No-Fault Case Law

The Court considered that Plaintiff seeks to recover first-party no-fault insurance benefits for medical services rendered to its assignors who were injured in an automobile accident. Plaintiff made a prima facie showing that defendant failed to pay or deny the claims within 30 days after receiving plaintiff's demands and that payment of plaintiff's claims was overdue. The sworn statement of plaintiff's billing manager that the claim forms were mailed to defendant on the date each was signed was uncontradicted on this record. The main issue decided was whether the plaintiff's unopposed motion for summary judgment should have been granted, and the Court held that since Plaintiff made a prima facie showing that defendant failed to pay or deny the claims within 30 days after receiving the demands and that payment of plaintiff's claims was overdue, the Plaintiff's unopposed motion for summary judgment should have been granted.

The case involves a first-party benefits action after a motor vehicle accident in which the plaintiff, Dr. Hellander, provided diagnostic testing to the injured party, Mr. Espinoza. State Farm Insurance Company denied payment for the claim, alleging lack of standing of the plaintiff and lack of medical necessity of the diagnostic testing. At trial, the plaintiff provided evidence of the assignor's signature and the statutory forms of proof of claim and the amount of the loss. State Farm objected to the assignment of benefits based on the lack of authentication of the signature on the form, and also argued that spinal ultrasound testing was not medically necessary. The court held that the plaintiff had established a prima facie case, and that the burden of proof shifted to State Farm on the claim of lack of medical necessity. The court found that State Farm's expert's testimony was equivocal and did not meet the burden of proof necessary to establish that the testing was not medically necessary, and therefore the judgment was rendered for the plaintiff.

The case New York & Presbyt. Hosp. v Allstate Ins. Co. involves an action to recover no-fault medical payments where the plaintiff alleged that the defendant failed to issue a denial of the claim within 30 days of its receipt. The first cause of action was for a claim submitted as the assignee of Adrian Leaf, and the second cause of action was for a claim submitted as the assignee of Noemi Gomez. The plaintiff was granted summary judgment on both causes of action by the Supreme Court, Nassau County. However, the Appellate Division, Second Department reversed the order, with costs, and denied the motion. The court decided that the plaintiff was entitled to judgment on their first cause of action as there were no timely denials of the claims. However, the coverage limits of the policy could be a defense, and there were issues of fact as to whether the coverage limits were exhausted. For the second cause of action, the defendant submitted evidence that the disputed claim was the second of two successive claims for the same services, and the first was properly denied. Therefore, failure to issue a timely denial of the second of these two successive but identical claims would not warrant granting the plaintiff judgment.

The court considered whether the plaintiff was entitled to recover unpaid no-fault insurance benefits. The main issues were whether the plaintiff was intoxicated at the time of the accident within the meaning of the no-fault insurance law, and whether his intoxication was a proximate cause of the accident. The court held that there were issues of fact regarding the plaintiff's intoxication that precluded granting the defendant's cross motion for summary judgment dismissing the complaint. As a result, the court modified the order to deny the cross motion and reinstate the complaint, and affirmed with costs payable to the plaintiff. The plaintiff's remaining contentions were deemed without merit by the court.

The relevant facts of the case were that the plaintiff health care providers sought to recover first-party no-fault benefits for medical services provided to their assignor. They established a prima facie entitlement to summary judgment by submitting the statutory claim form and showing that the defendant failed to pay or deny the claim within the 30-day statutory period. The main issue decided was whether the defendant was precluded from raising most defenses due to its failure to timely deny the claim, and whether the defendant could assert the defense that the collision was in furtherance of an insurance fraud scheme. The holding of the case was that while the defendant was precluded from raising most defenses, it was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme. The court found that the defendant demonstrated the existence of a triable issue of fact as to whether there was a lack of coverage, and therefore the plaintiffs' motion for summary judgment was properly denied.

The relevant facts that the court considered in this case were that a health care provider, S & M Supply Inc., was seeking to recover no-fault benefits for medical services rendered to its assignor, Michael Monsignal. The issue before the court was whether the health care provider had established a prima facie entitlement to summary judgment, and whether the insurance company, State Farm Mutual Automobile Insurance Company, was precluded from raising defenses due to failure to pay or deny the claim within the 30-day claim determination period. The holding of the court was that the health care provider had established a prima facie entitlement to summary judgment, and the insurance company was precluded from most defenses due to the untimely denial of the claim. However, the insurance company was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and since they demonstrated the existence of a triable issue of fact as to lack of coverage, the plaintiff's motion for summary judgment was properly denied.

Relevant facts considered by the court include an automobile accident that occurred on February 20, 1999, injuries sustained by the respondent Stephanie Drasgow, and a claim for additional personal injury protection (APIP) benefits. The main issues decided in this case included whether the notice of the claim for APIP benefits was given within the 90 days after the accident, as required by petitioner's policy, and whether it was impossible for respondent to provide notice due to specific circumstances beyond her control. The holding of the case was that the Supreme Court properly granted the petition seeking to vacate the arbitration award directing the petitioner to pay additional personal injury protection (APIP) benefits to the respondent. The court concluded that there was no rational basis for the arbitrator's finding that it was impossible for the respondent to provide notice within the 90-day period because of circumstances beyond her control. Two of the judges dissented and argued that the arbitrator's finding was based upon the weighing of factual matters and the record supports that determination. They requested that the order be reversed, petitioner's petition to be denied, and respondent's petition be granted, confirming the arbitrator's award.

The main issues considered in this case were whether the appellant, David Bett, was entitled to supplementary uninsured motorist (SUM) benefits under his policy from New York Central Mutual Fire Insurance Company. The court also had to decide whether the recorded statement given by Bett to the company's independent insurance adjusting firm soon after the accident was sufficient notice to the insurer of the claim for SUM benefits. The court's decision was that Bett failed to give timely notice of his SUM claim to the insurer, which was a condition of SUM coverage in his policy. The court acknowledged that Bett had given a recorded statement to the insurance company a week after the accident, but still held that the notice of his SUM claim was untimely. As a result, the petition for a permanent stay of arbitration was granted, denying Bett SUM coverage under his policy.

The court considered the fact that the plaintiff sought to recover first-party no-fault benefits for medical services rendered to their assignor, as well as statutory interest and attorney's fees, and that the defendant failed to pay or deny the claims within the statutory 30-day period as required by Insurance Law section 5106(a). The main issue decided was whether the plaintiff was entitled to summary judgment, and the court held that the plaintiff's motion for summary judgment was granted in its entirety, with a judgment in favor of the plaintiffs in the amount of $14,628.06, together with appropriate statutory interest and attorneys' fees. The court also found that the defendant failed to comply with follow-up procedures and timetables for verification, and failed to submit evidentiary proof to establish that the benefits sought for medical supplies were not in conformity with the charges permissible under the workers' compensation fee schedule law, precluding the defendant from raising certain defenses in its opposition to the motion. The court did not consider the defendant's amended affirmation in opposition in rendering its decision and order, as the amended papers were not timely served upon the plaintiffs.

In this case, the court considered the motion for an order disqualifying the law firm representing the plaintiff in the proceeding. The defendant alleged that the law firm was in violation of the Code of Professional Responsibility as one of its members ought to be called as a witness in the proceeding. The facts of the case involved a medical services provider billing an insurance carrier under the state No-Fault Law, with the firm preparing and mailing bills on behalf of the provider. The defendant argued that a non-attorney member of the firm was necessary to establish a prima facie case. The main issue decided was whether the law firm should be disqualified based on this allegation. The court held that a clerk of the law firm employed in the mailroom, responsible for mailing the plaintiff's bills and proof of claim, would not cause the law firm to be disqualified from representing the plaintiff, simply because the clerk's testimony was necessary in establishing the elements of plaintiff's case. It was concluded that the rules governing lawyers' disqualification do not apply to non-lawyer employees of a law firm, and therefore, the law firm was not disqualified from representing the plaintiff. Thus, the court denied the defendant's motion for disqualification.