No-Fault Case Law

The primary factual matter considered was whether the defendant had sent a timely mailing of a denial form to the plaintiff. The main issue in this case was whether the defendant successfully established a triable issue of material fact in opposition to the plaintiff's motion for summary judgment. The court held that the defendant had provided sufficient evidence through an affidavit with personal knowledge of the facts, which demonstrated the form's actual mailing, as well as the defendant's standard operating procedures for ensuring the mailing of the denial. Therefore, the court deemed that the defendant had established a triable issue of fact, and the order was affirmed with some modification. The plaintiff's motion for summary judgment was ultimately denied.

The relevant facts considered by the court were that the plaintiff, Boai Zhong Yi Acupuncture Services P.C., sought to recover first-party no-fault benefits for health care services rendered to its assignor, Stefaniya Martynuk, and moved for summary judgment. The plaintiff submitted three NF-3 forms, but on two of the forms, the required information was not completed. On the third form, the treating provider was identified as an independent contractor. The main issue decided was whether a billing provider who seeks to recover no-fault benefits for services rendered by an independent contractor treating provider is entitled to recover "direct payment" of assigned no-fault benefits from the insurer. The court held that the plaintiff's motion for summary judgment was properly denied due to the factual issues raised by the plaintiff's submissions, and therefore affirmed the order without costs. The court did not address any other issues in the case.

The court considered the denial of the plaintiff's cross motion for summary judgment in an action to recover overdue first-party no-fault benefits for a CAT scan provided to its assignor. The main issue decided was whether the defendant's affirmed peer review report established a triable issue of the procedure's medical necessity. The court held that the peer reviewer's conclusion, which stated that the available medical documentation did not establish the medical necessity of a CAT scan, was sufficient to raise a triable issue of the procedure's medical necessity. Therefore, the court affirmed the order denying the plaintiff's cross motion for summary judgment.

The relevant facts the court considered were that M.G.M. Psychiatry Care P.C. had submitted claims for first-party no-fault benefits to Utica Mutual Insurance Company, and that payment was overdue. The main issue decided was whether the defendant had timely denied the claims within the 30-day statutory period. The holding of the case was that the deficiencies in the plaintiff's moving papers were cured by the denial of claim forms, and that the defendant had failed to timely deny the claims, making them precluded from raising certain defenses. Therefore, the order granting the plaintiff's motion for summary judgment was affirmed.

The plaintiff supplier sought assigned first-party no-fault benefits for medical supplies from rental car company defendants and moved for summary judgment, while the defendants cross-moved to compel discovery. The Appellate Term held the plaintiff made a prima facie case, since the defendants' acknowledgment of receipt on their denial form cured the plaintiff's insufficient proof of mailing. The defendants' papers showing a fraudulent scheme in the happening of the accident demonstrated a founded belief that the injuries did not arise from an insured incident, so summary judgment was properly denied. The defendants also asserted an improper self-referral defense under Public Health Law § 238-d, based on 40 injured persons treated by the same chiropractor who prescribed nearly identical equipment obtained from the plaintiff. The court held that such a defense, like a Mallela defense, is not precluded by an untimely denial and that discovery on it was proper, so the order was affirmed.

In a provider's action for assigned first-party no-fault benefits, the Appellate Term had previously granted the plaintiff summary judgment because the insurer failed to prove it mailed pre-claim IME requests. The insurer then moved in the District Court to renew its opposition, submitting IME vendor affidavits it had earlier offered only on appeal and claiming law office failure as the excuse. The court held that these affidavits were not newly discovered evidence or new facts, since all operative facts were presented in the original opposition. It also held the insurer showed no due diligence, because it waited for the appellate ruling before seeking renewal, and a post-appeal movant bears a heavy burden. The denial of the motion to renew was affirmed.

The relevant facts the court considered were that the plaintiff, Bronxborough Medical, P.C., was seeking to recover assigned first-party no-fault benefits from Allstate Insurance Co., who denied the claim on the grounds that the injuries were not caused by the accident. The main issue decided by the court was whether the plaintiff's failure to respond to defendant's discovery demands and appear for an examination before trial warranted the dismissal of the complaint, or if the plaintiff should be compelled to respond to the discovery demands and appear for an examination before trial. The holding of the court was that the plaintiff's failure to challenge the defendant's notice of discovery within the prescribed time "foreclosed inquiry into the propriety of the information sought except with regard to requests that are privileged under CPLR 3101, or as to requests which are palpably improper" and therefore, the order compelling plaintiff to respond to defendant's discovery demands and appear for an examination before trial was affirmed.

The relevant facts considered in this case were that Vista Surgical Supplies, Inc. was seeking to recover no-fault benefits from Liberty Mutual Insurance Co. after having its motion for summary judgment denied. The main issue decided was whether Vista Surgical Supplies, Inc. had submitted the claims for no-fault benefits and established that payment was overdue in order to be entitled to summary judgment. The court determined that in order to establish a prima facie entitlement to summary judgment, Vista Surgical Supplies, Inc. had to prove that it submitted the claims and that payment was overdue. The holding of the case was that Vista Surgical Supplies, Inc. failed to provide competent proof that the claim forms were mailed to Liberty Mutual Insurance Co., and therefore their motion for summary judgment was properly denied.

The court considered an appeal from an order denying plaintiff's motion for summary judgment and granting defendant's cross motion to compel discovery in a case to recover assigned first-party no-fault benefits. The main issue was whether the plaintiff health care provider had established a prima facie entitlement to summary judgment by proving submission of claim forms to the defendant. The court held that the plaintiff failed to adequately establish proof of proper mailing and submission of claim forms, as required by law. The court also dismissed the appeal from the portion of the order granting defendant's cross motion to compel discovery, as the plaintiff failed to submit written opposition to the cross motion, resulting in a default. Therefore, the court affirmed the order to deny plaintiff's motion for summary judgment and dismissed the appeal from the portion of the order granting defendant's cross motion to compel discovery.

The relevant facts of the case were that Bronx Expert Radiology, P.C. had filed a motion for summary judgment, as it believed that it had responded to Travelers Insurance Co.'s verification request. However, the affidavit of plaintiff's representative did not create a presumption of mailing, as it did not state that the verifications were actually mailed to the defendant, nor did it describe the plaintiff's mailing office practice and procedures. The main issue was whether the insurer was obligated to pay or deny a claim before receiving verification of all relevant information requested. The holding of the case was that the motion for summary judgment should have been denied, as the plaintiff's submission was insufficient to raise a presumption of receipt, and the matter was remanded to Civil Court for further proceedings.