No-Fault Case Law

Two providers sued GEICO for first-party no-fault benefits and the Civil Court granted them summary judgment. The Appellate Term found that GEICO's documents raised issues of fact about whether one provider, Devonshire, complied with state licensing requirements under 11 NYCRR 65-3.16(a)(12) and Mallela, so its partial summary judgment was denied. As to the other provider, Carnegie Hill, GEICO was precluded from asserting a provider-fraud billing defense because it failed to deny the claims within 30 days. GEICO's own documents also established that it received Carnegie's claims. The order was modified accordingly and otherwise affirmed.

The main facts considered by the court were that the plaintiff's motion for summary judgment was denied due to the insufficiency of certain documents and the lack of justification for not presenting new facts. The main issue was whether the plaintiff had a reasonable justification for failing to present the new facts and whether there had been a change in the law that would warrant a renewed motion for summary judgment. The court held that the plaintiff failed to provide a reasonable justification for not presenting the new facts on the original motion and that the cases cited by the plaintiff did not represent changes in the decisional law. Therefore, the denial of the motion for summary judgment was affirmed, and it was determined that a motion should have been made to reargue if the plaintiff felt that the motion court had overlooked or misapprehended existing law.

The main issue in this case was whether the plaintiff, Psychological Practice, P.C., was entitled to summary judgment in a lawsuit to recover assigned first-party no-fault benefits from NY Central Mutual Fire Ins. Co. The court considered the sufficiency of the affidavit submitted by the plaintiff's owner, which stated conclusorily that the documents attached to the motion papers were plaintiff's business records. The court found that the affidavit was insufficient to establish the owner's personal knowledge of the plaintiff's practices and procedures, and therefore failed to lay a foundation for the admission of the documents as business records. As a result, the plaintiff failed to make a prima facie showing of its entitlement to summary judgment, and the denial of the motion for summary judgment was affirmed. Therefore, the holding of the case was that the plaintiff's motion for summary judgment was properly denied.

The provider sued MVAIC for assigned first-party no-fault benefits, and MVAIC cross-moved for summary judgment because the claim was submitted more than 130 days after the services. The court noted that MVAIC has the rights and obligations of an insurer under article 51, so the 45-day submission requirement applied. MVAIC's denial had invited the provider to supply reasonable justification for the delay. The provider offered no admissible evidence of such justification in opposition. The Appellate Term reversed and granted MVAIC's cross motion for summary judgment.

The relevant facts considered by the court were that Diamond Chiropractic, P.C. appealed a judgment from the Civil Court of the City of New York, which denied their petition to vacate the master arbitrator's award and dismissed the proceeding. The main issue decided was whether there was a rational basis for the determination of the master arbitrator upholding the arbitrator's award which denied petitioner's claims for first-party no-fault benefits. The holding of the court was that there was indeed a rational basis for the determination of the master arbitrator, and therefore the judgment was modified to confirm the master arbitrator's award. The court also noted that the petition was timely filed.

Facts: The plaintiff, East Acupuncture, P.C., brought a lawsuit against Electric Insurance Co. to recover assigned first-party no-fault benefits. The plaintiff filed two separate motions for summary judgment to recover treatment costs for different individuals. Defendant then cross-moved for summary judgment. Plaintiff’s proof of mailing of the claim forms was insufficient for one of the claims. Issues: The main issues in this case were whether the plaintiff’s motions for summary judgment should be granted and whether the defendant’s denials were untimely, and if the plaintiffs were defrauding the defendant. Holding: The court modified the order by denying plaintiff’s motions for summary judgment and affirmed without costs. The court ruled that the plaintiff’s motion for summary judgment should have been denied in one of the claims due to insufficient proof of mailing. In addition, the defendant’s denials were found to be untimely, and there was not enough proof that the plaintiffs were defrauding the defendant, so the defendant was not precluded from asserting a defense.

The relevant facts considered by the court were that the Plaintiff was seeking to recover no-fault first party benefits for medical services provided following a motor vehicle accident. The Plaintiff argued that the Defendant failed to pay or issue a valid denial within thirty days of receipt of the claim. The Defendant argued that it had issued a denial based on the untimeliness of the Plaintiff's claim. The main issue decided by the court was whether the Defendant's proof of mailing of its denial was sufficient to defeat the Plaintiff's motion for summary judgment. The holding of the court was that the Plaintiff's motion for summary judgment was granted, and the Defendant's cross-motion for summary judgment was denied. The Plaintiff was entitled to a judgment in the amount of $12,734.17, plus interest, statutory attorneys' fees, costs, and disbursements of the action.

The relevant facts of the case are that the plaintiff, VA Acutherapy Acupuncture, P.C., sought to recover assigned first-party no-fault benefits, providing evidence of the submission of a statutory claim form and overdue payment. The main issue was whether the defendant, State Farm Ins. Co., was justified in denying the plaintiff's claims due to suspicions of insurance fraud and a belief that the plaintiff was fraudulently incorporated. The holding of the case was that the denial of the plaintiff's claims by the defendant was justified based on a founded belief that the alleged injuries did not arise from an insured incident. The court also found that the defendant's opposition papers raised a genuine issue of fact as to whether the plaintiff was fraudulently incorporated and therefore ineligible for reimbursement of no-fault benefits. As a result, the plaintiff's motion for summary judgment was denied.

The plaintiff supplier sued the no-fault carrier for the cost of medical supplies furnished to the insured. The carrier neither paid nor denied the claims within 30 days and denied them nearly two years later, relying on the insured's statement that he received no supplies. The Second Department considered whether a late-denying carrier could still assert a fraud defense that supplies were never delivered. It held that the defense was not based on a lack of coverage, so the failure to pay or deny within 30 days precluded it. The court noted that insurers could investigate and deny on such grounds within the statutory period, and it affirmed the Appellate Term's grant of summary judgment to the plaintiff.

The court considered the fact that Respondent, Response Equipment, Inc., was seeking to recover assigned first-party no-fault benefits on claims submitted for Hypolite Francis. The main issue decided was whether Francis was acting as an employee at the time of the accident, as this would require the plaintiff to pursue a compensation claim before the Workers' Compensation Board. The court held that the defendant's proof, including the police accident report, raised a question of fact as to whether Francis was acting as an employee, and this issue must be resolved by the Workers' Compensation Board. Therefore, the order was reversed, and the matter was remanded to the court below with the direction to hold the matter in abeyance pending a prompt application to the Workers' Compensation Board for a determination of the parties' rights under the Workers' Compensation Law.