No-Fault Case Law

The court addressed ethical concerns raised by irregularities in papers submitted by the plaintiffs’ counsel, Edward Shapiro, in seven cases for assigned first-party no-fault benefits. The law firm submitted affirmations affirming that the plaintiff's "bills" were mailed on a specific date by "Edward Shapiro, Attorney at Law" to establish timely mailing, but there were signatures that were contradictory and misleading. While the plaintiffs argued that the office inadvertently failed to change its name from "Edward Shapiro, Attorney at Law" to "Edward Shapiro, P.C.," the court concluded that there was a deliberate attempt to mislead the court. The court held that the failure to sign the affirmations filed in each action nullified the motions, and the complaint in each action was dismissed without prejudice. The court found the actions of Mr. Shapiro and Mr. Moroff to be sanctionable under 22 NYCRR 130-1.2 for intent to deceive the court and their adversaries. The court assessed a total fine of $35,000 ($5,000 for each action) against counsel for the plaintiffs.

The court considered the fact that the plaintiff, a medical supply company, was seeking to recover no-fault benefits for medical supplies furnished to its assignor. The main issue decided was whether the plaintiff was entitled to summary judgment, as it had submitted statutory claim forms and payment of the benefits was overdue. The court held that the plaintiff had established prima facie entitlement to summary judgment and that the defendant had failed to establish the existence of a triable issue of fact. The holding of the case was that the plaintiff's motion for summary judgment was granted, and the matter was remanded for a calculation of statutory interest and an assessment of attorney's fees.

The court considered the denial of plaintiff's claim for $1,243.43 and an additional claim for $1,196.21 more than 30 days after it was submitted, and the insurer's right to an independent medical examination (IME) following a notice of claim. Plaintiff's motion for summary judgment was granted in part, awarding partial summary judgment in the principal sum of $1,243.43, but neither party was entitled to summary judgment on the claim of $1,196.21. The court found that the insurer had a right to an IME and had timely denied the claim on the ground that the plaintiff's assignor failed to comply with the IME request. Because of this, the insurer's motion for summary judgment should have been denied as well, as questions of fact existed regarding the medical necessity of the benefits provided. Ultimately, the holding of the case was that the plaintiff was entitled to partial summary judgment for the amount of $1,243.43, but no summary judgment was granted regarding the claim of $1,196.21. Additionally, because the insurer timely denied the $1,196.21 claim due to the assignor's failure to comply with the IME request, and the plaintiff failed to establish medical necessity, the plaintiff's motion for summary judgment was properly denied and the insurer's motion for summary judgment should have been denied as well.

The case involved a medical services company seeking to recover first-party no-fault benefits for medical services provided to an individual injured in a motor vehicle accident. The company moved for summary judgment in the amount of $4,366.28, and although the court granted partial summary judgment for the company in the amount of $2,176.30, it remanded the case for the calculation of statutory interest and assessment of attorney's fees. The main issue in the case was whether the medical services company had established its entitlement to summary judgment on its claims, which it did for three specific claims totaling $2,176.30. The court considered whether the company had submitted properly completed claim forms to the insurance company, and found that the company had established its entitlement to summary judgment for these specific claims. Therefore, the holding of the case was that the medical services company was granted partial summary judgment in the principal sum of $2,176.30, with the matter remanded to the lower court for further proceedings.

The court considered the fact that the defendant denied the plaintiff's claims for first-party no-fault benefits based on lack of medical necessity and the plaintiff's assignor's failure to appear for scheduled independent medical examinations. The main issue decided was whether the defendant effectively rebutted the presumption of medical necessity which ordinarily attaches to plaintiff's claim forms, and whether a triable issue of fact as to medical necessity was raised. The holding was that the defendant's proof of mailing IME scheduling letters demonstrated that they adhered to established business practices of proper mailing and that the plaintiff's failure to provide an acceptable excuse for its assignor's nonattendance warranted the granting of defendant's cross motion for summary judgment. The court also noted that if the issue of fees charged for the medical equipment had been raised, they would have entertained it.

The relevant facts in this case included an insurance company denying a health provider’s claim for $969.61 in assigned first-party no-fault benefits because the eligible injured person failed to appear for independent medical examinations before the provider filed its statutory claim forms. The main issue was whether the insurer's proof of the assignor's nonappearance established a defense to the action, and the court decided that the insurance regulations provide for independent medical examinations as part of the insurer's entitlement to "additional verification" following the insurer's receipt of a provider's statutory claim forms in order to determine the medical necessity of the health benefits provided to the injured person. The court held that because the examination was performed 7 days after the claim was submitted, the verification was untimely. Therefore, the ruling ordered that the portion of the order granting plaintiff summary judgment be deleted, and affirmed the order as modified.

The case NYC Med. & Neurodiagnostic, P.C. v Republic W. Ins. Co. involved a dispute over first-party no-fault benefits for medical services provided in an automobile accident. The insurance company, Republic Western Ins. Co. denied the claim, arguing that the court lacked jurisdiction over them. The court considered evidence regarding the defendant's business activities, insurance policies, and involvement in New York City. The main issues were whether the defendant was authorized to do business in New York and whether the court had jurisdiction over the case. The holding of the case was that the court erred in denying the defendant's motion to dismiss and that it was found that the defendant had been authorized to do insurance business in New York, therefore service of process on the Superintendent of Insurance was proper, and jurisdiction was granted over the defendant.

The court considered whether an assignment of benefits is an essential element of a claim for no-fault benefits, and whether the failure to include it is a waivable defect. Plaintiff, who was the assignee of Melvin Reyes, brought this action to recover $3,080 in first-party no-fault benefits, alleging that he was injured in a car accident and received treatment from the plaintiff who was assigned rights to benefits. The main issue was whether the absence of an assignment in a no-fault case could be waived, and whether its absence prevented an insurer from objecting to the claim. The court held that an assignment is an essential element of a claim for no-fault benefits, which cannot be waived even if the insurance company failed to assert it in the denial of claim form. The court also concluded that the insurer has no contractual obligation if an assignment is not present and thus plaintiff's motion for summary judgment was denied.

The plaintiffs appealed from the Supreme Court's order which granted the defendant's motion for summary judgment and denied the plaintiffs' cross motion. The plaintiffs had submitted a claim for no-fault benefits to the defendant's insurance company after the injured plaintiff was injured in a motor vehicle accident. The defendant sought to examine the injured plaintiff under oath, to which the plaintiffs refused unless both of them could be present. After this requested was denied, the defendant denied the plaintiffs' claim for no-fault benefits. The Supreme Court concluded that the plaintiffs' failure to cooperate with the insurer constituted a material breach of the policy. The Appellate Court disagreed and held that the defendant failed to demonstrate the plaintiffs engaged in a pattern of unreasonable and willful noncooperation, so the defendant's denial of no-fault insurance benefits on the ground of the plaintiffs' noncooperation was improper. The matter was remitted to the Supreme Court for the entry of a judgment declaring such.

The relevant facts the court considered in this case were that Ultimate Medical Supplies sought to recover $2,517.00, as well as statutory legal fees and interest, from Lancer Insurance Company for orthopedic devices provided to Cedric Wright. Lancer denied payment claiming medical necessity as a defense. Both parties presented their cases at trial, with Ultimate Medical Supplies providing the testimony of their principal, Peter Tiflinsky, and five exhibits, while Lancer presented the testimony of Dr. Francine Moshkovski and four exhibits. The main issues decided by the court were whether Dr. Moshkovski's testimony qualified as that of an expert, if Ultimate Medical Supplies had established a prima facie case, if there was evidence of the necessity for a specific orthopedic device, the credibility of the evidence presented regarding medical necessity, and the evidentiary effect of the failure of the claimant/assignor to appear subject to subpoena. The court held that Dr. Moshkovski's testimony qualified as that of an expert, Ultimate Medical Supplies had established a prima facie case, there was evidence of the necessity for the orthopedic device, and it declined to infer negative testimony from the failure of the claimant/assignor to appear. The holding of the case was in favor of Ultimate Medical Supplies, with the court directing the clerk to enter judgment in their favor against Lancer Insurance Company in the amount of $2,517.00, plus statutory legal fees and interest from May 2, 2000.