No-Fault Case Law

The court considered the facts of a case where a provider sought to recover assigned first-party no-fault benefits from an insurance company. The insurance company had paid the provider at a reduced rate based on the workers' compensation fee schedule, while the provider contended that the amounts charged were reasonable and within the prevailing fees in the area. The main issue decided was whether the insurance company's use of the workers' compensation fee schedule to determine the amount payable to the provider was proper. The court held that the insurance company had established its entitlement to summary judgment by showing that it timely mailed its denial of claim forms, and that it was proper for the insurance company to use the workers' compensation fee schedule for acupuncture services performed by chiropractors to determine the amount which the provider was entitled to receive. Therefore, the insurance company's motion for summary judgment dismissing the complaint was granted.

The court considered a case where medical service providers were seeking to recover first-party no-fault benefits from an insurance company. The main issue decided was whether the insurance company's failure to pay or deny the claims within the prescribed period and failure to establish that the period was extended precluded it from raising most defenses. The holding of the court was that the insurance company's failure to pay or deny the claims within the prescribed period and failure to establish that the period was extended precluded it from raising most defenses, resulting in summary judgment being awarded to the medical service providers on certain claims. The court also found that the insurance company's submissions were insufficient to raise a triable issue of fact with respect to certain claims, and thus summary judgment was awarded to the medical service providers on those claims. The case was remanded for the calculation of statutory interest and attorney's fees.

The court considered the facts that the medical services company was seeking first-party no-fault benefits for services rendered to an individual, and that the case was dismissed due to the plaintiff's lack of readiness to proceed. The court decided that the case was dismissed on default, and that the plaintiff did not adequately demonstrate a reasonable excuse for the default or a meritorious cause of action. The court further held that the dismissal was correct because the plaintiff failed to sustain its burden in failing to calendar the trial date, and thus affirming the earlier judgment.

The relevant facts of this case involve a lawsuit brought by State Farm Mutual Automobile Insurance Company against several professional medical corporations and individuals for common-law fraud and unjust enrichment. State Farm alleged that the defendant professional corporations were fraudulently incorporated and owned and controlled by unlicensed individuals in violation of applicable statutes and regulations. State Farm also alleged that the defendant professional corporations were not entitled to receive payments for no-fault claims submitted as they were not solely owned and controlled by a licensed medical physician and the services provided were not rendered by employees. The main issues decided by the court were whether the defendant professional corporations were entitled to collect no-fault benefits for charges submitted to the plaintiff, and whether the third and fourth causes of action asserted by the plaintiff stated viable claims for declaratory relief. The court held that the plaintiff's withholding of payments to defendant professional corporations for services rendered by independent contractors was a justiciable controversy capable of disposition in an adversarial context, and that the plaintiff's causes of action stated viable claims for declaratory relief. Therefore, the motion by the defendants to dismiss the third and fourth causes of action was denied.

The court considered the fact that the plaintiff, Omni Chiropractic, P.C., as the assignee of YACKUELIN RODRIGUEZ, was seeking to recover assigned first-party no-fault benefits from Travelers Insurance Co. The sole witness for the plaintiff testified that he generated and mailed the bills at issue. The Civil Court found in favor of the defendant, determining that the plaintiff had failed to establish that the bills were unpaid. Plaintiff appealed, but the judgment was affirmed, as the provider failed to establish that payment of the no-fault benefits at issue was overdue. The main issue decided was whether the provider had established their prima facie case for the recovery of assigned first-party no-fault benefits. The holding of the case was that the judgment in favor of the defendant was affirmed, as the provider failed to establish that payment of the benefits at issue was overdue.

The main issue in this case was whether Delta Diagnostic Radiology, P.C. was entitled to recover assigned first-party no-fault benefits from Country-Wide Insurance Company. The court considered the fact that Country-Wide Insurance Company's follow-up verification requests were premature and without effect, and thus denied the defendant's motion for summary judgment. The holdng of the case was that defendant's motion for summary judgment was properly denied because of the premature and ineffective follow-up verification requests, which violated General Construction Law § 20 and Insurance Department Regulations. The court affirmed the order without costs, with one judge dissenting.

The main issues in this case were whether the defendant had established the mailing of verification requests and whether the action was premature due to plaintiff's failure to respond to verification requests. The court considered the affidavit of the defendant's claims specialist, who attested to the mailing of the verification requests, and determined that it was sufficient to establish the mailing. The court also considered the plaintiff's argument that the defendant failed to demonstrate personal knowledge of the mailing or set forth defendant's standard office practices and procedures, but found that the affidavit was adequate. The holding of the case was that the order, insofar as appealed from, was affirmed, and the defendant's cross motion for summary judgment dismissing the complaint was granted.

The main issue in St. Vincent Med. Care, P.C. v Country-Wide Ins. Co. was whether the defendant's verification requests properly tolled the 30-day claim determination periods. The Court held that the defendant's follow-up verification requests were premature and had no effect, as they were mailed on the 30th calendar day after the original requests, which was in violation of the relevant regulation. The Court also held that the plaintiff's motion for summary judgment was properly granted as to the remaining claims because the defendant failed to timely deny the claims and was precluded from raising most defenses. However, the Court reversed the award for services rendered on February 22, 2006, and vacated the order granting summary judgment on this claim, as the defendant established that it timely denied this claim. This case highlighted the importance of adherence to procedural requirements in the no-fault claim process, and the consequences of failing to meet those requirements.

The main issue in this case was whether a peer review report submitted by an insurance company, in support of its denial for lack of medical necessity, was sufficient to defeat a plaintiff's motion for summary judgment or to grant a defendant's cross motion for summary judgment. The court considered the fact that the plaintiff had established its prima facie case by submitting evidentiary proof that the prescribed statutory billing forms were mailed and received, and that payment of no-fault benefits were overdue. The plaintiff's motion for summary judgment was opposed by the defendant, who cross-moved for summary judgment on the grounds that the services provided by the plaintiff were not medically necessary based on the peer review report provided by the defendant's chiropractor. The court held that the peer review report submitted by the defendant was not sufficient to warrant granting of summary judgment to the defendant insurer, even when the plaintiff did not submit evidence to rebut the report. As a result, the case was to proceed to trial.

The court considered whether the submission of a notice to admit was enough to establish a prima facie case to recover no-fault first party benefits for unpaid medical expenses. The main issue was whether the use of a notice to admit was permissible to seek admissions to material issues regarding the receipt of claim forms, bills, and denials by the insurer. The holding of the case was that although the use of a notice to admit to establish that the defendant received the claim forms was permissible, it did not relieve the plaintiff from establishing that the claim forms were admissible as a business record exception to prove the truth of the matters asserted therein. As the plaintiffs failed to establish that the claim forms were business records, they did not establish a prima facie case, and their actions were dismissed.