No-Fault Case Law

The court considered whether a plaintiff health care provider was entitled to summary judgment to recover first-party no-fault benefits for health care services rendered to the assignor, for the principal sum of $1,125.01. The main issue was whether the health care provider submitted a claim and if the payment of no-fault benefits were overdue. The court decided that the plaintiff had established a prima facie entitlement to summary judgment on its claim for $1,125.01 by providing proof of the submission of the claim and that payment was overdue. The defendant failed to establish that the denial for the claim was mailed within the prescribed 30-day period, and is precluded from raising its proffered defense of lack of medical necessity. Plaintiff's motion was insufficient for the claims in the amounts of $1,200.92 and $540.56, and the matter was remanded for further proceedings on the remaining claims. The holding of the case was that plaintiff's cross motion for summary judgment was granted to the extent of awarding partial summary judgment in the principal sum of $1,125.01 and the award of $50 costs to the defendant was stricken.

The relevant facts considered by the court in this case were that the plaintiff, Doshi Diagnostic Imaging Services, sought to recover no-fault benefits for medical services rendered to its assignor. Plaintiff had provided the defendant, Progressive Insurance Company, with an assignment of benefits form, but the form did not contain the signature of the medical provider, as required by New York regulations. Defendant objected to the incomplete form and requested an assignment containing the provider's signature, but plaintiff failed to provide the requested verification. The main issues decided in this case were whether the defendant had established that payment of no-fault benefits was not overdue due to the incomplete assignment of benefits form provided by the plaintiff, and whether the court should grant defendant's motion for summary judgment dismissing the complaint and deny plaintiff's cross motion for summary judgment. The holding of the case was that the court affirmed the order without costs, finding that since the plaintiff had failed to provide the requested verification consisting of an assignment with the provider's signature, the statutory period in which the defendant had to pay or deny the claim had been tolled, and therefore, the defendant had established that payment of no-fault benefits was not overdue. As a result, the court properly granted defendant's motion for summary judgment dismissing the complaint and denied plaintiff's cross motion for summary judgment.

The relevant facts considered in this case involved a health care provider seeking to recover first-party no-fault benefits for medical services rendered to its assignor. The provider submitted all required claim forms but was denied payment by the insurance company due to a determination that the treatment was not medically necessary. The main issue decided was whether the denial of claim by the insurance company was valid, and whether the health care provider was entitled to summary judgment. The court ultimately held in favor of the health care provider, reversing the previous order denying summary judgment, and remanded the case for the calculation of statutory interest and an assessment of attorney's fees. The court determined that there was no evidence that the peer review report was sent to the provider within the 30-day claim determination period, and that the denial of claim was devoid of any factual basis or medical rationale, and therefore the insurance company was precluded from asserting lack of medical necessity as a defense.

The court considered an appeal from a lower court order granting plaintiff's motion for summary judgment in the sum of $2,941.01 in a case to recover assigned first-party no-fault benefits for medical services. Plaintiff submitted claims and proved that payment of a portion of the claims was overdue. The court determined that the denial of the initial claim was untimely on its face, thereby precluding the defenses based on the application of the fee schedules to the specific services provided. However, the court held that the denial forms that were timely set forth in detail the specific grounds for the denials, but some of these denials were factually insufficient, conclusory, and vague. The court decided to modify the order by granting plaintiff partial summary judgment in the principal sum of $2,595.42.

The court considered whether the plaintiff, a healthcare provider, had submitted sufficient evidence to establish its entitlement to first-party no-fault benefits for medical services rendered to its assignor. The main issues decided were whether plaintiff's claims were properly denied by the defendant, and whether plaintiff was entitled to summary judgment. The holding of the case was that the denial of the plaintiff's claim forms by the defendant were insufficient to assert the defense of lack of medical necessity, and therefore the plaintiff was entitled to partial summary judgment in the sum of $3,935.24. The case was remanded to the lower court for the calculation of statutory interest and an assessment of attorney's fees on said amount and for further proceedings on the remaining $687 claim.

The court considered the fact that the plaintiff's assignor had withdrawn her claim for medical services, and that the driver of the vehicle involved in the collision had also withdrawn his claim, both due to suspicions about insurance fraud. The main issue decided was whether the defendant's refusal to pay the claim was justified based on a "founded belief that the alleged injur[ies] do[] not arise out of an insured incident." The holding of the case was that the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and that there was an issue of fact as to whether there was a lack of coverage. The court also ordered a hearing to address whether the prosecution of the appeal seeking summary judgment in favor of the plaintiff was frivolous and subject to sanctions.

The main issue decided in this case was whether the plaintiff, a healthcare provider, was entitled to summary judgment in its action to recover first-party no-fault benefits for medical services rendered. The court considered the fact that the plaintiff had established a prima facie entitlement to summary judgment by submitting claim forms and that the defendant failed to pay or deny the claim within the prescribed period. However, the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme. The holding of the case was that the plaintiff's motion for summary judgment was properly denied because an issue of fact existed as to whether there was a lack of coverage, and that the conduct of the plaintiff's counsel in continuing to prosecute the appeal was subject to sanction.

The court considered the fact that PDG Psychological, P.C. (the plaintiff) filed an action for first-party benefits, attorney's fees and statutory interest as an assignee of Sergey Potapov against State Farm Insurance Company (the defendant) for bills totaling $2,758.76 for psychological treatment. Defendant denied the claims due to alleged fraud. The main issue decided was whether the plaintiff had proven its prima facie case of entitlement to benefits and whether the defendant had sustained its burden of proving that the collision was intentional, precluding coverage. The holding was that the plaintiff failed to prove its prima facie case and the evidence offered by the defendant did not meet its burden of producing evidence of a fact or founded belief that the collision was intentional. Therefore, the defendant's motion for a directed verdict was granted based on the plaintiff's failure to prove its prima facie case.

The relevant facts considered by the court were that the plaintiff, a health care provider, submitted a claim form for no-fault benefits for services rendered to its assignor, and that payment of benefits was overdue. The main issue decided by the court was whether the insurance policy in effect contained an endorsement authorizing examinations under oath (EUO) pursuant to 11 NYCRR 65-1.1(d). The court held that the plaintiff established a prima facie entitlement to summary judgment by proving that they submitted the claim form and that payment of benefits was overdue. The court also held that the revised insurance regulations, including EUOs, were inapplicable until the issuance of new or renewal policies containing the revised endorsement, and that the no-fault protection created by statute may not be qualified by the conditions of the liability portion of the insurance policy. Therefore, the court affirmed the order granting the plaintiff's motion for summary judgment.

The court considered evidence and arguments regarding the relationship between Elite Medical Care, P.C. and the health care providers for the plaintiff's assignor. The defendant raised issues regarding the NF-3 forms and the relationship of the health care provider and the plaintiff. The main issue decided was whether the plaintiff was entitled to first-party benefits, attorney's fees, and statutory interest under New York Insurance Law and No-Fault regulations as the assignee of the plaintiff's assignor. The holding of the case was that the plaintiff failed to prove a prima facie case of entitlement to no-fault benefits as they did not introduce evidence of a properly executed assignment, and therefore the judgment was entered in favor of the defendant and the complaint was dismissed.