No-Fault Case Law

The case revolves around an action taken by Hospital for Joint Diseases to recover unpaid no-fault benefits. The Supreme Court decided on an order that granted the defendant's cross motion for summary judgment dismissing the first and second causes of action and denied the plaintiff's motion for summary judgment. The Appellate Division of the Supreme Court ordered that this decision be modified. They decided that the Supreme Court erred in concluding that the plaintiff lacked standing to bring the action absent proof of a valid assignment from each claimant. They also found that the defendant failed to raise a triable issue of fact as to whether the insured's 2002 medical expenses were for injuries for which expenses for treatment had not been submitted within one year of his accident. The holding of the case was that the Supreme Court's order was modified to deny the defendant's motion for summary judgment, reinstate the first and second causes of action, and grant the plaintiff's motion for summary judgment on the first cause of action. Both parties were denied summary judgment on the second cause of action.

The court considered the case of A.B. Medical Services PLLC, D.A.V. Chiropractic P.C., and Lvov Acupuncture P.C. suing Allstate Insurance Company for $6,523.32 in first-party no-fault benefits for medical services rendered to their assignor. The health care providers moved for partial summary judgment in the sum of $6,326.52, which was comprised of various claims for each provider. The main issue decided was whether the health care providers were entitled to the requested sum, and the court held that the providers were entitled to partial summary judgment in the aggregate amount of $6,334.98. The court found that the providers established a prima facie entitlement to partial summary judgment by showing that they submitted claims setting forth the fact and the amount of the loss sustained, and that payment of no-fault benefits was overdue. The burden then shifted to the defendant to show a triable issue of fact, but the defendant failed to establish by competent evidence that its denial of claim forms were timely mailed within the requisite 30-day period to pay or deny the claims. Therefore, the court granted the provider's motion for partial summary judgment and remanded the case for a calculation of statutory interest and an assessment of attorney's fees on the aggregate sum of $6,334.98.

The relevant facts were that the plaintiff, Great Wall Acupuncture, P.C., sought to recover $789.10 in first-party No-Fault benefits from defendant GEICO General Insurance Co. for acupuncture treatment provided to June Jackson. The defendant had reimbursed only $380.90 for the treatment, arguing that the fee billed exceeded the permissible charges for similar procedures under existing fee schedules. The main issue was whether acupuncture performed by a licensed acupuncturist should be reimbursed at a rate higher than what was considered permissible for chiropractors. The court held that plaintiff's motion for summary judgment was denied, as they failed to establish that a licensed acupuncturist should receive higher fees, and the fact that a licensed acupuncturist's services are similar to that of a chiropractor was not resolved. The only remaining issue for trial was whether the defendant had properly reduced the amount billed.

The court considered that defendant insurer had moved for summary judgment dismissing the complaint. The main issue was whether the record established, as a matter of law, that the plaintiff failed to submit proof of his claims for medical expenses and lost wages within the applicable time limitations. The court held that the Supreme Court erred in granting the defendant insurer's motion for summary judgment dismissing the complaint. The record did not establish, as a matter of law, that plaintiff failed to submit proof of his claims for medical expenses and lost wages within the applicable time limitations. The existing record also did not establish the defense of seeking a double recovery as a matter of law. Finally, the plaintiff was not precluded from asserting the claims at bar based on an assignment of benefits executed more than six years prior to the accident.

A provider sued the Motor Vehicle Accident Indemnification Corporation for first-party no-fault benefits for services to its assignor, and the Civil Court granted MVAIC's cross motion without prejudice. The Appellate Term noted that Insurance Law article 52 provides no-fault benefits to qualified persons injured by uninsured vehicles and that claimants must comply with article 52 requirements. Although MVAIC's denial was untimely, that was immaterial because the denial rested on lack of coverage. The record showed that the assignor never filed a timely notice of claim or sought leave to file late, so he was not a covered person and a condition precedent was unmet. The court modified to dismiss the action with prejudice and denied the plaintiff's motion as academic.

A provider sought first-party no-fault benefits of $987.05 and $1,181.63 for two assignors and moved for summary judgment on the ground that the insurer failed to timely deny. The court held that the insurer waived objections to the proof of claim and assignments by not requesting verification within the prescribed period, and that medical necessity is not part of the provider's prima facie case. The insurer did not address one claim at all. As to the other, the mailroom supervisor's and litigation supervisor's affidavits did not establish the timely mailing of the particular denial. The court held that the insurer was therefore limited to fraud or lack of coverage defenses and that its fraud allegations lacked particularity. It granted the provider summary judgment of $2,168.68 plus interest, costs and attorney's fees.

The court considered a case where Ocean Diagnostic Imaging P.C. sought summary judgment in a dispute with Allstate Insurance Company over the payment of a claim for diagnostic imaging services. The main issue decided was whether the court erred in ordering an assessment of damages after awarding summary judgment in favor of the plaintiff. The holding of the case was that the court did err in setting the matter down for an assessment of damages, as the plaintiff had met the burden of proof for their claim and the calculation of interest and attorney's fees was prescribed by statute. The court remanded the matter for a calculation of statutory interest and an assessment of attorney's fees in accordance with the relevant laws and regulations, and did not address any other issues.

The court considered the fact that plaintiff commenced the action to recover no-fault benefits as the assignee of 11 injured individuals, with claims arising from separate accidents. Defendant moved to sever the assigned claims into separate actions, which the court previously denied. The main issue decided was whether the claims of each assignor should be severed into separate actions. The holding of the case was that the appellate court reversed the previous denial, granted the defendant's motion to sever the claims of each assignor into separate actions, and found that the particular facts relating to each claim are likely to raise few, if any, common issues of law or fact, even if the assignors' insurance policies are identical.

Providers sued as assignees for first-party no-fault benefits, and the insurer had denied some claims for the assignors' failure to attend IMEs. The Appellate Term held that the post-claim verification follow-up rules do not apply to preclaim IME requests, but that a provider may prevail by showing a valid excuse for nonattendance. The assignors' uncontested affidavit showed that they could not attend, tried to reschedule in good faith, and that the insurer cancelled one appointment and refused to reschedule another. For the remaining claims the insurer had issued no timely denials and was precluded. The court also held that a prior arbitration award for a different provider had no res judicata or collateral estoppel effect because the providers were not in privity. It reversed and granted summary judgment, remanding for interest and attorney's fees.

The plaintiff provider obtained summary judgment on its no-fault claim, but the Civil Court set the matter down for an assessment of damages. The Appellate Term held that the provider had made a prima facie case by proving the claim and the amount of loss under Insurance Law § 5106. It noted that interest and attorney's fees are prescribed by statute and regulation, so there was no basis for an assessment of damages. The court modified the order to grant the motion outright, deleting the assessment provision, and remanded for calculation of statutory interest and attorney's fees. One justice concurred in the result only.