No-Fault Case Law

The court considered the plaintiff's motion for summary judgment to recover No-Fault benefits, statutory interest, and attorney's fees, as well as the defendant's cross-motion for the same relief based on the argument that the services were not medically necessary. The main issue decided was whether the plaintiff had provided sufficient evidence to demonstrate entitlement to No-Fault benefits and whether the defendant had proven that there were triable issues of fact with regards to the medical necessity of the services provided. The holding of the case was that the plaintiff's motion for summary judgment was granted only as to the claim for attorney's fees for one of the amounts, while the defendant's cross-motion for summary judgment was denied. The court found that issues of fact existed regarding the medical necessity of the claims in the other amounts.

The case involved Allstate Insurance Company and Belt Parkway Imaging, P.C. The main issue was whether Allstate had the right to withhold payments for claims made by Belt Parkway Imaging, P.C. before April 4, 2002. The court held that Allstate could indeed withhold payments for those claims, and dismissed the causes of action for fraud and unjust enrichment regarding payments made before April 4, 2002. This decision was based on an Insurance Department regulation that stated a provider of health care services is not eligible for reimbursement if they fail to meet the necessary licensing requirements. The Court of Appeals upheld this regulation, allowing insurance carriers to withhold payment for medical services provided by fraudulently incorporated enterprises, and stated that no cause of action for fraud or unjust enrichment would lie for payments made before the regulation took effect. The court found this regulation did not impair vested rights or create a new right.

The court considered the case of SpineAmericare Medical, P.C. v State Farm Mutual Automobile Insurance Company, in which the plaintiff was seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff had established its prima facie entitlement to summary judgment by proving the submission of statutory claims forms and that payment of no-fault benefits was overdue. The holding of the case was that the plaintiff's motion for summary judgment was granted to the extent of awarding partial summary judgment in the principal sum of $5,404.38. The matter was remanded for the calculation of statutory interest and an assessment of attorney's fees, as well as for further proceedings on the remaining claims. The court found that the plaintiff's moving papers were insufficient to establish the mailing of the forms to the defendant, but the defendant's letters to plaintiff adequately established that the defendant had received 10 of the 12 claims being sued upon.

The relevant facts the court considered in this case were that the plaintiff was seeking to recover first-party no-fault benefits for medical services rendered to its assignor. The plaintiff had submitted the claims and proof that the payment of the benefits was overdue. The main issue decided was whether the defendant had established a triable issue of fact and whether the defendant had mailed a timely denial of claim form to the plaintiff. The holding of the case was that the plaintiff's motion for summary judgment should have been granted because the defendant failed to establish that it mailed a timely denial of claim form to the plaintiff, and as a result, the defendant was precluded from raising the defense of lack of medical necessity. The matter was remanded to the court for the calculation of statutory interest and an assessment of attorney's fees.

The court considered the stipulated facts submitted by the parties in a case where Dependable Ambulette, Inc. sought to recover sums for transportation services rendered after April 5, 2002, based on automobile insurance policies that contained assignability clauses. The main issue decided was whether the NYS Insurance Commissioner's April 5, 2002 amendment to Art. 68 terminated existing policy endorsements, and if the Regulation 68 amendment barred the assignability of ambulance transportation services. The holding of the case was that the April 5, 2002 amendment voided any existing policy assignment language as "contrary to public policy", and the Court dismissed the plaintiff's complaint based on this conclusion.

The relevant facts considered by the court were that a health care provider brought an action to recover assigned first-party no-fault benefits. The court found that the attorney's affirmation in support of the motion for summary judgment lacked probative value as it did not lay a sufficient foundation to establish personal knowledge. The court also noted that defendant's opposition to plaintiff's motion for summary judgment demonstrated the existence of a triable issue of fact as to whether the alleged injuries did not arise out of an insured incident. The main issue decided was whether plaintiff's motion for summary judgment was supported by competent evidence to establish a prima facie case, and whether there was a triable issue of fact for the alleged injuries. The holding of the court was that plaintiff's motion for summary judgment was denied, and the order entered September 16, 2005 was vacated.

The main issue in this case was whether the appellant was entitled to recover first-party no-fault benefits from the respondent insurance company. The court considered the evidence submitted by the appellant in support of their motion for summary judgment, which included copies of the respondent's denial of claim forms acknowledging receipt of the claims, as well as an affidavit of an officer of the appellant provider. The main issue decided was whether the appellant had established its prima facie entitlement to summary judgment, which hinged on the submission of the statutory claim forms to the respondent. The court found that while the motion papers contained necessary evidence, there was a discrepancy with the affidavit of the appellant's officer, which was allegedly signed in blank and undated. As a result, the court held the matter in abeyance and remanded it to the lower court to report whether the affidavit included in the record on appeal was the same one considered by the motion court.

In the case, 563 Grand Medical, PC sought to recover first-party no-fault benefits from Prudential Property & Casualty Insurance Company for medical services provided to a patient. The court granted Prudential's motion to dismiss the complaint, as the master arbitrator's award was less than $5,000, and therefore, the plaintiff was not entitled to initiate the action for a trial de novo under Insurance Law § 5106 (c). The court concluded that the plain language of the statute indicated that the amount of the master arbitrator's award must be at least $5,000 before an insurer or claimant could commence an action to adjudicate the dispute de novo. Moreover, the court denied the plaintiff's application to convert the action to a special proceeding to vacate the master arbitrator's award, as the plaintiff failed to assert any grounds for vacating the award as required by CPLR 7511 (b) or 11 NYCRR 65-4.10. Therefore, the order granting Prudential's motion to dismiss the complaint and denying the plaintiff's application to convert the action was affirmed.

The court considered an action to recover first-party no-fault benefits involving multiple assignors and the submission of multiple bills on different dates. The issue was how attorney's fees should be calculated when dealing with action involving multiple assignors. The New York State Insurance Department interpreted the relevant regulation to state that the attorney's fee awarded to the provider should be based on the aggregate amount of payment required to be reimbursed, and not on a "per bill" basis. The court adopted the Department of Insurance's interpretation of the regulation and held that for each assignor in the action, the plaintiff was entitled to an attorney's fee in the amount of $60 or 20% of the total amount of first-party benefits awarded for services provided to that assignor, plus interest thereon, whichever amount is greater, subject to a maximum of $850.

The relevant facts that the court considered in this case involved a medical provider seeking first-party no-fault benefits for MRI services rendered to its assignor, based on medical necessity. The main issue decided by the court was whether the diagnostic center could be denied first-party no-fault benefits based upon a lack of medical necessity when it merely performed MRIs pursuant to the instructions of its assignor's examining physician, without directly examining the patient. The holding of the case was that the diagnostic center could not be automatically denied first-party no-fault benefits based on a lack of medical necessity, as the burden of proof shifted to the defendant to establish the lack of medical necessity, and then back to the plaintiff to present its own evidence of medical necessity. The court ultimately found that the defendant's expert's testimony regarding the lack of medical necessity was sufficient to demonstrate a lack of medical necessity and shifted the burden to the plaintiff to show that the MRIs were medically necessary. Since the plaintiff failed to submit evidence to establish medical necessity, they were not entitled to judgment in their favor, and the court directed the judgment to be entered in favor of the defendant dismissing the action.