No-Fault Case Law

The main issue in T & G Med. Supplies, Inc. v National Grange Mut. Ins. Co. was whether the plaintiff had standing to sue. The defendant claimed that the plaintiff lacked standing because no valid assignment had been exchanged, while the plaintiff argued that the defendant's failure to state any deficiency regarding the assignment in its denial waived any defense not included in the denial. The court decided that the plaintiff did not have standing to maintain the action. The undated assignment provided by the plaintiff did not contain the name of the assignor, the signature of the assignee or the date of the alleged occurrence, and failed to establish the right to maintain the action. Therefore, the court granted the defendant's motion and dismissed the action.

The relevant facts the court considered in Multiquest, PLLC v Allstate Ins. Co. were that the plaintiff, Multiquest, PLLC, sued to recover payment under the No-Fault Law for medical services it provided to an assignor, Paulette Cleckley. Multiquest moved for summary judgment after submitting a timely notice of claim which was not timely denied by the defendant, Allstate Insurance Co. Defendant cross-moved for summary judgment, contending that plaintiff's medical facility was fraudulently incorporated at the time it provided the services and that the services were administered by individuals who were not licensed to do so. The main issue was whether the medical services provided by the plaintiff were covered under the No-Fault Law and if the plaintiff was entitled to recover payment for such services. The court held that due to the defendant's allegations of fraud and misconduct by the plaintiff, and the plaintiff's failure to rebut those allegations with sufficient evidence, the medical services provided to the assignor were not covered under the No-Fault Law. Therefore, plaintiff's motion for summary judgment was denied and the case was dismissed.

The court considered the argument from Mr. Richard Martinez and Geico Insurance Company that the action against them was barred by the three year statute of limitations for personal injury and subrogation actions. The defendants claimed that the accident occurred on August 17, 2001, and the action was commenced on September 8, 2004, well over three years from the date of the accident. The court also considered the plaintiff's argument that the action was tolled based on the tolling provisions of CPLR §204 (b), and that the subrogation rights were preserved. The main issue decided by the court was whether the action against Mr. Martinez was barred by the applicable three year statute of limitations for personal injury and subrogation actions. The holding of the case was that the motion by Mr. Richard Martinez and Geico Insurance Company to dismiss the action was granted, as the action was indeed time barred by the three year statute of limitations.

The main issue in this case was whether an insurer timely denied no-fault claims on the ground that the assignors failed to attend independent medical examinations (IMEs) scheduled at the insurer's request. Plaintiffs A.B. Medical Services PLLC and D.A.V. Chiropractic P.C. sought summary judgment for overdue no-fault benefits for medical services rendered to their assignors. The court held that the lack of authentication of an assignor's signature did not constitute a defect in the absence of any statutory and regulatory requirement for the same. The defendant's failure to seek verification of the assignments and to allege any deficiency in the assignments in its denial of claim forms constituted a waiver of any defenses with respect to authentication. Additionally, the court determined that the opposition papers were insufficient to rebut the presumption of medical necessity, and granted summary judgment in favor of plaintiffs A.B. Medical Services PLLC and D.A.V. Chiropractic P.C. The matter was remanded for the calculation of statutory interest and an assessment of attorney's fees.

The court considered the fact that Amaze Medical Supply Inc. was seeking to recover first-party no-fault benefits for medical supplies they had furnished to their assignor, Lilliana Lopez. The main issue decided was whether Amaze Medical Supply Inc. had established a prima facie entitlement to summary judgment by proving that they submitted a claim, setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. The holding of the case was that Amaze Medical Supply Inc. was entitled to summary judgment because the defendant, State Farm Mutual Automobile Insurance Company, failed to rebut the prima facie case established by plaintiff and did not offer any evidence in admissible form to establish the failure of the plaintiff's assignor to appear for pre-claim independent medical examinations. Therefore, the judgment was unanimously affirmed in favor of Amaze Medical Supply Inc. without costs.

The court considered whether Progressive Insurance Company properly denied first-party no-fault benefits for medical supplies furnished to S&M Supply Inc.'s assignors, Clara Suckragh and Peter Suckragh. S&M Supply Inc. established that it submitted the claims and that payment of no-fault benefits was overdue, and thus appealed the denial of its cross motion for summary judgment. The court held that S&M Supply Inc. was entitled to summary judgment in the sum of $1,432.43, as there was insufficient evidence to support Progressive Insurance Company's denial of the claims. The court also ruled that the matter should be remanded to the lower court for a calculation of statutory interest and an assessment of attorney's fees, pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

The main issue in this legal case was whether first-party no-fault benefits could be denied by an insurer for lack of medical necessity, when the provider had submitted proper proof of claim for the services. American Transit Insurance Company had denied payment for medical and rehabilitation services provided to Sandra Berger, citing lack of medical necessity based upon a medical examination conducted by Dr. Irving Liebman, a board-certified orthopedic surgeon. The court considered whether Dr. Liebman's findings provided sufficient evidence to establish prima facie that the subsequent treatment was not medically necessary. The court ultimately held that Dr. Liebman's report did not establish prima facie the absence of "serious injury" and therefore denied the plaintiff's motion for summary judgment and the defendant's cross-motion for summary judgment. The court ruled that the "presumption of medical necessity" that attaches to the provider's claim forms was not sufficiently rebutted to establish that the insurer was entitled to judgment as a matter of law.

The court considered a motion for summary judgment in a case involving a claim for first-party no-fault benefits for medical supplies provided to an assignor. The plaintiff established a prima facie case for summary judgment by demonstrating that it submitted claims and that payment of the benefits was overdue. In response, the defendant submitted peer reviews that raised a triable issue as to the medical necessity of the equipment. The main issue decided in the case was whether the plaintiff was entitled to summary judgment for the recovery of first-party no-fault benefits. The court held that the order denying the plaintiff's motion for summary judgment was affirmed without costs, indicating that there was a genuine issue as to the medical necessity of the equipment, and therefore summary judgment was not appropriate.

The court considered a billing dispute between a psychiatric services provider and an insurance company. The main issue in the case was whether the services provided were medically necessary. The court decided that based on the testimony of the expert witnesses and the evidence presented, the comprehensive intake interview was never performed, and therefore the payment for certain services was denied. The court found that a comprehensive intake interview was necessary to determine the medical necessity and appropriateness of the various tests performed, which was not done in this case. Based on this, the court denied payment for the psychological testing and for the explanation and interpretation of results to the primary physician. However, the court did award payment for the review of records for medical diagnosis, as the insurance company had failed to prove that it was not medically necessary. Therefore, judgment was entered in favor of the plaintiff for the amount of $67.24, along with statutory interest and attorney's fees and costs.

The case revolves around an action taken by Hospital for Joint Diseases to recover unpaid no-fault benefits. The Supreme Court decided on an order that granted the defendant's cross motion for summary judgment dismissing the first and second causes of action and denied the plaintiff's motion for summary judgment. The Appellate Division of the Supreme Court ordered that this decision be modified. They decided that the Supreme Court erred in concluding that the plaintiff lacked standing to bring the action absent proof of a valid assignment from each claimant. They also found that the defendant failed to raise a triable issue of fact as to whether the insured's 2002 medical expenses were for injuries for which expenses for treatment had not been submitted within one year of his accident. The holding of the case was that the Supreme Court's order was modified to deny the defendant's motion for summary judgment, reinstate the first and second causes of action, and grant the plaintiff's motion for summary judgment on the first cause of action. Both parties were denied summary judgment on the second cause of action.