No-Fault Case Law

MVAIC appealed a judgment awarding the provider $2,172.18 plus interest and fees, arguing that the provider could not recover because it had not shown that its assignor was a qualified person. The court held that the 30-day period to pay or deny a claim applies to MVAIC as to other insurers and runs from receipt of the claim forms regardless of whether the injured person has been deemed qualified. MVAIC admittedly neither denied the claims within 30 days nor timely requested verification. Its purported requests for information were not shown to have been sent, and its letter to a law firm was neither a valid verification request nor a proper denial on the prescribed form. MVAIC was therefore precluded from raising most defenses, and the judgment was affirmed.

The court considered the affidavit of the provider's corporate officer, which stated in a conclusory manner that the attached documents were the provider's business records. The insurer argued that the affidavit failed to lay a foundation for admission of the documents as business records. The court held that the affidavit was insufficient to show that the officer had personal knowledge of the provider's practices and procedures. Because a proper foundation was not laid, the provider failed to make a prima facie showing of entitlement to summary judgment. The order denying the provider's motion for summary judgment was affirmed.

The court considered the fact that the insured's claim for workers' compensation benefits had been denied, as he was deemed to be self-employed and not required to carry workers' compensation insurance on himself as a cab driver. The petitioner argued that the insured's "base affiliation" with Kenmore Cab Dispatch Service obligated the latter to secure workers' compensation coverage for the insured, but failed to provide evidence that Kenmore was the insured's employer at the time of the accident. Additionally, the petitioner did not submit evidence in admissible form that the insured had actually violated his insurance contract. As a result, the court denied the petition to permanently stay arbitration of the insured's no-fault insurance claim. The main issue decided was whether there was a basis for permanently staying arbitration of the insured's no-fault insurance claim, and the holding was that the petitioner failed to provide sufficient evidence to support their argument, and thus the order was affirmed with costs.

Two passengers injured in a March 2004 accident demanded uninsured-motorist arbitration, and the petitioner sought a permanent stay, arguing that the other vehicle's insurer had not validly disclaimed coverage. After a framed-issue hearing, the Supreme Court found the disclaimer invalid and stayed arbitration. The evidence showed that neither the insured driver nor the claimants gave the insurer notice of the personal injury lawsuit or forwarded the papers as the policy required, and the insurer first learned of it from a default judgment motion. The Appellate Division held that the written disclaimer for failure to give notice was therefore valid. The other vehicle was thus uninsured, the order was reversed, and the petition to stay arbitration was denied and the proceeding dismissed.

The provider sought partial summary judgment of $1,617.60 in no-fault benefits against MVAIC, and the Civil Court denied the motion. The Appellate Term found that the provider made a prima facie showing by evidence that the statutory billing forms were mailed and received and that payment was overdue. In opposition, MVAIC relied on an unsworn chiropractor's report to support a lack of medical necessity defense. That report was not in admissible form and had to be excluded, so no triable issue was raised. The order was reversed and the provider's motion granted.

The court considered the evidence presented in the form of an affirmation from plaintiff's counsel, an affidavit by a corporate officer of plaintiff, and various supporting documents. The main issue was whether plaintiff's motion for summary judgment in a case to recover assigned first-party no-fault benefits should be granted. The court held that the affidavit executed by plaintiff's corporate officer was insufficient to establish that said officer possessed personal knowledge of plaintiff's practices and procedures to lay a foundation for the admission of the documents annexed to plaintiff's moving papers as business records. Therefore, the court affirmed the denial of plaintiff's motion for summary judgment.

The court considered the appeal from an order of the Civil Court of the City of New York, Kings County, which had granted the plaintiff's motion for summary judgment and denied the defendant's cross motion for summary judgment. The main issue in this action to recover assigned first-party no-fault benefits was whether the defendant had established timely mailing of its denial forms. The holding of the court was that the defendant failed to establish timely mailing of its denial forms, as the affidavit of its claims processor did not provide a sufficiently detailed description of the standard office mailing procedure to give rise to the presumption of mailing. Additionally, the defendant's additional affidavits produced for the first time in its papers submitted in reply to the plaintiff's opposition were disregarded by the court and may not be considered on appeal, thus defendant was precluded from raising the defense asserted. Therefore, the order of the Civil Court of the City of New York, Kings County, was affirmed without costs.

In an action to recover assigned first-party no-fault benefits, the insurer served an untimely answer and the provider then obtained a default judgment. The insurer moved to vacate the default judgment and to compel acceptance of its late answer, arguing that the provider had waived the untimeliness by failing to reject the answer. The record showed that the provider received the answer and did not reject it within the statutory time. The court held that retention of the answer without timely objection waived any objection to its untimeliness and precluded a default judgment. The default judgment was vacated, and the request to compel acceptance of the answer was denied as academic.

In this case, Long Island Radiology commenced an action against several insurance companies to recover assigned no-fault benefits for MRIs provided to patients injured in motor vehicle accidents pursuant to prescriptions from physicians and/or medical providers. The defendants moved for summary judgment on the issue of whether they may raise lack of medical necessity as a basis to deny reimbursement claims to radiologists for MRIs. The Supreme Court denied the defendants' motion, and instead granted the plaintiff's cross motion which asked for a determination that the defense of lack of medical necessity is not available against radiologists performing MRIs pursuant to prescriptions. The appellate division reversed the decision, and held that a radiologist who accepts assignments of no-fault benefits stands in the shoes of the injured party and thus the defense of lack of medical necessity is available to the defendants against such radiologists. In summary, the main issue decided was whether the defense of lack of medical necessity is available to deny reimbursement claims by radiologists for MRIs provided to no-fault patients pursuant to prescriptions. The holding of the case was that the defense of lack of medical necessity is indeed available against radiologists who accept assignments of no-fault benefits, allowing the defendants to raise this defense to deny claims for reimbursement to radiologists seeking payment for MRIs.

The court considered the motion for summary judgment by Bath Medical Supply, Inc. to recover assigned first-party no-fault benefits. The court below denied the motion on the grounds that the plaintiff's moving papers failed to allege personal knowledge of the mailing of the claims. On appeal, the defendant raised the argument that the affidavit by plaintiff's corporate officer failed to lay a proper foundation for the documents annexed to plaintiff's moving papers. The court found that the affidavit submitted by plaintiff's corporate officer was insufficient to establish personal knowledge of plaintiff's practices and procedures, leading to a failure to make a prima facie showing. Therefore, the court affirmed the denial of the motion for summary judgment, holding that plaintiff failed to establish a prima facie case. The main issues decided in this case were whether the plaintiff's moving papers alleged personal knowledge of the mailing of the claims and whether the affidavit by plaintiff's corporate officer laid a proper foundation for the documents annexed to plaintiff's moving papers. The court's holding was that plaintiff's motion for summary judgment was properly denied due to the failure to establish a prima facie case.