No-Fault Case Law

The court considered whether the essential facts of the case had been construed correctly by the lower court and if the plaintiff's counter claims were acceptable. It was decided that the lower court's implication that the defendant in the case is entitled to the full amount claimed without proper proof of no-fault coverage was incorrect. The holding of the case was that defendant's cross-motion for summary judgment was only granted to the extent of awarding summary judgment dismissing so much of the complaint as sought to recover upon plaintiff's claims in the sums of $793.24 and $274.20 and the unpaid portions of plaintiff's claims in the sums of $3,227.26 and $878.80. The cross-motion was only granted for some of the complaint, while the remaining part of the application was not accepted.

The case involved a dispute over the payment of first-party no-fault benefits to Acupuncture Works, P.C. as the assignee of Luis Quizhpi. The trial court granted the defendant's motion for summary judgment and dismissed the complaint. The main issues considered were whether the denial of claim forms had been timely mailed, if the defendant had fully paid the plaintiff in accordance with the workers' compensation fee schedule, and if there was a lack of medical necessity for the services based on an independent medical examination. The appellate court affirmed the judgment, stating that the defendant's motion for summary judgment was properly granted and the plaintiff's cross motion for summary judgment was properly denied based on the evidence presented. The holding of the case was that the appellate court affirmed the judgment of the trial court, dismissing the complaint by Acupuncture Works, P.C. The court found that the defendant had established that the denial of claim forms had been timely mailed, had fully paid the plaintiff in accordance with the workers' compensation fee schedule, and that there was a lack of medical necessity for the services based on the independent medical examination. Therefore, the defendant's motion for summary judgment was deemed proper and the plaintiff's cross motion for summary judgment was properly denied.

The main facts the court considered were the timely mailing of the independent medical examination (IME) scheduling letters by the defendant, and the failure of plaintiff's assignor to appear for the scheduled IMEs. The main issue decided was whether the defendant had timely denied the claims at issue based on the failure of the plaintiff's assignor to appear for the IMEs, thus establishing its prima facie entitlement to judgment as a matter of law. The holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint should have been granted, as the plaintiff's submission of an affirmation of counsel failed to raise a triable issue of fact. Therefore, the order was reversed, plaintiff's motion for summary judgment was denied, and defendant's cross motion for summary judgment dismissing the complaint was granted.

The relevant facts considered by the court were that a provider, Parsons Medical Supply, Inc., had filed claims for $865 and $1,737 on January 28, 2008 and February 6, 2008, and the defendant insurance company did not pay or deny the claims within 30 days of receipt. The insurance company had sent letters to the provider indicating that they were investigating the claims and obtaining verification, including examinations under oath. The main issue decided by the court was whether the insurance company's delay letters were sufficient to toll the 30-day statutory time period within which a claim must be paid or denied. The holding of the case was that the insurance company's delay letters, which requested no verification, were insufficient to toll the 30-day statutory time period, and therefore the insurance company failed to demonstrate that the claims had been timely denied. As a result, the judgment was reversed, the order granting the insurance company's cross motion for summary judgment dismissing the complaint was vacated, and the insurance company's cross motion was denied.

The court considered a prior arbitration proceeding involving the defendant and a third health care provider who had provided services to the same assignor for injuries from the same accident. The main issue was whether the doctrine of collateral estoppel, based on the prior arbitration decision, should bar the relitigation of the issue in the Civil Court, requiring the complaints to be dismissed. The court held that the doctrine of collateral estoppel applies only against those who were either a party, or in privity with a party, to a prior proceeding, and as it had not been demonstrated that the plaintiff was either a party or in privity with a party to the prior arbitration proceeding, the doctrine of collateral estoppel was inapplicable. Therefore, the judgment was reversed, the order granting the defendant's motion to dismiss the complaints was vacated, the defendant's motion was denied, and the matter was remitted to the Civil Court for all further proceedings.

The court considered an appeal from an order denying defendant's motion for summary judgment dismissing the complaint in a case by a provider to recover assigned first-party no-fault benefits. The only issue on appeal was whether the services provided were medically necessary, as the timeliness of defendant's denials was conceded by the plaintiff. Defendant submitted two affirmed peer review reports to support their motion, which stated there was a lack of medical necessity for the services. However, the plaintiff submitted an affidavit from a doctor which demonstrated the existence of a question of fact as to medical necessity. The court affirmed the order without costs, holding that there was a question of fact as to the medical necessity of the services provided.

The relevant facts the court considered in this case were that Quality Health Products filed a notice of trial and certificate of readiness stating that all discovery had been completed, even though they had failed to provide responses to the defendant's demand for discovery and inspection. The main issue decided was whether the defendant's motion to vacate the notice of trial and to compel plaintiff to respond to defendant's outstanding discovery demands should be granted. The holding of the case was that the defendant's timely motion to vacate the notice of trial was properly granted, as Quality Health Products had failed to provide responses to the defendant's demand for discovery and inspection. The court also compelled Quality Health Products to provide responses to the defendant's outstanding discovery demands, as they did not challenge the propriety of the defendant's demand for discovery and inspection in a timely manner.

The relevant facts the court considered in this case were that the defendant had timely mailed letters scheduling independent medical examinations (IMEs) for the plaintiff's assignor. However, the plaintiff's assignor had failed to appear for the scheduled IMEs. The defendant had also timely denied the plaintiff's claim on the ground that the assignor had failed to appear at the scheduled IMEs. The main issue decided by the court was whether the defendant was entitled to summary judgment dismissing the complaint. The holding of the case was that the judgment in favor of the plaintiff was reversed, the order granting the plaintiff's motion for summary judgment was vacated, and the defendant's cross motion for summary judgment dismissing the complaint was granted. Therefore, the defendant was entitled to summary judgment dismissing the complaint.

The relevant facts considered by the court in the case of Biddle v Safeco Ins. Co. included a dispute over first-party no-fault benefits, with the plaintiff, a medical provider, seeking to recover assigned benefits from the defendant insurance company. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint should be granted. The court held that the motion for summary judgment was properly denied, as the defendant's motion papers failed to establish the timeliness of the denial of claim form and the defense that the plaintiff's assignor had misrepresented her residence in connection with the insurance policy. The court found that the affidavit of the defendant's claims representative did not constitute evidence in admissible form, and as a result, the motion for summary judgment was properly denied.

The court considered the fact that the defendant had timely mailed the initial and follow-up requests for verification to the plaintiff, but had not received the requested verification. As a result, the 30-day period within which the defendant was required to pay or deny the claims did not begin to run and the plaintiff's action was found to be premature. The main issue decided was whether the defendant's failure to receive the requested verification prior to the commencement of the action justified the denial of plaintiff's motion for summary judgment and the granting of defendant's cross motion for summary judgment dismissing the complaint. The holding was that the order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment dismissing the complaint was affirmed.