Supplies sought to recover $2,517.00, as well as statutory legal fees and interest, from Lancer Insurance Company for orthopedic devices provided to Cedric Wright. Lancer denied payment claiming medical necessity as a defense. Both parties presented their cases at trial, with Ultimate Medical Supplies providing the testimony of their principal, Peter Tiflinsky, and five exhibits, while Lancer presented the testimony of Dr. Francine Moshkovski and four exhibits. The main issues decided by the court were whether Dr. Moshkovski's testimony qualified as that of an expert, if Ultimate Medical Supplies had established a prima facie case, if there was evidence of the necessity for a specific orthopedic device, the credibility of the evidence presented regarding medical necessity, and the evidentiary effect of the failure of the claimant/assignor to appear subject to subpoena. The court held that Dr. Moshkovski's testimony qualified as that of an expert, Ultimate Medical Supplies had established a prima facie case, there was evidence of the necessity for the orthopedic device, and it declined to infer negative testimony from the failure of the claimant/assignor to appear. The holding of the case was in favor of Ultimate Medical Supplies, with the court directing the clerk to enter judgment in their favor against Lancer Insurance Company in the amount of $2,517.00, plus statutory legal fees and interest from May 2, 2000.

The relevant facts considered by the court were that a health care provider submitted a claim form for first-party no-fault benefits for medical services rendered to its assignor, and that the insurance company failed to pay or deny the claim within the 30-day prescribed period. The main issue decided was whether the insurance company was precluded from raising defenses due to the delayed payment of the claim. The holding of the court was that the insurance company was precluded from raising most defenses due to the delayed payment, but it could assert the defense that the alleged injuries did not arise out of a covered accident. The court affirmed the lower court's decision to deny the health care provider's motion for summary judgment, as the insurance company demonstrated the existence of a triable issue of fact regarding the lack of coverage for the alleged injuries.

The relevant facts in the case involved a dispute over first-party no-fault benefits for medical services provided to a patient by the plaintiffs. The main issue decided by the court was whether the defendant insurance company was precluded from raising defenses due to their failure to pay or deny the claim within the 30-day prescribed period. The holding of the court was that the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, despite the untimely denial of the claim. The court determined that the defendant's special investigator's affidavit was sufficient to demonstrate a founded belief that the alleged injuries did not arise out of an insured incident, and as a result, the motion for summary judgment by the plaintiffs was properly denied.

The court considered the case of Amaze Medical Supply Inc. v Allstate Ins. Co. where the plaintiff appealed from an order denying their motion for summary judgment. Plaintiff had submitted complete proofs of claims for the amount of $1,737, which were not denied until more than 30 days after they were submitted. The issue was whether the insurer, Allstate Insurance Co., was precluded from raising defenses, including lack of medical necessity, due to the untimely denial of the claims. The court held that plaintiff's motion for summary judgment should have been granted, as the insurer was precluded from raising most defenses and the claims were submitted on time. The decision was reversed, and the matter was remanded for a calculation of statutory interest and an assessment of attorney's fees.

The court considered whether plaintiff was entitled to summary judgment for first-party no-fault benefits for medical supplies provided to its assignor. Plaintiff established its entitlement to summary judgment by submitting a claim, setting forth the fact and the amount of the loss sustained, and proving that payment of no-fault benefits was overdue. However, the burden shifted to defendant to raise a material issue of fact, and defendant was able to show through an investigator's affidavit that they possessed a "founded belief that the alleged injur[ies] do[ ] not arise out of an insured incident," thus raising an issue of fact warranting denial of plaintiff's motion for summary judgment. Therefore, the main issue decided was whether defendant's untimely denial of the claim precluded them from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and the holding of the court was that defendant was not precluded from asserting this defense.

The relevant facts considered by the court were that the plaintiffs were seeking to recover first-party no-fault benefits for services rendered to their assignor and that they established their prima facie entitlement to summary judgment by proving that they submitted a claim and that payment of benefits was overdue. The main issue decided was whether the defendant, State Farm Mutual Automobile Insurance Company, was precluded from raising defenses due to their failure to pay or deny the claim within the prescribed 30-day period. The holding of the case was that the defendant was not precluded from asserting the defense of an insurance fraud scheme despite the untimely denial of the claim, as their affidavit demonstrated a founded belief that the alleged injuries did not arise out of an insured incident. Therefore, the plaintiffs' motion for summary judgment was properly denied.

The relevant facts considered by the court in Ocean Diagnostic Imaging, P.C. v State Farm Mut. Auto. Ins. Co. include a medical services provider seeking to recover first-party no-fault benefits for services rendered to its assignor. The main issue decided was whether the provider was entitled to summary judgment, as it had established a prima facie case by submitting a claim and showing that payment of benefits was overdue. The court held that the provider was entitled to summary judgment, as the insurance company failed to pay or deny the claim within the prescribed period, and was precluded from raising most defenses. However, the insurance company was not precluded from asserting the defense of an insurance fraud scheme. The court found that the insurance company's denial was based on a "founded belief" that the injuries did not arise from an insured incident, and therefore, there was a triable issue of fact as to whether there was a lack of coverage. As a result, the provider's motion for summary judgment was properly denied.