No-Fault Case Law

The court considered the fact that the plaintiff's assignor had withdrawn her claim for medical services, and that the driver of the vehicle involved in the collision had also withdrawn his claim, both due to suspicions about insurance fraud. The main issue decided was whether the defendant's refusal to pay the claim was justified based on a "founded belief that the alleged injur[ies] do[] not arise out of an insured incident." The holding of the case was that the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme, and that there was an issue of fact as to whether there was a lack of coverage. The court also ordered a hearing to address whether the prosecution of the appeal seeking summary judgment in favor of the plaintiff was frivolous and subject to sanctions.

The main issue decided in this case was whether the plaintiff, a healthcare provider, was entitled to summary judgment in its action to recover first-party no-fault benefits for medical services rendered. The court considered the fact that the plaintiff had established a prima facie entitlement to summary judgment by submitting claim forms and that the defendant failed to pay or deny the claim within the prescribed period. However, the defendant was not precluded from asserting the defense that the collision was in furtherance of an insurance fraud scheme. The holding of the case was that the plaintiff's motion for summary judgment was properly denied because an issue of fact existed as to whether there was a lack of coverage, and that the conduct of the plaintiff's counsel in continuing to prosecute the appeal was subject to sanction.

The court considered the fact that PDG Psychological, P.C. (the plaintiff) filed an action for first-party benefits, attorney's fees and statutory interest as an assignee of Sergey Potapov against State Farm Insurance Company (the defendant) for bills totaling $2,758.76 for psychological treatment. Defendant denied the claims due to alleged fraud. The main issue decided was whether the plaintiff had proven its prima facie case of entitlement to benefits and whether the defendant had sustained its burden of proving that the collision was intentional, precluding coverage. The holding was that the plaintiff failed to prove its prima facie case and the evidence offered by the defendant did not meet its burden of producing evidence of a fact or founded belief that the collision was intentional. Therefore, the defendant's motion for a directed verdict was granted based on the plaintiff's failure to prove its prima facie case.

The relevant facts considered by the court were that the plaintiff, a health care provider, submitted a claim form for no-fault benefits for services rendered to its assignor, and that payment of benefits was overdue. The main issue decided by the court was whether the insurance policy in effect contained an endorsement authorizing examinations under oath (EUO) pursuant to 11 NYCRR 65-1.1(d). The court held that the plaintiff established a prima facie entitlement to summary judgment by proving that they submitted the claim form and that payment of benefits was overdue. The court also held that the revised insurance regulations, including EUOs, were inapplicable until the issuance of new or renewal policies containing the revised endorsement, and that the no-fault protection created by statute may not be qualified by the conditions of the liability portion of the insurance policy. Therefore, the court affirmed the order granting the plaintiff's motion for summary judgment.

The court considered evidence and arguments regarding the relationship between Elite Medical Care, P.C. and the health care providers for the plaintiff's assignor. The defendant raised issues regarding the NF-3 forms and the relationship of the health care provider and the plaintiff. The main issue decided was whether the plaintiff was entitled to first-party benefits, attorney's fees, and statutory interest under New York Insurance Law and No-Fault regulations as the assignee of the plaintiff's assignor. The holding of the case was that the plaintiff failed to prove a prima facie case of entitlement to no-fault benefits as they did not introduce evidence of a properly executed assignment, and therefore the judgment was entered in favor of the defendant and the complaint was dismissed.

The relevant facts considered in this case were related to a plaintiff, A.B. Medical Services PLLC, seeking first-party no-fault benefits for medical services rendered to its assignor. The defendant, Clarendon National Insurance Company, opposed the motion for summary judgment, arguing that the verification requests for certain claims were insufficient and that the defense of lack of medical necessity was not precluded. The main issues decided were whether the letters asserted by the defendant as verification requests were insufficient and if the defense of lack of medical necessity was precluded. The holding of the case was that the verification requests asserted by the defendant were insufficient and did not toll the statutory time period for paying or denying the claims. Additionally, the court determined that the lack of medical necessity defense was precluded due to the defendant's failure to provide the necessary facts and medical rationale to establish the defense. Therefore, the court reversed the order denying the plaintiff's motion for summary judgment, granted the motion, and remanded the case for the calculation of statutory interest and an assessment of attorney's fees.

The relevant facts considered by the court were that the plaintiff submitted claims for medical supplies provided to its assignor, and the defendant insurance company timely denied the claims on the basis of lack of medical necessity. The main issue decided was whether the plaintiff was entitled to summary judgment for first-party no-fault benefits, and whether the denial of the claims by the insurance company was justified based on lack of medical necessity. The holding of the case was that the plaintiff's motion for summary judgment was properly denied, as the peer review report from the insurance company provided a factual basis and medical rationale for the conclusion that there was no medical necessity for the supplies, raising a triable issue. Therefore, the order to deny the plaintiff's motion for summary judgment was affirmed without costs.

The case involved Bronx Radiology, P.C. seeking to recover $912 for medical services rendered to Liberty Mutual Insurance Company's insured pursuant to New York State's No-fault law. Liberty Mutual Insurance Company claimed that Bronx Radiology was not entitled to payment because its assignor failed to appear for two Independent Medical Examinations (IMEs). Bronx Radiology argued that the fact of its assignor failing to appear was irrelevant because the services had been rendered before the first scheduled IME. The main issue the court considered was Liberty Mutual Insurance Company's motion to vacate a decision and order granting plaintiff's unopposed motion for summary judgment and the default judgment entered thereupon, and the timeliness of this motion. The court held that the motion to vacate the decision and order of May 9, 2005, and the judgment entered thereupon, was denied because it was untimely, and the default judgment cannot be vacated.

The plaintiff supplier moved for summary judgment on two claims for $635.50 and $1,023 for medical supplies furnished to its assignor, and the rental car defendants cross-moved to compel discovery. The Appellate Term dismissed the appeal from the discovery portion because the plaintiff failed to oppose it and so defaulted. On the merits, the insurer's denial form cured the plaintiff's inadequate proof of mailing for the $1,023 claim, giving the plaintiff a prima facie case. The defendants' papers showing a fraudulent scheme in the happening of the accident established a founded belief that the injuries did not arise from an insured incident, a defense not precluded by an untimely denial. The denial of summary judgment was affirmed.

In an action for assigned first-party no-fault benefits against rental car defendants, an earlier order denied the plaintiff's summary judgment motion and directed it to respond to the defendants' discovery demands within 45 days. The plaintiff did not appeal that order but failed to respond, and after being given additional time it served a response that objected to two demands even though its time to object had expired. The Civil Court then directed an amended response and denied the plaintiff's cross motion for a protective order. The Appellate Term held that a litigant cannot ignore court orders with impunity and that the plaintiff, having not appealed the earlier order, was obligated to provide the discovery. It described the plaintiff's willful noncompliance as wasting judicial resources, and affirmed.