No-Fault Case Law

By stipulation, this decision governed several hundred actions in which the plaintiff provider sought assigned first-party no-fault benefits from the insurer. The insurer moved to dismiss on the ground that the provider was not a real party in interest because it had assigned the claims to financing companies. The court reviewed the loan and security agreement, revolving note, guaranty, and billing and collection agreement, under which advances were secured by the provider's accounts receivable and collections ran through a lockbox. It found that the provider financed its receivables through a commercially customary arrangement and that the insurer made no showing that the terms were unreasonable. Since the financing companies were barred by regulation from directly collecting no-fault benefits and the arrangement was not shown to be illegitimate, the court denied the insurer's motion and granted summary judgment to the plaintiff on the issue.

The plaintiff supplier sued for assigned first-party no-fault benefits for medical supplies, and the Civil Court denied its summary judgment motion and granted the defendants' cross motion to compel a deposition and document production. After that order the Civil Court dismissed the action. The Appellate Term held that the dismissal rendered the appeal academic and dismissed the appeal.

The court considered the case of A.M. Medical Services, P.C. seeking to recover first-party no-fault benefits for medical services rendered to its assignor. The relevant fact considered was the submission of statutory claim forms and the denial of the claim by the insurance company. The main issue decided was the entitlement to summary judgment by the medical service provider for overdue payment of no-fault benefits. The holding of the case was that the plaintiff established a prima facie entitlement to summary judgment, particularly in relation to the $1,784.95, $205.77, $2,290 and $390.85 claims, due to the insurance company's failure to establish the mailing of verification requests, and was granted partial summary judgment for those claims. They affirmed the defendant's denial of the claim for $1,968.36, as the insurance company timely denied the plaintiff's claim based on a sufficiently detailed affirmed peer review. The court also denied the defendant's cross motion for summary judgment dismissing the action.

The court considered the fact that the case involved a claim to recover assigned first-party no-fault benefits, and involved a dispute over the medical necessity of certain diagnostic tests conducted by the plaintiff. The main issue decided was whether the testimony of the defendant's expert, which was based on medical records prepared by the plaintiff, should be precluded. The court held that the plaintiff's challenge to the reliability of the medical records was not valid because they were prepared by the plaintiff's principal, who personally treated the assignor and conducted the tests in question. Therefore, the defendant's expert opinion, based on those records, was deemed to be derived from a reliable source and not precluded. The case was reversed, with costs, and remanded for a new trial.

A hospital as assignee of an injured person sent the insurers its facility forms demanding $18,145.76, and the insurers timely extended their time by requesting verification and then partially denied $10,385.08 by letter on the ground that the hospital used an incorrect DRG code. Supreme Court denied the hospital's motion for summary judgment on that cause of action. The Appellate Division held that a letter denial is permissible if approved by the Department of Insurance, issued in duplicate and containing substantially the same information as the prescribed form. The letter here conveyed the required information, but the insurers failed to establish it was issued in duplicate and approved by the Department. Having thus failed to properly deny that portion of the claim in time, the insurers were precluded from asserting a defense, and the hospital's motion was granted.

The plaintiff provider sued for first-party no-fault benefits, and the insurer cross-moved for summary judgment on the ground that the provider did not submit proof of claim within 45 days of the services under 11 NYCRR 65-1.1 (d). It was uncontroverted that the plaintiff missed the 45-day period. The Appellate Term held, however, that an insurer is precluded from asserting late submission unless it issued a timely denial. The insurer's claims representative's affidavit neither stated that she actually mailed the denial nor described the office mailing practices, so proof of timely denial was lacking. The insurer's reply affidavit could not be considered to establish its prima facie case, and the denial of its cross motion was affirmed.

The main issue in this legal case was whether the plaintiff had established a prima facie entitlement to summary judgment in an action to recover no-fault benefits for medical supplies furnished to its assignor. The plaintiff moved for summary judgment and the defendant cross-moved to compel examinations before trial of the plaintiff, plaintiff's assignor, and plaintiff's treating physicians. The court denied the plaintiff's motion for summary judgment and granted the defendant's cross-motion to the extent of directing all parties to appear for examinations before trial. The plaintiff failed to establish that it submitted the claim forms to the defendant or that the payment of no-fault benefits was overdue. The court held that the plaintiff failed to establish its prima facie entitlement to summary judgment and affirmed the denial of the plaintiff's motion for summary judgment. The plaintiff's appeal was dismissed, and the decision was made on August 14, 2006.

The plaintiff acupuncture provider sought $480 in no-fault benefits from MVAIC for treatment of an assignor allegedly injured in a June 2003 accident, claiming it mailed claim forms and received neither payment nor a denial. MVAIC moved for summary judgment, arguing the assignor never filed the Notice of Intention to Make Claim required by Insurance Law § 5208 as a condition precedent to coverage. MVAIC's claims representative stated there was no such form in its file, and the plaintiff did not address the filing of the notice within 180 days. The court held a qualified person must first comply with Article 52 before Article 51 no-fault rights apply, so the plaintiff was not a covered person. MVAIC's failure to timely deny did not preclude the lack-of-coverage defense, and the complaint was dismissed.

The court in this case considered a dispute between Pueblo Medical Treatment, P.C. and State Farm Mutual Automobile Insurance Company regarding the denial of no-fault benefits. The main issues decided were the dismissal of the third and fourth causes of action pertaining to an assignor, Ramon Albino, due to the claims being submitted to arbitration prior to the commencement of the action. The court also affirmed the denial of State Farm's cross-motion for summary judgment seeking dismissal of the causes of action pertaining to assignors Odilis Garcia and Gilberto Hernandez, stating that there were issues of fact regarding the defenses raised by the insurance company. The holding of the court was that the denial of State Farm's cross-motion for summary judgment was affirmed, but certain aspects of the discovery and the dismissal of certain causes of action were modified.

The court considered the defendant's appeal from an order of the Civil Court, which denied its cross motion to compel discovery and granted the plaintiff's motion for a protective order. The main issue decided was whether the plaintiff must fully respond to item 10 of the defendant's demand for discovery and inspection, and comply with the defendant's amended notice of examination before trial. The court held that the plaintiff is directed to fully comply with item 10 of the demand for discovery and inspection, as it pertains to the employment status of the treating health provider and is relevant to the issue of whether the medical services were performed by an independent contractor. The court also held that the plaintiff's motion for a protective order with regard to the defendant's remaining discovery demands was properly granted, as the disclosure sought was deemed improper, duplicative, unduly burdensome, irrelevant, and pertaining to defenses not at issue in the case. Furthermore, the court ruled that the defendant did not meet the threshold requirement of "good cause" and was not entitled to disclosure pertaining to a defense related to potential fraudulent incorporation of a professional corporation.