No-Fault Case Law
A Khodadadi Radiology, P.C. v Travelers Prop. Cas. Ins. Co. (2008 NY Slip Op 50910(U))
April 25, 2008
The court considered the fact that the plaintiff, a provider, had filed a motion for summary judgment to recover first-party no-fault benefits, but the defendant had timely denied the claim based on a peer review report stating that the services provided were not medically necessary. The main issue decided was whether the denial of the claim form was timely mailed according to the defendant's standard office practice and procedure, and whether the peer review report submitted by the defendant was sufficient to demonstrate an issue of fact with respect to the defense of lack of medical necessity. The holding of the case was that the denial of claim form was found to have been timely mailed, and the peer review report submitted by the defendant was deemed to be enough to show the existence of an issue of fact, so the order denying the plaintiff's motion for summary judgment was affirmed.
City Wide Social Work & Psychological Servs., P.L.L.C. v State-Wide Ins. Co. (2008 NY Slip Op 50909(U))
April 25, 2008
The relevant facts considered by the court were that plaintiff, City Wide Social Work and Psychological Services, P.L.L.C., sought to recover assigned first-party no-fault benefits, and defendant, State-Wide Ins. Co., failed to submit opposition to plaintiff's motion for summary judgment, resulting in the entry of a default judgment against defendant. The main issue decided was whether defendant's motion to vacate the default judgment should be granted. The court held that the default judgment should not be vacated, as defendant failed to demonstrate a reasonable excuse for its default and a meritorious defense to the action. The court found that defendant did not show that its proffered defenses were set forth in timely denial of claim forms, as required by Insurance Department Regulations, or that defendant possessed a defense which was not subject to preclusion. Therefore, defendant's motion to vacate the default judgment was denied.
State Farm Mut. Auto. Ins. Co. v Clouden (2008 NY Slip Op 03823)
April 25, 2008
The issue in the case was whether the Supreme Court erred in denying the dismissal of the claims to recover PIP and APIP benefits. Defendant James W. Celotto contended that Supreme Court made an error in denying his cross motion seeking dismissal of the claims. However, the court found that the complaint was never amended and did not contain any such claims. Therefore, it concluded that the court properly denied the cross motion. The Appellate Division, Fourth Department affirmed the order of Supreme Court, holding that there was no error in denying the cross motion for dismissal of the claims. Therefore, the complaint containing the claims to recover PIP and APIP benefits could not be dismissed.
Boris Kleyman, P.C. v Kemper Ins. Co. (2008 NY Slip Op 50877(U))
April 24, 2008
The court considered whether the plaintiff was entitled to summary judgment in a case to recover assigned first-party no-fault benefits. The main issue was whether the services rendered were medically necessary, and the court ultimately held that the plaintiff was entitled to summary judgment. The court found that the plaintiff had established its entitlement to summary judgment by proving the submission of a statutory claim form and that payment of no-fault benefits was overdue. The burden then shifted to the defendant to raise a triable issue of fact, but the peer review reports submitted by the defendant were found to be illegible, and therefore failed to demonstrate the existence of a triable issue of fact as to medical necessity. As a result, the plaintiff's motion for summary judgment was granted.
A.T. Med., P.C. v State Farm Ins. Co. (2008 NY Slip Op 50875(U))
April 24, 2008
The relevant facts of the case include that the plaintiff, A.T. Medical, P.C., sought to recover first-party no-fault benefits as an assignee of an individual. The court granted the plaintiff's motion for summary judgment, awarding them $3,458.29. However, the defendant, State Farm Insurance Company, appealed the decision, arguing that an injunction issued by Justice Kenneth Davis barred the plaintiff from commencing suit against them to recover the benefits. The Appellate Term agreed with the defendant, finding that the injunction indeed barred the plaintiff from making the summary judgment motion. As a result, the judgment was reversed, the order granting summary judgment was vacated, and the plaintiff's motion for summary judgment was denied without prejudice. Therefore, the plaintiff's motion for summary judgment was ultimately unsuccessful due to the injunction.
Executive MRI Imaging, P.C. v State Farm Ins. Co. (2008 NY Slip Op 50902(U))
April 21, 2008
The court considered the affidavit submitted by plaintiff's corporate officer in support of their motion for summary judgment, which failed to lay a proper foundation for the admission of the documents annexed to the moving papers. The main issue decided was whether the affidavit was sufficient to establish personal knowledge of the plaintiff's practices and procedures to lay a foundation for the admission of the documents as business records. The holding was that the affidavit submitted was insufficient, and as a result, the plaintiff failed to make a prima facie showing of their entitlement to summary judgment. Therefore, the court reversed the order granting plaintiff's motion for summary judgment and denied the motion.
Orthotic Surgical & Med. Supply, Inc. v GEICO Ins. Co. (2008 NY Slip Op 50869(U))
April 14, 2008
The court considered the case of Orthotic Surgical & Medical Supply, Inc. v GEICO Ins. Co. where the plaintiff was seeking to recover first-party no-fault benefits. The main issue decided was whether the affidavit submitted by an employee of plaintiff's former attorney laid a proper foundation for the documents annexed to plaintiff's moving papers, and whether the plaintiff failed to establish a prima facie case. The holding of the court was that the affidavit submitted was insufficient to establish that the employee possessed personal knowledge of the plaintiff's practices and procedures, and therefore failed to lay a foundation for the admission of the documents as business records. As a result, the plaintiff failed to make a prima facie showing of its entitlement to summary judgment. The judgment was reversed, the order granting the plaintiff's motion for summary judgment was vacated, and the plaintiff's motion for summary judgment was denied.
Health & Endurance Med., P.C. v Liberty Mut. Ins. Co. (2008 NY Slip Op 50864(U))
April 14, 2008
The main issue in this case was whether a billing provider could recover no-fault benefits for services performed by an independent contractor. The court considered the fact that the plaintiff was seeking to recover for services performed by an independent contractor and that the claim forms submitted by the plaintiff stated that the treating professional was an independent contractor. The court held that where a billing provider seeks to recover no-fault benefits for services not rendered by it or its employees, but by an independent contractor, it is not considered a "provider" of the medical services within the meaning of Insurance Department Regulations and is not entitled to recover "direct payment" of assigned no-fault benefits from the defendant insurer. Therefore, the court affirmed the order denying the plaintiff's motion for summary judgment and granting the defendant's cross motion for summary judgment dismissing the complaint.
All-Boro Med. Supplies, Inc. v Progressive Northeastern Ins. Co. (2008 NY Slip Op 50766(U))
April 11, 2008
The court considered the fact that the plaintiff sought to recover first-party no-fault benefits for medical supplies provided to Ramel King, who was injured in an automobile accident. The main issue decided was whether the defendant's request for additional verification of the claim tolled the 30-day period in which the defendant had to pay or deny the claim. The court held that the defendant's request for a prescribed NF-3 form constituted additional verification of the claim, which tolled the 30-day period, and therefore, the plaintiff had not established that payment of no-fault benefits was overdue. The court ultimately entered judgment in favor of the defendant, dismissing the plaintiff's claim as premature.
First Aid Occupational Therapy, PLLC v New York Cent. Mut. Fire Ins. Co. (2008 NY Slip Op 50863(U))
April 8, 2008
The court considered the appeal from an order of the Civil Court of the City of New York, Queens County, which granted the plaintiff's motion for summary judgment in a case involving a provider seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the affirmation submitted by the plaintiff's billing manager was sufficient to establish that the documents annexed to the plaintiff's moving papers were admissible as business records. The court held that the affirmation executed by the billing manager was insufficient to establish personal knowledge of the plaintiff's office practices and procedures, and therefore failed to make a prima facie showing of entitlement to summary judgment. As a result, the judgment was reversed, the order granting plaintiff's motion for summary judgment was vacated, and plaintiff's motion for summary judgment was denied.