No-Fault Case Law

The relevant facts the court considered in this case were that a medical services provider, as an assignee of a patient, filed a lawsuit to recover unpaid first-party no-fault benefits from the insurance company. The provider alleged five unpaid claims, and the Civil Court granted summary judgment as to four of the claims. The insurance company then moved to modify the proposed judgment to limit the award of attorney's fees to $850, arguing that fees should be calculated on an aggregate basis. The main issue in the case was whether attorney's fees in no-fault insurance cases should be calculated on a per claim basis or on an aggregate basis. The holding of the case was that as per the opinion of the Court of Appeals in LMK Psychological Servs., P.C. v State Farm Mut. Auto. Ins. Co., attorney's fees in no-fault insurance cases should be calculated based on the aggregate of all bills for each insured, with a maximum of $850. Therefore, the court reduced the award of attorney's fees to the medical services provider from $1,745.47 to $850.

The court considered the fact that the plaintiff is a professional service corporation owned by a licensed physician, but the physician was not certified to perform acupuncture at the time the services at issue were provided. The court also considered that the services were provided by a licensed acupuncturist employed by the plaintiff. The main issues were whether the plaintiff had standing to recover no-fault benefits for acupuncture services and whether a professional service corporation owned solely by a doctor, who is not a certified acupuncturist at the time the services were rendered, is entitled to reimbursement of assigned no-fault benefits for such services. The holding was that a professional service corporation owned solely by a doctor who is not a certified acupuncturist at the time the services were rendered is not entitled to reimbursement of assigned no-fault benefits for such services, even if the services were rendered by a licensed acupuncturist employed by the corporation. Therefore, the judgment was reversed and the complaint was dismissed.

In this case, the plaintiff offered into evidence a notice to admit asking the defendant to admit receiving the plaintiff's claim for no-fault medical provider services. The defendant did not respond to this notice and presented no alternative evidence. The issue presented to the court was whether a no-fault medical service provider can establish its section 5106 (a) prima facie cause of action through a notice to admit, which the court ruled that it can. The court found that the plaintiff had established a prima facie cause of action pursuant to Insurance Law § 5106 (a) as the defendant failed to rebut the claim. Therefore, the court entered judgment for the plaintiff in the sum of $1,184.66 plus statutory interest from 30 days after its claim date, statutory attorneys fees, and costs.

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits, where the plaintiff had moved for summary judgment or, in the alternative, for an order pursuant to CPLR 3212 (g) limiting issues of fact for trial. The District Court had denied the branch of plaintiff's motion seeking summary judgment, and upon reargument, denied the branch seeking an order limiting issues of fact for trial. The main issue decided was whether the plaintiff had made a prima facie showing of entitlement to summary judgment, and the court held that they had failed to do so. Consequently, the court affirmed the District Court's denial of the motion seeking a determination pursuant to CPLR 3212 (g).

The court considered an appeal to vacate an arbitrator's award and a master arbitrator's award in a proceeding to recover first-party no-fault benefits that had been denied. The main issue was whether the arbitrator and the master arbitrator had properly denied the petitioner's claim for assigned first-party no-fault benefits. The court held that the standard for judicial review of an award in a compulsory arbitration proceeding is whether the award had evidentiary support and was not arbitrary and capricious. Applying this standard, the court found no basis to vacate the arbitrator's award and the master arbitrator's award, and affirmed the lower court's decision to confirm the awards. The appellate court noted that a special proceeding should terminate in a judgment, not an order.

The case involved Progressive Medical, Inc. seeking to recover assigned first-party no-fault benefits. The issue was the medical necessity of the equipment billed for by the medical provider. The defendant's peer review doctor testified that the medical equipment billed for was not medically necessary, but the plaintiff objected to the testimony on the grounds that it was based on records that were not in evidence and upon a study, the reliability of which had not been established, and the court sustained the objection and ordered the testimony stricken. The court dismissed plaintiff's complaint, finding that plaintiff "specifically declined to present a prima facie case." The Appellate Term reversed the judgment and remitted the matter to the District Court for the entry of a judgment in favor of plaintiff in the principal sum of $1,123.75, plus statutory interest and attorney's fees. They found that the only issue for trial was defendant's defense of lack of medical necessity and that there was no basis for the court's finding that plaintiff was required to submit a claim form in order to establish prima facie "the health benefit's medical necessity." Additionally, they found no basis to disturb the court's decision to strike defendant's witness's testimony.

The case AP Orthopedics & Rehabilitation, P.C. v Allstate Ins. Co. was about an insurance company's defense that the medical expenses bill for a shoulder surgery was not medically ascertainable within a year of the accident. The insurance company timely denied the bill to raise this defense. Defendant presented the testimony of its claims examiner as proof of the defense, testifying that there were no further bills submitted for the shoulder after the accident, and there was no indication that the claim for shoulder surgery was related to the accident. The main issue decided in the case was what type of proof was required by the insurance company to prove that the injury is not medically ascertainable within a year of the accident. The court held that there was no obligation to pay for services rendered after a year if it is not clear with certainty that further expenses may be incurred. The court found that the insurance company had met its burden of proving that the injury to the assignor's shoulder was not ascertainable within one year of the accident and thus, the insurance company did not have to pay for the plaintiff's medical services.

The court considered that the plaintiff had commenced actions to recover first-party no-fault benefits in March 2003, with the cases being consolidated for trial in December 2004. The actions were marked off the trial calendar on January 6, 2006, and the plaintiff moved to restore them in January 2009. The main issue decided was whether the plaintiff had met the requirements to restore the actions, including demonstrating the merits of its claims, a lack of prejudice to the defendant, a lack of intent to abandon the action, and a reasonable excuse for the delay in moving to restore the actions. The holding of the court was that the plaintiff failed to offer a reasonable excuse for its three-year delay in seeking to restore the actions, and therefore the motion should have been denied.

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits, and that the defendant had filed a cross motion for summary judgment based on lack of medical necessity. The main issue decided was whether the affidavits submitted by the defendant were sufficient to prove the timely mailing of the denial of claim form. The holding of the court was that the affidavits submitted by the defendant were indeed sufficient to establish that the denial of claim form was timely mailed in accordance with the defendant's standard office practice and procedure. As a result, the court affirmed the order without costs. The court also noted that the plaintiff's remaining contentions were improperly raised for the first time on appeal.

The relevant facts in this case involved a medical supply company seeking to recover no-fault benefits from an insurance company. The medical supply company moved for summary judgment, but the insurance company opposed the motion on the grounds that the patient had failed to appear for scheduled independent medical examinations (IMEs). The insurance company argued that it had timely denied the claims based on this failure. The main issue decided by the court was whether the insurance company's opposition was sufficient to establish that the patient had not appeared for the IMEs, thus justifying the denial of the claims. The court held that the insurance company's affidavits were insufficient to establish that the patient had failed to appear for the IMEs, and as a result, the insurance company failed to raise a triable issue of fact. Therefore, the court affirmed the judgment in favor of the medical supply company.