No-Fault Case Law
Victoria Ins. Co. v Utica Mut. Ins. Co. (2004 NY Slip Op 04859)
June 10, 2004
The main facts considered by the court were that Utica Mutual Insurance Company failed to answer a petition brought by Victoria Insurance Company to confirm three arbitration awards. Utica argued that the arbitrator committed misconduct by refusing to grant an adjournment to permit its investigator to appear. Utica also claimed that the claims paid by Victoria Insurance and for which it sought reimbursement were fraudulent. Additionally, Utica argued that the truck involved in the accident was not modified to increase its weight to more than 6,500 pounds and that there was no basis for reimbursement of nonreimbursable no-fault benefits. The main issue decided by the court was whether Utica made the necessary showing of merit in its application to vacate its default. The holding of the court was that Utica did not make the necessary showing of merit, and that the denial of the vacatur application was affirmed.
Melbourne Med., P.C. v Utica Mut. Ins. Co. (2004 NY Slip Op 24221)
June 7, 2004
The court unanimously affirmed the orders in this action to recover $765 in first-party no-fault benefits for medical treatment provided to the assignor Jose Cabreja. Once the prima facie case was established by plaintiff Melbourne Medical, P.C., the conceded failure of Utica Mutual Insurance Co. to pay or reject the claim within 30 days prevented them from interposing most defenses. The court decided that the insurance regulations did not provide for examinations under oath (EUOs) as a form of verification, and a new regulation was inapplicable to the instant claim. An insurer was not able to rely on letters merely informing a claimant that a decision on the claim was delayed pending investigation. The court then considered a fraud allegation and decided that the defense survives preclusion and would constitute a complete defense if substantiated, but defendant did not submit proof in admissible form to create a triable issue of fraud.
A.B. Med. Servs. Pllc v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 50575(U))
June 4, 2004
The relevant facts of the case include that the plaintiffs were seeking to recover assigned first-party no-fault benefits and the defendant submitted an affidavit from an investigator employed within defendant's Special Investigations Unit. The main issue at hand was whether there was a lack of coverage because the alleged injuries did not arise from an insured incident. The court found that the investigator's detailed affidavit set forth ample facts and founded beliefs to establish the existence of a triable issue of fact, therefore denying plaintiffs' motion for summary judgment. The holding of the case was that the denial of plaintiffs' motion for summary judgment was affirmed, and plaintiffs' remaining contentions were also considered lacking in merit.
S & M Supply, Inc. v Nationwide Mut. Ins. Co. (2004 NY Slip Op 50557(U))
June 3, 2004
The court considered whether plaintiff was entitled to summary judgment for first-party no-fault benefits for medical supplies provided to its assignor. Defendant delayed more than 30 days in denying the claim and the plaintiff moved for summary judgment on this ground. Defendant cross-moved for summary judgment seeking dismissal based on the assignor's failure to submit to examinations under oath. The main issue decided was that plaintiff was entitled to summary judgment as defendant did not pay or deny the claim within 30 days, and the time period for payment or denial was not tolled by the requirement for the assignor to submit to an examination under oath. The holding was that plaintiff's motion for summary judgment was granted, and the matter was remanded to the court for the calculation of statutory interest and attorney's fees.
Rockaway Blvd. Med. P.C. v Progressive Ins. (2004 NY Slip Op 24184)
June 2, 2004
The court considered the claim form submitted by the plaintiff to the defendant, the absence of disclosure of the business relationship between the treating provider and the billing provider, and the significance of the information required by form N-F 3. The main issues decided were whether the claim submitted by the plaintiff was sufficient to establish its right to payment from the defendant, and whether the plaintiff submitted a proper proof of claim. The holding of the case was that the plaintiff did not submit a proper proof of claim, and therefore did not establish a prima facie case of entitlement to payment of no-fault benefits, resulting in the denial of the motion for summary judgment.
Nyack Hosp. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 04304)
June 1, 2004
The court considered an action to recover no-fault benefits, with the defendant appealing from an order that granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment. The main issue in the case was whether the plaintiff demonstrated its entitlement to summary judgment by establishing that the defendant did not deny or pay the two claims in question within 30 days, and if the defendant submitted sufficient evidence to raise a triable issue of fact regarding the medical treatment alleged in the first cause of action and whether the underlying contract of insurance alleged in the third cause of action had been cancelled. The holding of the case was that the plaintiff's motion for summary judgment was properly granted because the defendant did not submit sufficient evidence in admissible form to raise a triable issue of fact, and as a result, the defendant's remaining contentions were deemed academic.
Ocean Diagnostic Imaging v Geico Ins. (2004 NY Slip Op 50511(U))
May 28, 2004
The relevant facts considered by the court were that Ocean Diagnostic Imaging, a health service provider, sought assigned first-party no-fault benefits from Geico Insurance. The main issue decided was whether Ocean Diagnostic Imaging was entitled to summary judgment, and the court held that they were. The court found that Ocean Diagnostic Imaging had established a prima facie entitlement to summary judgment by submitting proper proof of the claim and the amount of the loss, and that Geico Insurance had failed to raise any triable issues of fact. The court also found that Geico Insurance did not respond to the claim within the required 30-day period and that their requests for examinations under oath did not toll the 30-day period, therefore Ocean Diagnostic Imaging's motion for summary judgment should have been granted. The matter was remanded for the calculation of statutory interest and an assessment of attorney's fees.
A.B. Med. Servs., Pllc v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50550(U))
May 26, 2004
The court considered an action to recover first-party no-fault benefits for medical services rendered to an assignor. The plaintiffs moved for summary judgment, and the court granted summary judgment on certain claims. The main issue was whether the defendant had provided proof in admissible form to rebut the plaintiff's prima facie showing of entitlement to summary judgment. The court found that the defendant had failed to provide sufficient proof to raise a triable issue of fact as to the medical necessity of the services rendered, which would warrant denial of the plaintiff's motion for summary judgment. Therefore, the court held that the plaintiff's motion was properly granted and affirmed the judgment in their favor.
A.B. Med. Servs. v N. Y. Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 50507(U))
May 26, 2004
In this case, the plaintiffs sought to recover first-party no-fault benefits for medical services rendered to their assignor, totaling $5,773.94, as well as statutory interest and attorney's fees. The lower court granted summary judgment on claims totaling $2,576.32, while denying summary judgment on the remaining $1,440 claim. The issue before the appellate court was whether the denial of the motion for summary judgment on the $1,440 claim was proper, and if the remaining claims were properly granted summary judgment. The appellate court affirmed the judgment, finding that the plaintiffs had established their entitlement to summary judgment by submitting complete proofs of claims, and that the defendant had failed to provide proof in admissible form to rebut the plaintiff's showing of medical necessity, as required by law. Therefore, the plaintiffs' motion for summary judgment was properly granted, and the judgment was affirmed.
Park Neurological Servs. P.C. v GEICO Ins. (2004 NY Slip Op 24210)
May 26, 2004
The court in this case was considering a claim for first-party no-fault benefits. The plaintiff, a neurological services provider, had submitted the claim to the defendant insurance company, but the claim was denied based on a peer review. The provider then filed a lawsuit seeking to recover the amount of the original claim, as well as statutory interest and attorney's fees. The main issue was whether the defendant's denial was valid, and the court determined that the denial was not sufficiently supported with reasons, and therefore the defendant was precluded from asserting the defense of lack of medical necessity. The holding of the court was to reverse the lower court's order, grant the plaintiff's motion for summary judgment, and remand the case for the calculation of statutory interest and an assessment of attorney's fees.