No-Fault Case Law
Ocean Diagnostic Imaging P.C. v Eagle Ins. Co. (2004 NY Slip Op 51640(U))
December 15, 2004
The relevant facts considered by the court were that a health care provider submitted a claim form for first-party no-fault benefits for medical services rendered to its assignor, and that the insurance company failed to pay or deny the claim within the 30-day prescribed period. The main issue decided was whether the insurance company was precluded from raising defenses due to the delayed payment of the claim. The holding of the court was that the insurance company was precluded from raising most defenses due to the delayed payment, but it could assert the defense that the alleged injuries did not arise out of a covered accident. The court affirmed the lower court's decision to deny the health care provider's motion for summary judgment, as the insurance company demonstrated the existence of a triable issue of fact regarding the lack of coverage for the alleged injuries.
A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51639(U))
December 15, 2004
The relevant facts in the case involved a dispute over first-party no-fault benefits for medical services provided to a patient by the plaintiffs. The main issue decided by the court was whether the defendant insurance company was precluded from raising defenses due to their failure to pay or deny the claim within the 30-day prescribed period. The holding of the court was that the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, despite the untimely denial of the claim. The court determined that the defendant's special investigator's affidavit was sufficient to demonstrate a founded belief that the alleged injuries did not arise out of an insured incident, and as a result, the motion for summary judgment by the plaintiffs was properly denied.
Amaze Medical Supply Inc. v Allstate Ins. Co. (2004 NY Slip Op 51636(U))
December 15, 2004
The court considered the case of Amaze Medical Supply Inc. v Allstate Ins. Co. where the plaintiff appealed from an order denying their motion for summary judgment. Plaintiff had submitted complete proofs of claims for the amount of $1,737, which were not denied until more than 30 days after they were submitted. The issue was whether the insurer, Allstate Insurance Co., was precluded from raising defenses, including lack of medical necessity, due to the untimely denial of the claims. The court held that plaintiff's motion for summary judgment should have been granted, as the insurer was precluded from raising most defenses and the claims were submitted on time. The decision was reversed, and the matter was remanded for a calculation of statutory interest and an assessment of attorney's fees.
Amaze Med. Supply Inc. v AIU Ins. Co. (2004 NY Slip Op 51629(U))
December 15, 2004
The court considered whether plaintiff was entitled to summary judgment for first-party no-fault benefits for medical supplies provided to its assignor. Plaintiff established its entitlement to summary judgment by submitting a claim, setting forth the fact and the amount of the loss sustained, and proving that payment of no-fault benefits was overdue. However, the burden shifted to defendant to raise a material issue of fact, and defendant was able to show through an investigator's affidavit that they possessed a "founded belief that the alleged injur[ies] do[ ] not arise out of an insured incident," thus raising an issue of fact warranting denial of plaintiff's motion for summary judgment. Therefore, the main issue decided was whether defendant's untimely denial of the claim precluded them from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and the holding of the court was that defendant was not precluded from asserting this defense.
A.B. Med. Servs. PLLC v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51627(U))
December 14, 2004
The relevant facts considered by the court were that the plaintiffs were seeking to recover first-party no-fault benefits for services rendered to their assignor and that they established their prima facie entitlement to summary judgment by proving that they submitted a claim and that payment of benefits was overdue. The main issue decided was whether the defendant, State Farm Mutual Automobile Insurance Company, was precluded from raising defenses due to their failure to pay or deny the claim within the prescribed 30-day period. The holding of the case was that the defendant was not precluded from asserting the defense of an insurance fraud scheme despite the untimely denial of the claim, as their affidavit demonstrated a founded belief that the alleged injuries did not arise out of an insured incident. Therefore, the plaintiffs' motion for summary judgment was properly denied.
Ocean Diagnostic Imaging, P.C. v State Farm Mut. Auto. Ins. Co. (2004 NY Slip Op 51624(U))
December 14, 2004
The relevant facts considered by the court in Ocean Diagnostic Imaging, P.C. v State Farm Mut. Auto. Ins. Co. include a medical services provider seeking to recover first-party no-fault benefits for services rendered to its assignor. The main issue decided was whether the provider was entitled to summary judgment, as it had established a prima facie case by submitting a claim and showing that payment of benefits was overdue. The court held that the provider was entitled to summary judgment, as the insurance company failed to pay or deny the claim within the prescribed period, and was precluded from raising most defenses. However, the insurance company was not precluded from asserting the defense of an insurance fraud scheme. The court found that the insurance company's denial was based on a "founded belief" that the injuries did not arise from an insured incident, and therefore, there was a triable issue of fact as to whether there was a lack of coverage. As a result, the provider's motion for summary judgment was properly denied.
A.B. Med. Servs. PLLC v Nationwide Mut. Ins. Co. (2004 NY Slip Op 24506)
December 10, 2004
The main issue in this case was whether the plaintiff, A.B. Medical Services, PLLC, was entitled to no-fault benefits from Nationwide Mutual Insurance Company. The affidavit submitted by the plaintiff, signed by David Safir, was determined to be insufficient to establish that the plaintiff provided defendant with properly completed claim forms. The trial court had initially denied the plaintiff's motion for summary judgment on the ground that the plaintiff did not submit admissible proof authenticating the signature of the plaintiff's assignor on the assignment form. However, the court noted that the insurance regulations do not require that a claimant's signature be authenticated. As such, the plaintiff satisfied its burden by submitting an assignment to the insurer that conformed to the regulations. The court further observed that the defendant's failure to seek verification of the assignment constituted a waiver of any defenses with respect to it. Therefore, the order was affirmed without costs.
PSG Psychological, P.C. v State Farm Ins. Co. (2004 NY Slip Op 51701(U))
December 8, 2004
The court considered the facts that PSG Psychological, P.C. was seeking to recover $1,340.30 in first party no-fault benefits from State Farm Ins. Co. on behalf of Arthur Scott, who was injured in a car accident and received treatment from PSG. State Farm Ins. Co. denied the claim on the grounds of fraudulent billing practices and lack of verification. The main issues decided were whether the denial of the claim by State Farm Ins. Co. was timely and whether there was sufficient evidence to support the claim of fraudulent billing practices. The holding of the case was that State Farm Ins. Co. failed to establish that its denial of the claim was timely and did not provide sufficient evidence to support the claim of fraudulent billing practices, therefore their motion for summary judgment was denied.
King’s Med. Supply Inc. v New York Cent. Mut. Fire Ins. Co. (2004 NY Slip Op 51550(U))
December 8, 2004
The main issue in this case was whether the court should reverse the order granting the plaintiff's motion for summary judgment on default and should restore the matter to the motion calendar for a determination of the plaintiff's underlying motion on the merits. The relevant facts considered by the court were that the defendant denied the assignor's claims on the basis of each assignor's failure to appear for a scheduled independent medical examination (IME). However, the court held that an assignor's failure to attend a single requested IME did not afford the insurer a valid basis to deny a no-fault claim where the insurer failed to exhaust the follow-up verification protocols. The court reversed the order and denied the defendant's motion to vacate the order granting the plaintiff's motion for summary judgment, reinstating the judgment in favor of the plaintiff.
Ocean Diagnostic Imaging, P.C. v Lancer Ins. Co. (2004 NY Slip Op 24501)
December 8, 2004
The relevant facts included a health care provider's claim for no-fault benefits for services rendered to an assignor. The claim was received by the defendant on October 5, 2001, and was not denied until December 19, 2001. The main issue was whether the defendant's denial of the claim was within the prescribed 30-day period, and whether the alleged injuries were causally related to the accident. The court held that the defendant's denial was ineffective due to being past the 30-day limit, and that there was no proof of an extension by a request for verification. The court also held that the defendant was not precluded from asserting the defense that the injuries were not causally related to the accident, but that the affidavit and "Automotive Engineering Report" submitted by the defendant were insufficient to raise a triable issue of fact. The dissenting judge disagreed, arguing that there was, in fact, an issue of fact as to whether the injuries resulted from the claimed accident, and that the "Automotive Engineering Report" was sufficient to raise a triable issue of fact.