No-Fault Case Law

The plaintiff provider sued to recover first-party no-fault benefits for medical supplies furnished to its assignor, and the Civil Court granted the plaintiff summary judgment and denied the insurer's cross motion. The Appellate Term held that the plaintiff made a prima facie showing by proving it submitted claims and that payment was overdue, and rejected the insurer's argument that the assignment had to be authenticated. The record showed, however, that the insurer mailed timely verification requests within 15 business days and timely follow-up requests. Because the insurer asserted without contradiction that the plaintiff never responded to the requests before suing, the insurer's time to pay or deny had not elapsed. The court reversed, denied the plaintiff's motion and granted the insurer's cross motion dismissing the complaint as premature.

The court considered the plaintiff's action to recover first-party no-fault benefits as the assignee of 11 alleged injured persons, arising from 11 separate accidents. The defendant failed to timely answer, and a default judgment was entered, after which the defendant moved to vacate the default judgment and sever the causes of action. Plaintiff also cross-moved for summary judgment. The main issue decided was whether the court below properly exercised its discretion in granting defendant's motion to sever plaintiff's causes of action and in denying plaintiff's cross motion for summary judgment. The holding of the case was that the court below properly exercised its discretion in granting defendant's motion to sever plaintiff's causes of action, as the defenses raised by the defendant were likely to raise few, if any, common issues of law or fact, even if the assignors' insurance policies were identical, and the plaintiff's cross motion for summary judgment was properly denied.

The court considered whether the plaintiff, Amaze Medical Supply Inc., was entitled to summary judgment in a case to recover first-party no-fault benefits for medical supplies furnished to its assignor, Marta Yepes. Although the plaintiff established a prima facie entitlement to summary judgment by showing that it submitted a claim and the payment of benefits was overdue, the defendant, Allstate Insurance Company, provided evidence demonstrating the timely mailing of its denial of claim based on the assignor's failure to appear for a pre-claim independent medical examination (IME). In addition, the record showed that the assignor failed to appear for the scheduled IME. The court held that the plaintiff's motion for summary judgment was properly denied, affirming the order without costs. Golia, J.P., concurred with the result only, expressing disagreement with certain propositions of law set forth in the majority's decision.

The court considered that the plaintiff provided proof that it submitted claims for first-party no-fault benefits for medical supplies, and that payment of these benefits was overdue. The plaintiff established that it mailed these claims to the defendant via certified mail, and a corporate officer attested to the usual procedure for sending billing by certified mail. The defendant failed to provide a timely denial of the claim within the 30-day statutory period, and their requests for examinations under oath did not toll the 30-day claim determination period. As a result, the defendant failed to show that its time to deny the claims was tolled and is precluded from raising most defenses. Therefore, the plaintiff was entitled to partial summary judgment in the sum of $1,997. The main issues decided were whether the plaintiff was entitled to summary judgment on the claims for first-party no-fault benefits for medical supplies, and whether the defendant's requests for examinations under oath tolled the 30-day claim determination period. The holding of the case was that the plaintiff was entitled to partial summary judgment in the sum of $1,997 due to the defendant's failure to provide a timely denial of the claim within the 30-day statutory period.

The case involved SZ Medical, as well as other medical practices, bringing a lawsuit against Country-Wide Insurance to recover no-fault benefits for medical treatments rendered. The medical practices showed that they submitted claims and that the payments for the no-fault benefits were overdue. Country-Wide Insurance then needed to prove there were any material factual issues in question. In its claim denial form, the insurance company considered and adjusted amounts for several of the claims submitted. The Supreme Court decided that the medical practices were entitled to receive summary judgment after sufficiently showing that payments for no-fault benefits were overdue, and that the insurance company's denials based on lack of medical necessity were insufficient. The matter was then sent back to the lower court for calculation of statutory interest and assessment of attorney's fees.

A supplier, as assignee, sued for first-party no-fault benefits for medical supplies, and its cross motion for summary judgment was denied. The Appellate Term found the plaintiff made a prima facie case that claims were submitted and payment was overdue. The insurer submitted a supervisor's affidavit describing a standard office practice for mailing independent medical examination requests and stating the assignor did not attend. Because the plaintiff offered no valid excuse for the nonappearance and did not show the requests were unreasonable, a triable issue was raised. The denial of summary judgment was affirmed.

The court considered the medical supplies provided by the plaintiff to its assignor after an auto accident, and the defendant's defense that the supplies were not medically necessary. The main issue decided was whether the medical supplies provided were necessary for the treatment of the injuries sustained in the auto accident. The holding of the court was that after reviewing the evidence presented, including invoices and prescriptions, the medical supplies provided were found to be medically necessary. Therefore, the court ruled in favor of the plaintiff, Expo Medical Supplies, Inc., ordering the defendant, Clarendon Insurance Company, to pay $2,882.85 for the medical supplies provided.

The relevant facts the court considered in State Farm Mut. Auto. Ins. Co. v Baltz Concrete Constr., Inc. were that State Farm Mutual Automobile Insurance Company sought to recover insurance benefits paid to its insured from Baltz Concrete Construction, Inc. The main issue decided by the court was whether the Insurance Law prohibited State Farm from seeking recovery of benefits it had paid to its insured for "extended economic loss" pursuant to an "additional personal injury protection" endorsement. The holding of the case was that the defendants were entitled to judgment as a matter of law because the plaintiff's subrogor had unsuccessfully sought to recover damages for his extended economic loss from them in a prior action, and the jury verdict in that action had preclusive effect on the issue of the plaintiff's entitlement to recoup the benefits it had paid to its subrogor for extended economic loss. Therefore, the motion for summary judgment dismissing the complaint was properly granted.

The civil court case of Universal Open MRI of the Bronx, P.C. v State Farm Mut. Auto Ins. involved the plaintiff seeking to recover first-party no-fault benefits for health care services rendered to an assignor allegedly injured in an automobile accident. The defendant denied the claims on the basis that the injuries did not arise out of an insured incident, and presented evidence that the accident was deliberate and staged. The main issue decided was whether the defendant's evidence was admissible and sufficient to prove that the injuries were not covered by no-fault insurance, and the court held that the defendant failed to come forward with admissible evidence to establish intentional collision, and thus ruled in favor of the plaintiff for the recovery of the benefits. In summary, the relevant facts considered by the court included the defendant's evidence based on its investigation of the accident, and the main issue decided was whether the defendant had provided sufficient admissible evidence to prove lack of coverage under the insurance policy. The holding of the court was in favor of the plaintiff, as it ruled that the defendant failed to provide admissible evidence to establish intentional collision, and judgment was granted for the plaintiff in the amount of $1,842.26.

A provider sued for $6,406.53 in first-party no-fault benefits, and the Civil Court dismissed the complaint on the insurer's motion. The insurer argued that a $5,801.37 claim was not submitted within 180 days of the services, and that the remaining $605.16 was denied for exceeding fee schedules. The Appellate Term held that the regulations allow submission within 180 days after written notice, which an NF-2 form may satisfy. A question of fact existed as to the date the insurer received that form, which precluded summary judgment on the larger claim. As to the $605.16, the insurer failed to prove the charges exceeded fee schedules, so the court granted the plaintiff summary judgment for that amount and remanded.