No-Fault Case Law

The court considered the fact that St. Vincent's Hospital of Richmond and Lenox Hill Hospital filed a motion for summary judgment. St. Vincent's Hospital argued that payment of no fault benefits was overdue, while Lenox Hill Hospital sought to join the lawsuit based on a uniform policy of insurance. The main issues decided were whether St. Vincent's Hospital was entitled to summary judgment for the unpaid balance of a patient's bill, and whether Lenox Hill Hospital could join the lawsuit against State Farm Mutual Automobile Insurance Company. The holding was that a question of fact existed with respect to whether the fees charged by St. Vincent's Hospital were in excess of the Workers' Compensation fee schedule, and therefore a hearing was necessary to determine how much should have been billed. The court also decided to sever the second cause of action and allow Lenox Hill Hospital to proceed with a separate lawsuit against State Farm Mutual Automobile Insurance Company.

The case involves an action to recover assigned first-party no-fault benefits. The plaintiff, Delta Diagnostic Radiology, P.C., sought summary judgment, which was denied by the court. The plaintiff's motion for summary judgment was denied because the affidavit executed by plaintiff's corporate officer was insufficient to establish a foundation for the admission of documents as business records. Defendant's cross motion for summary judgment was granted due to plaintiff's failure to provide evidence rebutting the peer review report annexed to defendant's cross motion. The court found that there was no medical necessity for the MRIs performed by the plaintiff, as established by the defendant's peer review report. The court ultimately affirmed the order without costs. Ultimately, the court held that the plaintiff failed to make a prima facie showing of entitlement to summary judgment and that the defendant's cross motion for summary judgment was properly granted due to the plaintiff's failure to rebut the evidence provided by the defendant's peer review report.

The main issue in this case was whether the rationale for the conclusion in the peer review reports, upon which the defendant's denial of claim forms was based, was correct. The court considered the fact that the defendant timely mailed the two denial of claim forms at issue which stated that the plaintiff's claims were denied, based upon peer reviews, on the ground of lack of medical necessity. Plaintiff moved to preclude testimony by the medical expert proffered by the defendant on the grounds that his opinion would be hearsay and that plaintiff would be prejudiced by its inability to cross-examine the doctors who prepared the peer review reports upon which plaintiff's claims were denied. The court granted plaintiff's motion to preclude testimony by defendant's medical expert. The holding of the case was that the judgment was reversed and a new trial was ordered.

The court considered the facts that Delta Diagnostic Radiology, P.C. sought to recover assigned first-party no-fault benefits from Progressive Casualty Insurance Co. and that the defendant had initially denied plaintiff's claim for $879.73 but later paid it after the 30-day claim determination period. The main issue decided was whether the plaintiff was entitled to recover statutory interest and attorney's fees on the $879.73 claim. The holding of the case was that the plaintiff was entitled to summary judgment upon that portion of its cause of action seeking statutory interest and attorney's fees on the claim for $879.73, and the matter was remanded to the court below for the calculation of statutory interest and an assessment of attorney's fees due thereon, and for all further proceedings on the remaining claims.

The court considered the issue of psychological services providers who sued an automobile insurance company to recover on no-fault claims assigned to them by individuals injured in automobile accidents. Defendant argued that plaintiffs failed to establish standing to commence the action by submitting documentation of the assignment of the claims to them. However, in light of the Court of Appeals decision in Hospital for Joint Diseases v Travelers Prop. Cas. Ins. Co. (9 NY3d 312 [2007]), this challenge was withdrawn. The court rejected the defendant's contention that the Supreme Court improperly awarded interest to plaintiffs by not tolling the interest for the period between 30 days after plaintiffs received the claim denial until the action was commenced. The court also upheld the Supreme Court's decision to award counsel fees on a per claim basis rather than a per assignor basis, as the Superintendent of Insurance's opinion letter that counsel fees should be calculated on a per assignor basis, did not conflict with the explicit language of the controlling statute. Therefore, the orders and judgment were affirmed.

The court considered the fact that CPT Medical Services, P.C., as the assignee of Jason King, was seeking first party no-fault benefits from New York Central Mutual Fire Insurance Co. for diagnostic testing. The issue decided was whether the diagnostic testing giving rise to the plaintiff's claim for first party no-fault benefits lacked medical necessity. The court held that defendant demonstrated prima facie entitlement to judgment by submitting competent medical evidence that the diagnostic testing was not medically necessary. In opposition, the plaintiff relied upon an attorney's affirmation accompanied by a single, unsworn and undated doctor's report, which was not properly before the court and should not have been considered. Additionally, even if considered, the unsworn report of the plaintiff's doctor was insufficient to defeat summary judgment.

The main issue in this case was whether the respondents had satisfied the conditions precedent of coverage under an insurance policy in order to arbitrate their claim seeking coverage for uninsured motorist benefits. The court held that the respondents had failed to file a sworn statement with the insurance company within 90 days of the alleged hit-and-run accident, as required by the uninsured motorist endorsement of the insurance policy. The Supreme Court's decision to deny the petition for a permanent stay of arbitration was reversed, and the petition to permanently stay the arbitration was granted. The court also noted that the fact that the insurance company had received some notice of the accident through an application for no-fault benefits did not negate the breach of the policy requirement. The remaining contention of the petitioner was not addressed in light of the court's determination.

The main issues the court decided in Todaro v GEICO General Insurance Company, was whether the lower court correctly vacated an inquest and denied defendant's motion to dismiss (which would determine the amount of damages that GEICO would have to pay to plaintiff), and whether the lower court incorrectly ordered more discovery to be conducted. The facts the court considered were that plaintiff was injured in a car accident. She was initially paid no-fault insurance benefits by GEICO, but GEICO terminated those payments, claiming that plaintiff failed to appear for independent medical examinations. Plaintiff filed a lawsuit to recover benefits owed to her. The court held that the Supreme Court should not have vacated the inquest as the court determined that they did not need to order additional discovery before making a determination of damages. The matter was remitted to Supreme Court to determine the amount of damages.

The court considered whether an insurance company had failed to either pay or deny a claim for medical services provided to a patient under a no-fault insurance policy within the required 30-day time period. The main issue was whether the insurance company's request for verification of the claim, which included information regarding the patient's alleged intoxication at the time of the accident, extended the 30-day period within which the insurer must pay or deny the claim, as required by New York Insurance Law. The court held that the insurance company was entitled to all available information relating to the patient's condition at the time of the accident, and this extends the 30-day period. The court also held that the insurance company raised a triable issue of fact as to whether it timely denied the claim and whether the patient was intoxicated at the time of the accident, and whether his intoxication caused the accident. The court granted the insurance company's cross motion pending receipt of a certified toxicology report from the hospital, but did not consider portions of the written response mentioning improper attacks on the appellant's counsel as this was unwarranted.

The case heard in December 10, 2007 as cited in 2007 NY Slip Op 27542, was a dispute between Odessa Medical Supply, Inc and Government Employees Insurance Company. The dispute was regarding $1,152 Odessa Medical Supply, Inc. claimed for health services rendered following a motor vehicle accident on October 28, 2004. Government Employees Insurance Company denied the claim on the grounds that the medical equipment for which the plaintiff submitted a bill was not medically necessary. At trial, the court issued an order in favor of Odessa Medical Supply, Inc based on the authority of Appellate Term, Second and Eleventh Judicial Districts. This was on the grounds that Medical necessity was not specified on the defendants denial of claim form. The defendant appealed the decision and the case was renewed after a change in law on November 3, 2006. Upon renewal, the court vacated the previous decision and the plaintiff's motion for preclusion and for a directed verdict were denied. The case was to be restored for a new trial as a result of a change in the existing law made by the Appellate Division. The main issue that was decided was whether the initial case's decision should be vacated due to a change in law. The holding of the case was that the defendant's motion for leave to renew was granted. Thus, upon renewal, the initial decision was vacated, and the plaintiff's motions in limine for preclusion and for a directed verdict were denied. The court ordered the action to be placed upon an appropriate calendar for trial and to notify the respective parties. The case was being restored to the trial calendar as a result of a change in existing law made by the Appellate Division.