No-Fault Case Law

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.

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.