No-Fault Case Law

This case involved the timeliness of a lawsuit between an insurance company and a driver who had caused an accident that led to an insurance payout. The relevant facts are that the injured party in the accident had an insurance policy that provided extended economic loss coverage, for which the insurance company paid an extended economic loss beyond the mandatory no-fault coverage. The lawsuit was contested based on when the statute of limitations should be considered and whether it began from the date of the accident or the date when the APIP benefits were first paid. The court held that the statute of limitations runs from the date of the accident, not the date when the first APIP benefits were paid, and therefore, the insurer's action was deemed time-barred.

The relevant facts considered by the court were that a medical supply house filed a lawsuit to recover no-fault benefits for medical supplies provided to its assignor. The main issue decided was whether the defendant failed to pay or deny the claim within 30 days of receipt of the proof of claim, in violation of Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3) (now 11 NYCRR 65-3.8 [c]). The court held that the plaintiff was entitled to summary judgment because the defendant failed to show the existence of a triable issue of fact in opposing the motion. The court determined that as the defendant interposed no proper defense to the claim, summary judgment should have been granted, and the matter was remanded for a calculation of the statutory interest and an assessment of attorney's fees.

The court considered a case where A.B. Medical Services PLLC and G.A. Physical Therapy P.C. (plaintiffs) were seeking recovery of motor vehicle no-fault benefits for medical expenses they claimed were incurred by their assignor, Smolyanskiy. The record showed that A.B. Medical Services was entitled to summary judgment on their claim for neurological testing administered to Smolyanskiy on April 24, 2000 because the insurance company, CNA Insurance, did not deny the claim within 30 days of receipt. However, summary judgment was not warranted for the remaining no-fault claims. The peer review reports relied upon by CNA Insurance in denying the remaining claims were considered a proper defense of lack of medical necessity, and set forth sufficient facts to raise a triable issue. Therefore, the court modified the order to grant plaintiff's motion for summary judgment on one claim, but denied summary judgment on the remaining claims.

The relevant facts considered by the court in this case were that three patients, Marina Shaulov, Dwayne Dowdell, and Maria Arevalo, received medical treatment from the plaintiff, Behavioral Diagnostics, after being involved in motor vehicle accidents and had assigned their insurance benefits to the plaintiff. Allstate, the defendant, paid for some services but denied payment for others, stating that they were not "medically necessary" as required by regulations. The main issue decided in this case was whether the services rendered were medically necessary, and the court held that the burden rests on the defendant to prove that the services rendered were not medically necessary. The court considered expert testimony from doctors regarding the medical necessity of services, and the court ruled that some of the services billed by the plaintiff were not medically necessary, while others were deemed to be necessary. As a result, the court entered judgment in favor of the plaintiff for the amount of $67.24, along with interest and attorneys' fees.

The court considered the fact that the plaintiffs in this case had filed a motion for summary judgment in an action to recover first-party no-fault benefits for medical treatment provided to their assignor. Defendant opposed the motion and submitted nurses' unsworn reviews of the files, concluding that the treatments were medically unnecessary. The main issues decided were whether the nurses' reviews created a triable issue of medical necessity, and whether the benefits sought exceeded those permitted by Workers' Compensation schedules. The holding of the case was that the medical reviews failed to create a triable issue of material fact as to the treatment's medical necessity, and that the benefits sought did not exceed those permitted by Workers' Compensation schedules. The court granted partial summary judgment in favor of the plaintiffs in the sum of $2,559.39, and remanded the case for further proceedings on the remaining portion of the claim.

The court considered the plaintiffs' motion for summary judgment in an action to recover first-party no-fault benefits for medical treatment provided to an assignor. The main issue decided was whether the plaintiffs had sustained their burden to prove entitlement to no-fault benefits prima facie. The court held that the plaintiffs had established prima facie entitlement to no-fault benefits without the necessity of additional proof of the medical necessity of the treatments, and that the defendant's failure to timely deny the claims waived objections based on the sufficiency of the claim forms and most defenses as to the propriety of the claim itself. The court granted partial summary judgment in favor of the plaintiffs in the sum of $16,461.40 and remanded the matter for a calculation of statutory interest and an assessment of attorney's fees, and for all further proceedings on the remaining claims.

The court considered the case of All Health Medical Care, P.C. as the assignee of Eliyahu Malaev bringing suit to recover compensation under the No-Fault Law for medical services. Plaintiff's claim was submitted on May 23, 2001, and a verification request was issued by defendant on May 30, 2001. Plaintiff's initial response was deemed insufficient, resulting in a follow-up request for verification, and, finally, a denial from defendant. The main issue was whether or not defendant had any duty to act after receiving plaintiff's response to the verification requests. The court held that defendant's failure to act upon receipt of plaintiff's response to the verification request meant that plaintiff was entitled to payment. Furthermore, defendant's time to pay or deny was not overdue, and plaintiff's claim should be compensated. The court decided that defendant had a responsibility to act within 30 days of receipt of plaintiff's response and that there was nothing in the no-fault regulations or case law that allowed defendant to remain silent in the face of plaintiff's response to the verification request. Therefore, the regulations were found to be silent on what the insurance company must do if it receives insufficient verification, but the court held it seemed clear that the insurance company must act upon receipt of a response to its verification requests. Finally, it was found that since defendant took no steps to preserve its defenses to plaintiff's claim, it failed to comply with the No-Fault Law by failing to either pay or deny the claim, and judgment was awarded to plaintiff with statutory interest and fees.

The case Wolf v Holyoke Mutual Insurance Company deals with an automobile accident where the plaintiff, Elizabeth Wolf, was injured. The defendant, Holyoke Mutual Insurance Company, paid for her medical expenses, household assistance reimbursement, and lost wages until March 31, 2000, after which they denied further claims asserting that the plaintiff was no longer injured. The plaintiff then filed a lawsuit, and the Supreme Court determined that the plaintiff was still partially disabled. The Appellate Division upheld the Supreme Court's decision, noting that the plaintiff showed evidence of continuing disability post-March 2000. The court also determined that the plaintiff was entitled to 80% of her weekly salary from a certain point to cover lost wages and other economic loss due to restrictions on the amount. The Appellate Division reversed a portion of the decision involving the calculation of plaintiff's entitlement to loss of wage benefits and remitted the matter back to the Supreme Court for further proceedings.

The case involved an action to recover no-fault medical payments under an insurance contract. Wyckoff Heights Medical Center appealed from the Supreme Court's order that granted the defendant's cross motion to vacate an order and a judgment entered in favor of the plaintiff. The main issue was whether the defendant had a reasonable excuse and a meritorious defense to be relieved of its default. The court held that the defendant's conduct constituted an intentional default and was not excusable, and therefore the defendant's motion to vacate its default should have been denied. As a result, the order from the Supreme Court was reversed, the cross motion was denied, and the original order and judgment in favor of the plaintiff were reinstated.

The court considered the issue of whether an insurance carrier is entitled to an examination before trial (EBT) of a medical provider under the CPLR and UDCA in no-fault claims. It involved 48 cases where medical providers represented by the same law firm sought recovery of first-party benefits from Government Employees Insurance Company (GEICO) for injuries claim to have resulted from various motor vehicle accidents. The main issue decided by the court was whether the insurance carrier was entitled to an EBT of the medical provider. The court held that under certain conditions, an insurance carrier is entitled to an EBT of a medical provider in a no-fault case, where it has made a timely denial based on "medical necessity." However, in cases where the carrier failed to issue a timely denial, no further discovery, including an EBT of the medical provider, was permissible on any defense, except if the defense fell within limited exceptions. The plaintiff's decision to litigate rather than seek arbitration was mentioned, stating that the plaintiff must comply with the discovery procedures set forth in the CPLR and the UDCA.