No-Fault Case Law

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.

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.

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.

The main issues in the case were whether the plaintiffs were entitled to first-party, no-fault benefits for medical services provided to their assignor after he was injured in a car accident, and whether the insurer was within its rights to deny the claims on the basis of medical necessity. The court held that because the insurer did not pay or deny the claims within the 30 days allowed by the regulations, and because the insurer had not requested verification or objected to the form or sufficiency of the assignment of benefits within the required timeframe, the plaintiff had established its prima facie entitlement to summary judgment. Therefore, the court granted the plaintiffs' motion for partial summary judgment.

The court considered the facts of a rear-end collision between two vehicles insured by State Farm and Progressive insurance companies. State Farm disclaimed coverage for the collision, claiming it was an intentional, staged event to defraud the insurance company. The main issues decided were whether State Farm's disclaimer of coverage was valid, and whether the injured parties could seek arbitration under Progressive's uninsured motorist endorsement. The court held that State Farm's disclaimer was valid and that the collision was indeed an intentionally staged event. As a result, the injured parties could not seek compensation under Progressive's uninsured motorist endorsement, and the insurer's application for a permanent stay of arbitration was granted. The court also noted the injustice of innocent victims of intentional collisions being left without any recourse for compensation.

The case involved an action to recover no-fault medical payments, with the plaintiffs appealing from an order denying their motion for summary judgment. The plaintiffs argued that the defendant insurance company had not responded to their claims for no-fault medical benefits within the required 30 days. However, the defendant submitted evidence that the claims had been billed over a year earlier and denial of claim forms had been mailed at that time. The defendant's evidence raised triable issues of fact as to the timing of the claims and whether the defendant properly denied them. The court ultimately held that the evidence submitted by both parties created a genuine issue of fact and denied the motion for summary judgment.

The relevant facts considered by the court in this case were that the plaintiff submitted a claim for payment for medical treatment provided under the no-fault law to its assignor. The defendant denied the claim based on a lack of medical necessity, citing the opinion of a nurse in support of their denial. The main issue decided by the court was whether the denial of coverage based on lack of medical necessity needed to be supported by the opinion of a peer review doctor exclusively, or if a file-based review methodology could be used. The court held that since the defendant failed to prove lack of medical necessity through a medical examination or peer review, the denial was ineffective, and therefore summary judgment was granted in favor of the plaintiff. The holding of the case was that the plaintiff was entitled to judgment in the sum of $879.73, plus statutory interest, attorney's fees, and costs and disbursements.

The relevant facts considered by the court include a dispute between a no-fault insurance provider and medical corporations who employed acupuncturists to treat patients under the insurance policies. The main issues were whether a medical corporation could lawfully employ an acupuncturist and whether the corporation is entitled to reimbursement by the insurer for medical services provided. The court held that the insurance provider's fraud claim failed to state a cause of action and the unjust enrichment claim was unavailing. The court also granted the insurance provider's motion for summary judgment dismissing the counterclaim of one of the medical corporations, resulting in the dismissal of the complaint as against all defendants. The court addressed the lack of precedent directly addressing the issues and conflicting results in lower courts, providing a thorough analysis to reach its decision.

The court heard a motion from Lumbermans Mutual Insurance Company for a protective order denying Westbury Medical Care, P.C. disclosure of its entire no-fault file with respect to its assignor, Elaine McKeithan. Lumbermans Mutual Insurance Company provided no-fault insurance benefits to McKeithan as a result of an automobile accident on July 14, 2000. The provider, Westbury Medical Care, P.C., sought recovery of no-fault benefits from the insurer in the sum of $2,950.36, for medical services provided to its assignor. The main issue for the court to decide was whether the plaintiff was entitled to review the defendant's entire no-fault claims file, despite the defendant's objection. The court held that the plaintiff is entitled to disclosure of only those documents specifically concerning the alleged concurrent treatment and declined to permit the disclosure of protected health information of the entire no-fault file. The court found that an assignment, which the plaintiff had previously filed, did not constitute a valid authorization under HIPAA, as it failed to comply with HIPAA regulations. Therefore, the plaintiff was only entitled to review documents concerning the issue of concurrent care.

The relevant facts of this case are that Aviyon Medical Rehabilitation, P.C. brought an action against Allstate Insurance Company for its failure to pay the total amount due on assigned no-fault claims, leaving an unpaid balance of $105,218.78. Allstate Insurance Company moved to sever and dismiss the claims, arguing that the claims did not arise from a series of transactions or occurrences and that joinder would cause prejudice and lead to jury confusion. The main issues decided by the court were whether the claims should be severed and dismissed, and whether the court had subject matter jurisdiction. The holding of the court was that defendant's motion to sever and dismiss the claims was denied, and the court retained subject matter jurisdiction over the case. The court based its decision on the liberal joinder policy to prevent multiplicity of suits and the absence of logistical difficulties in preparing a defense to the claims.