No-Fault Case Law

The relevant facts considered in this case involved an action to recover assigned first-party no-fault benefits by a plaintiff health care provider who sought full reimbursement for acupuncture services rendered by a licensed acupuncturist based on their billed amounts. The defendant, an insurer, had partially denied the plaintiff's claims, stating that the fees charged exceeded the maximum allowance under applicable fee schedules. The main issue decided in this case was the appropriate fee to be paid for acupuncture services rendered by a licensed acupuncturist. The court held that in the absence of a separate fee schedule for acupuncture services performed by licensed acupuncturists, the permissible charge for such services should be the prevailing fee in the geographic location of the provider, subject to review by the insurer for consistency with charges permissible for similar procedures under schedules already adopted or established by the superintendent. Ultimately, the judgment was reversed, the order granting plaintiff's motion for summary judgment was vacated, and plaintiff's motion for summary judgment was denied, with the action being dismissed in favor of the defendant.

The court considered whether the hospital was entitled to judgment as a matter of law in a case to recover no-fault insurance payments. The court held that the insurer raised triable issues of fact because it requested medical verification of the claim and timely denied it based on a peer review report. The court found that the insurer was not required to set forth a medical rationale in its denial of claim form, and declined to award summary judgment in favor of the insurer. The court also found that the insurer's remaining contention was improperly raised for the first time on appeal, and ruled that the appellant was not allowed to challenge a point that had not been previously considered by the lower court.

The court considered a case regarding a medical facility suing an insurance company for regulations regarding insurance contracts. The issues decided by the court included the error of having an insurer denying a claim for first-party no-fault benefits on the ground of lack of medical justification to include a medical rationale in its denial of claim form. The holding of the case was reversed in that it was affirmed that the insurer and not the claimant should be required to set forth a medical rationale in the prescribed denial of claim form. The court also found that the medical facility made a prima facie showing of entitlement to judgment as a matter of law, however, in response the insurance company raised a triable issue of fact with respect to its argument that the claimed benefits were properly denied on the ground of lack of medical justification.

The court addressed an appeal in a case involving A.B. Medical Services, PLLC, and GEICO Casualty Insurance Co. in relation to no-fault benefits under an insurance contract. The Appellate Term of the Supreme Court modified the previous order of the Civil Court, denying A.B. Medical Services' motion for summary judgment. The plaintiff failed to make a prima facie showing of entitlement to judgment as a matter of law. Even if they had done so, the defendant was successful in raising a triable issue of fact in response. The defendant's denial of claim forms were not insufficient, as the Appellate Term concluded, and the court disagreed with their reasoning. The Department of Insurance regulations do not actually require the carrier to set forth a medical rationale in the prescribed denial of claim form, so the insurer's denial was sufficient. Therefore, the court reversed the order of the Appellate Term and the Civil Court, and denied the plaintiff's motion for summary judgment.

The provider sued MVAIC for $600 in no-fault benefits for acupuncture after a September 2002 accident, and MVAIC moved to dismiss for failure to state a cause of action, arguing the assignor never qualified for MVAIC benefits because the accident was not shown to have been reported to police within 24 hours. The court found that the complaint stated a cause of action on its face and that MVAIC's arguments went to the viability, not the sufficiency, of the claim. MVAIC's supporting affidavit was based on another claimant's file and hearsay, and its investigator's report was unsworn. MVAIC's purported denial was not on the prescribed form, and it bore the burden on its lack-of-coverage defense, which it did not meet. The statute of limitations branch was denied because the record did not show when the claim accrued, and MVAIC was ordered to answer.

The court considered a motion for summary judgment in a case where a medical services provider sought to recover first-party no-fault benefits from an insurance company. The plaintiff initially moved for summary judgment, which was supported by an affirmation of counsel, an affidavit of an officer of the plaintiff, and various documents. The defendant opposed the motion, arguing that the affirmation of counsel was of no probative value and that the affidavit of the plaintiff's officer was insufficient. The court denied the motion on these grounds. The plaintiff then moved to renew the motion, providing a more detailed affidavit from its officer. However, the court denied the motion to renew, as the plaintiff failed to present any new facts or a change in the law that would warrant a different determination. The main issue decided by the court was whether the plaintiff had a reasonable justification for the failure to present new facts on the prior motion for summary judgment. The court held that the plaintiff did not provide a reasonable justification and that the cases proffered did not represent changes in the decisional law. As a result, the motion for summary judgment and the motion to renew were both properly denied.

The court considered the affidavit of the provider's employee, 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 employee 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 plaintiff was injured in a motor vehicle accident in New York while a passenger in a vehicle that was registered in Florida, and issued an insurance policy in Florida. The main issue decided was whether plaintiff was eligible for no-fault benefits and if the defendant's denial of the benefits was untimely. The court held that Florida law allowed for the retroactive cancellation of an insurance policy due to material misrepresentation, and since the policy was void ab initio, defendant's denial of plaintiff's claim was proper. The court also determined that Florida law was controlling under New York's conflict of law rules, and defendant was not obligated to provide "no-fault" coverage to plaintiff.

The court considered a proceeding pursuant to CPLR article 75, seeking to permanently stay arbitration of a claim for uninsured motorist benefits. They granted a modification of the order to correct inaccuracies in the previous decisions and ordered the matter remitted to the Supreme Court, Kings County, for an evidentiary hearing on whether Allstate Insurance validly disclaimed coverage of the offending vehicle in an accident. The main issue decided was whether the petitioner was entitled to a stay of arbitration based upon the failure of the respondent to provide notice required by the automobile insurance policy, and whether Allstate Insurance disclaimed coverage of the offending vehicle. The court held that timely notice is sufficient and curbs fraud or collusion, and since the petitioner did not claim any prejudice arising from the late notice of the SUM claim, they were not entitled to a stay of arbitration. The court also held that an evidentiary hearing for Allstate Insurance to disclaim coverage of the offending vehicle was needed.

The court considered the timely submission of invoices and/or bills to the defendant, as well as the requirement for a provider to receive direct payment from the insurer under the no-fault regulations. The main issue decided was whether the denial of the claim was timely and whether the assignment of benefits was valid. The court held that the plaintiff was entitled to summary judgment as a matter of law, as the defendant's denial of claim forms was not timely and the assignment of benefits was valid. As a result, the court awarded summary judgment in favor of the plaintiff and against the defendant in the amount of $304.79, with interest, costs, and attorney's fees, and denied the defendant's cross-motion.