No-Fault Case Law
Kew Gardens Imaging v Liberty Mut. Ins. Co. (2004 NY Slip Op 51077(U))
September 27, 2004
The main issue in this case was whether the award of an arbitrator denying the disputed billing for MRIs, based on lack of documented medical necessity, was arbitrary, capricious, or incorrect as a matter of law. The court considered the fact that the insurer failed to deny the claim within the prescribed thirty-day period, as well as the legal precedent regarding the burden of proof in first-party no-fault claims. The court held that the insurer is precluded from raising any defense other than lack of coverage when it fails to comply with the rule requiring it to deny a claim within thirty days. Therefore, the court vacated the decision of the Master Arbitrator and found for the petitioner in the amount of $1,791.73, with statutory interest and fees as established in section 5106(a) of the Insurance Law.
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 24356)
September 24, 2004
The court considered whether an insurer was required to pay out a claim for a first-party benefit pursuant to New York's No-Fault Insurance Law within the statutory 30-day period following submission of the claim. The insurer argued that it was not subject to the provisions of the law because the person allegedly injured in the motor vehicle accident did not submit to several requests for an examination under oath, and also that the accident was staged. The court found that Regulation 68-A applied to claims filed after its effective date, and therefore denied the plaintiff's motion for summary judgment. Additionally, the court found that the insurer's argument that the plaintiff's assignor was not a covered person because of alleged fraud was without merit due to a lack of evidence. Therefore, the plaintiff's motion for summary judgment was denied.
Aurora Chiropractic, P.C. v Farm & Cas. Ins. Co. of Ct. (2004 NY Slip Op 51066(U))
September 23, 2004
The court considered the failure of the defendant to pay or deny claims for medical services rendered to Kathleen Marsh after an automobile accident. The main issues decided were whether the defendant had a reasonable excuse for its delay in answering the complaint and whether the defendant had a meritorious defense in claiming that the treatments rendered by the plaintiffs were not medically necessary. The court held that the defendant did not have a reasonable excuse for its delay in answering and did not have a meritorious defense, as the defendant was precluded from denying the claims due to the lack of a timely denial, and therefore the motion to vacate the default and set aside the judgment was denied.
CKC Chiropractic v Republic W. Ins. Co. (2004 NY Slip Op 24351)
September 23, 2004
The Civil Court of the City of New York, Kings County, decided the case of CKC Chiropractic v Republic W. Ins. Co. The plaintiff sought to recover first-party benefits under New York’s No-Fault Law and filed a motion for summary judgment against the defendant. The defendant argued that they did not have to pay the claim because the plaintiff was not currently registered with the New York State Department of Education. The main issue before the court was whether a health care provider who is registered with the New York State Department of Education at the time services are provided may recover the value of those services under New York's No-Fault Insurance Law if the provider is no longer registered at the time payment for those services is sought. The court held that a medical provider may be reimbursed for services rendered while he or she was registered to perform such services under the No-Fault Law, even if the provider subsequently becomes unregistered. As a result, the plaintiff’s motion for summary judgment was granted and the defendant's cross-motion was denied.
Ocean Diagnostic Imaging, P.C. v Geico Ins. (2004 NY Slip Op 51038(U))
September 20, 2004
The court considered the fact that the plaintiff, a health care provider, submitted proof that it had mailed statutory claim forms to the defendant, that the defendant received them, and that the defendant did not pay or deny the claims within the 30-day statutory period. The main issue decided was whether the defendant's untimely denial of benefits precluded them from asserting the defense that the alleged injuries did not arise from a covered accident. The holding of the court was that the plaintiff's motion for summary judgment was granted, and the case was remanded for the calculation of statutory interest and attorney's fees pursuant to Insurance Law. The court also determined that the affidavit of defendant's attorney, who had no personal knowledge of the facts and made bare and conclusory allegations of fraud, was insufficient to raise a triable issue of fact.
Allcity Ins. Co. v Eagle Ins. Co. (2004 NY Slip Op 24363)
September 20, 2004
The main facts considered in the case included a motor vehicle accident claim in which the petitioner sought reimbursement pursuant to New York state law for loss transfer compulsory arbitration for no-fault payments. The main issue was the application of the three year statute of limitations, which was imposed by the arbitrator from the date of the accident. Arbitration decisions were vacated repeatedly due to erroneous application of the statute of limitations. The court held that the compulsorily arbitration decision must have evidentiary support and cannot be arbitrary and capricious. The court ultimately vacated the arbitration award and set the motion for sanctions against the responsible company down for a hearing regarding evidence of attorney's fees expended.
King’s Med. Supply, Inc. v Hereford Ins. Co. (2004 NY Slip Op 24343)
September 20, 2004
The court considered the case of King's Medical Supply, Inc. seeking to recover no-fault benefits for medical supplies provided to its assignor from Hereford Insurance Company. Plaintiff moved for summary judgment in the amount of $980, but the motion was denied by the court. The main issue decided was whether the plaintiff's billing manager had to allege in his supporting affidavit that he had personal knowledge that the equipment was furnished to plaintiff's assignor. The court found that the exhibits submitted by the plaintiff's billing manager established that the supplies were furnished to the assignor but also found that a triable issue of fact existed regarding the timeliness of the defendant's denial of the claim. Therefore, the court affirmed the order denying the plaintiff's motion for summary judgment.
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51032(U))
September 17, 2004
The relevant facts considered by the court were that the plaintiff was seeking to recover $2,637.07 in first-party no-fault benefits for medical services rendered to an assignor pursuant to Insurance Law §5101 et seq. The main issues decided by the court were whether the affidavit provided by the billing manager for the plaintiff established that the attached exhibits were sufficiently accurate and trustworthy to merit their admission into evidence, and whether the defendant had raised a valid defense that the collision was a staged event in furtherance of an insurance fraud scheme. The holding of the case was that contrary to the determination of the court below, the affidavit of plaintiff's billing manager was adequate and laid a proper foundation for the court to consider the exhibits attached. Furthermore, the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, resulting in the plaintiff's motion for summary judgment being properly denied.
A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51031(U))
September 17, 2004
The relevant facts considered in this case included an action to recover first-party no-fault benefits where the plaintiff's affidavit in support of their motion for summary judgment did not establish that plaintiffs provided the defendant with properly completed claim forms. Additionally, there was no assignment of benefits form on behalf of one of the plaintiffs. The main issue decided was whether the plaintiffs' motion for summary judgment should have been denied, and whether the defendant was entitled to judgment dismissing the action. The holding of the case was that the plaintiffs' motion for summary judgment was denied, as their affidavit was insufficient to establish they provided the defendant with properly completed claim forms. However, the defendant's motion for summary judgment was also denied, as the claim that the underlying traffic incident was staged to defraud was supported by sufficient factual allegations in admissible form to require a trial.
Ocean Diagnostic Imaging P.C. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 24342)
September 17, 2004
The Court considered the fact that the Plaintiff, a health care provider, had established a prima facie entitlement to summary judgment by the submission of a complete proof of claim and the amount of the loss. The Defendant did not deny the claim within the statutory 30-day claim determination period, but argued that the collision was a staged event in furtherance of an insurance fraud scheme. The investigator's affidavit set forth sufficient facts to demonstrate that the Defendant possessed a "founded belief that the alleged injuries do not arise out of an insured incident." The main issue decided was whether the Defendant could assert the defense that the collision was a staged event in furtherance of an insurance fraud scheme, despite failing to deny the claim within the statutory 30-day claim determination period. The holding of the case was that the Defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, so that the Plaintiff's motion for summary judgment was properly denied.