No-Fault Case Law

The relevant facts the court considered in this case were that Lenox Hill Radiology, P.C. was seeking to recover assigned first-party no-fault benefits from Redland Insurance Company. Redland Insurance Company moved for summary judgment to dismiss the complaint, arguing that the denial of claim had been issued in duplicate. The main issue decided was whether the denial of claim had been issued in duplicate. The holding of the case was that the appellate court reversed the lower court's decision, stating that the affidavit submitted by the defendant established that the denial of claim had been issued in duplicate. Therefore, defendant's motion for summary judgment dismissing the complaint was granted.

The court considered a provider's claim to recover assigned first-party no-fault benefits, and the defendant insurance company moved for summary judgment to dismiss the complaint. In support of its motion, the insurance company submitted affirmed peer review reports and an independent medical examination report, which determined that there was a lack of medical necessity for the services rendered. The Civil Court denied the defendant's motion, stating that the matter shall proceed to trial on the issue of medical necessity. However, the appellate court reversed the decision, ruling in favor of the defendant, as the plaintiff failed to rebut the conclusions set forth in the defendant's reports. The holding of the case was that the defendant's motion for summary judgment dismissing the complaint was granted.

Issues: The main issue in this case was whether the defendant's refusal to pay the full $25,000 SUM coverage limits amounted to a breach of the implied covenant of good faith and fair dealing. Facts: Sarah Orman was involved in a car accident while making a left turn, and her car was struck in the rear by another vehicle. At the time of the accident, the other driver had an automobile insurance policy with limits of $25,000 per person and $50,000 per accident, and Orman had a policy with SUM coverage with the same limits. Geico, her insurance company, advised her to settle the case and even granted permission to settle a bodily injury claim with the adverse tort carrier. However, Orman requested the full $25,000 SUM coverage limits, which Geico refused to pay. Geico also requested medical authorizations and MRI films to properly evaluate the claim. Holding: The court granted Orman's motion to dismiss Geico's affirmative defenses and denied Geico's cross-motion to dismiss the claim for breach of the implied covenant of good faith and fair dealing, holding that the plaintiff was justified in understanding a promise of the full $25,000 SUM coverage limits was included in the contract. Since the insured must also meet the serious injury requirement before entitlement to supplementary benefits, the serious injury defense put forth by Geico did not constitute bad faith. Geico's refusal and negligence to pay Orman was not made in good faith, and thus, the court held that there was a valid cause of action for breach of the implied covenant of good faith and fair dealing.

The court considered the evidentiary proof submitted by the defendant-insurer, which established that its initial and follow-up verification letters were timely and properly mailed to the plaintiff medical provider's attorney. The main issue decided was whether the defendant was entitled to summary judgment dismissing the claim as premature, as the plaintiff failed to respond to the verification requests. The court held that the defendant was entitled to summary judgment dismissing the claim, as the plaintiff's attorney's denial of receipt of the verification letters was insufficient to raise a triable issue. The court also rejected the plaintiff's claim that 11 NYCRR 65-3.6(b) required the defendant to issue a delay letter to both the plaintiff and its attorney.

The court considered the defendant insurer's motion for summary judgment to dismiss the complaint and the plaintiff's cross motion for summary judgment. The main issue decided was whether the defendant insurer's verification requests were valid and if the plaintiff failed to respond to those requests. The court held that the defendant established its entitlement to summary judgment because the plaintiff failed to respond to the verification requests, and therefore, the underlying first-party no-fault claims were premature. The court also found that the defendant's requests for verification, made after the 15-day period but before the 30-day claim denial window expired, did not render the requests invalid, but only reduced the 30-day time period for payment or denial of the claim. Therefore, the court reversed the order, denied the plaintiff's cross motion, and granted the defendant's motion for summary judgment.

The court considered the fact that Advanced Neurological Care, P.C. ("Advanced") sought to recover first party no-fault benefits for MRI's performed on Daisha Sylvester on January 17, 2012 and other treatment provided on January 24, 2012, and that State Farm Mutual Automobile Ins. Co. ("State Farm") acknowledged receipt of the claim. The main issue was whether State Farm timely mailed and properly addressed verification requests and follow-up verification requests, and whether Advanced acted in accordance with the 30-day time frame for responding to verification requests. The holding of the case was that State Farm's motion for summary judgment was denied, as the court found questions of fact regarding the timely mailing and addressed verification requests, and Advanced's cross-motion for summary judgment was also denied, as its action would be dismissed as premature if the verification requests were found to be properly addressed and timely mailed.

The relevant facts considered by the court in this case involved a provider seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company had timely mailed verification requests and follow-up verification requests, but had not received all of the verification requested. The main issue before the court was whether the insurance company had met its obligations under the law to pay or deny the claims within a 30-day period. The court ultimately held that the insurance company had not received all the verification requested and the provider had not demonstrated that such verification had been provided before the commencement of the action, making the provider's action premature. Therefore, the judgment was reversed, the provider's motion for summary judgment was denied, and the insurance company's cross motion for summary judgment dismissing the complaint was granted.

The main issue in this case was whether or not the defendant insurance company was obligated to pay or deny a claim when the plaintiff had failed to respond to the defendant's verification requests. The court held that the defendant did not have to pay or deny a claim until it had received all relevant verification, and therefore the plaintiff's action was prematurely commenced. The court found that the defendant had timely mailed its requests and follow-up requests for verification, and that the plaintiff had not provided the requested verification to the defendant prior to the commencement of the action. As a result, the court affirmed the order granting the defendant's cross motion for summary judgment dismissing the complaint.

The main issue in this case was whether the Civil Court erred in denying the plaintiff's motion to enter a default judgment and deeming the defendant's answer "served and accepted and filed." The court found that the plaintiff did not establish their entitlement to the entry of a default judgment based on the evidence provided. However, the court also found that the Civil Court erred in deeming the defendant's answer "served and accepted and filed" as the defendant had not demonstrated a reasonable excuse for its default and a meritorious defense to the action. Therefore, the court modified the order by striking the provision deeming the defendant's answer as accepted and filed, and affirmed the order as modified.

The relevant facts considered by the court were that a medical provider sought to recover no-fault benefits from an insurance company, and the insurance company denied the claims on the basis that two of the medical provider's principals had failed to appear for examinations under oath. The main issues decided by the court were whether the medical provider had established its prima facie case, whether the insurance company's initial and follow-up examination requests had been timely and properly mailed, and whether the insurance company was precluded from raising certain defenses. The holding of the court was that the denial of the insurance company's motion to compel was reversed, and the medical provider was compelled to produce the principals for examinations before trial solely with respect to the issue of the provider's billing practices, while the provider's cross motion for summary judgment was denied.