No-Fault Case Law

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.

The relevant facts in this case were that the plaintiff was seeking first-party no-fault medical benefits for treatment rendered to its assignor. The main issue decided by the court was whether the plaintiff was entitled to summary judgment in the amount of $1,571.80, and whether the defendant was precluded from raising the defense of lack of medical necessity due to failure to timely deny the plaintiff's claim. The holding of the court was that the plaintiff's proof of its claim as submitted to the defendant was sufficient to establish its prima facie case for summary judgment. The court also held that the defendant, by failing to timely deny the plaintiff's no-fault claim within 30 days of receipt, was precluded from raising the defense of lack of medical necessity. Consequently, the plaintiff's cross-motion was granted, and the matter was remanded to the court for the calculation of statutory interest and an assessment of attorney's fees due on $1,571.80.

The relevant facts in the case were that plaintiff Amaze Medical Supply Inc. a/a/o Johnny Bermudez filed a lawsuit for $1,895 in first-party no-fault benefits. After he submitted his claim, the insurance company, Eagle Insurance Company, denied the claim, arguing that the medical equipment was unnecessary and failed to seek verification of the "proof of the fact and amount of loss sustained." The court held that the claim form submitted by the plaintiff was sufficient to place the burden on the insurer to object in a timely manner with the necessary supporting allegations. Since the insurance company did not do so, they were precluded from asserting that the health benefits were medically unnecessary. Therefore, the court granted the plaintiff partial summary judgment in the sum of $1,695 and remanded the matter back to the lower court for further proceedings.

The court decided on the case of Damadian MRI in Elmhurst v Liberty Mut. Ins. Co., and granted the plaintiff's motion for summary judgment in the principal sum of $879.73. The plaintiff moved for summary judgment in order to recover first-party no-fault benefits, which the defendant failed to either pay or deny within 30 days of receipt. The plaintiff argued that the completion of statutory forms was enough to establish medical necessity for the treatment received. The court agreed with the plaintiff, citing that a properly completed claim form was all that was necessary at the claim stage to establish the treatment's medical necessity. Therefore, the order was unanimously affirmed without costs.

The plaintiffs sued the defendant in an attempt to recover Uninsured Motorists (UM) benefits from their insurance company. The court concluded that the defendant followed the proper procedure in evaluating and denying the plaintiff's claim. Affirming the lower court's decision, the appellate court held that the plaintiff's failure to deny the defendant's fault for the accident entitled the defendant to summary judgment. The court reasoned that the guilty plea agreement that the plaintiff signed following the car accident did not explicitly say that the plaintiff's potential claims where he had been arrested and that he "intentionally caused the accident" would be covered.

The court considered the case of ABC Medical Management v GEICO General Insurance Company. On May 16, 1999, Velez, the individual represented by ABC as an assignee, consulted with Kenneth Pieratti, Doctor of Chiropractic following an automobile accident, and received treatment that included several medical supplies and equipment prescribed by Dr. Pieratti. The main issue in this case was to determine whether a plaintiff-assignee medical equipment supplier can recover no-fault first-party benefits where the prescription was written by a chiropractor rather than a physician. The court's holding, although not entirely free of doubt, went against the defendant's motion for summary judgement to dismiss the complaint, arguing that a chiropractor's prescription would infringe on Education Law § 6551 which prohibits chiropractors from prescribing such equipment. The court supported its findings with its observation that analogous arguments have been rejected by other courts, which maintains that chiropractors are allowed to utilize the equipment in question for treatment.

The court considered the issue of whether State Farm Mutual Automobile Insurance Company had failed to establish that the arbitrator's award for its compulsory arbitration of a no-fault claim was not based on the evidence and was arbitrary and capricious. The court also considered the issue of whether State Farm had failed to establish that the arbitrator exceeded his power or so imperfectly executed it regarding its uninsured motorist claim. The court held that State Farm failed to establish either of these claims and therefore, its petition to vacate the awards was properly denied. Additionally, the court did not address Travelers Insurance Company's cross petition to confirm the awards, as it had not been cross-appealed.

The main issues in the case were whether the plaintiff was entitled to recover for medical services provided to its assignor under the No-Fault Law, and whether the defendant's denial of the claims based on an affirmed peer review report submitted by its doctor was justified. The court considered the claim forms, denial of the claims, and the affirmed peer review report in making its decision. The court held that the plaintiff's prima facie showing was opposed by the affirmed medical report, which raised a triable issue of fact. It was determined that the defense of lack of medical necessity could be based on a sufficiently detailed peer review report, as implicitly provided by Insurance Regulation 11 NYCRR 65-3.8 (b) (4), and that the defendant's timely denial of the plaintiff's no-fault benefits claim was justified based on the file-based peer review. Therefore, the order denying the plaintiff's motion for summary judgment was affirmed.