No-Fault Case Law
Ocean Diagnostic Imaging v Motor Veh. Acc. Indem. Corp. (2005 NY Slip Op 51271(U))
July 28, 2005
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.
City Wide Social Work & Psychological Servs., P.L.L.C. v General Assur. Co. (2005 NY Slip Op 51197(U))
July 27, 2005
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.
Ocean Diagnostic Imaging P.C. v Allstate Ins. Co. (2005 NYSlipOp 51181(U))
July 21, 2005
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.
S.I.A. Med. Supply Inc. v GEICO Ins. Co. (2005 NYSlipOp 51170(U))
July 21, 2005
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.
A.B. Med. Servs. PLLC v USAA Gen. Indem. Co. (2005 NY Slip Op 25297)
July 21, 2005
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.
Ocean Diagnostic Imaging P.C. v General Assur. Co. (2005 NY Slip Op 51155(U))
July 21, 2005
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.
Poole v Allstate Ins. Co. (2005 NY Slip Op 06017)
July 18, 2005
The main issue in this case was whether the trial court properly denied the motion to sever the 47 causes of action to recover unpaid no-fault benefits asserted by the plaintiff. The defendant insurer contended that the claims at issue were being prosecuted by a single assignee against a single insurer but arose from 47 different automobile accidents on various dates and involved unrelated assignors with diverse injuries and medical treatment, as well as different reasons for the denial of benefits and varied defenses. The court ultimately held that it was an improvident exercise of discretion to deny the motion to sever, as a single trial of all the claims would be unwieldy and potentially confuse the trier of fact. Therefore, the appellate division reversed the order, granted the motion, and severed the causes of action to recover no-fault benefits.
New York & Presbyt. Hosp. v AIU Ins. Co. (2005 NY Slip Op 06014)
July 18, 2005
The plaintiff New York and Presbyterian Hospital filed a suit to recover unpaid no-fault insurance medical benefits from the defendant AIU Insurance Company. The Supreme Court granted the plaintiff's motion for summary judgment on the first cause of action and denied the defendant's cross motion for summary judgment. The defendant appealed this ruling and also moved for leave to renew that branch of the plaintiff's prior motion which was for summary judgment on the first cause of action. However, the defendant failed to establish its entitlement to summary judgment dismissing the complaint based on the intoxication exclusion. The court awarded one bill of costs to the defendant and reversed the order and judgment, denying the plaintiff's motion for summary judgment. The court vacated the decision entered in June and the order entered in August.
Lumbermens Mut. Cas. Co. v Inwood Hill Med., P.C. (2005 NY Slip Op 51101(U))
July 12, 2005
The insurer sought a declaration of no coverage for an alleged single-car accident, after the occupants and the policyholder failed to appear for examinations under oath and independent medical examinations. Three providers counterclaimed for $6,398.58 in no-fault benefits. The court held that the insurer's delay letters identifying the claimant and the EUO sought were sufficient to toll the 30-day period and that the denial forms were sufficiently specific. It found a triable issue on whether the denials were timely mailed to one provider and held that another provider lacked standing for lack of a proper assignment. The failure to appear rebutted the presumption of medical necessity but did not require dismissal, and no fraud was shown. It denied the providers' motion and granted the insurer's cross motion only as to one assignor's claims and certain counterclaims.
Boai Zhong Yi Acupuncture Servs., P.C. v New York Cent. Mut. Fire Ins Co. (2005 NY Slip Op 51058(U))
July 8, 2005
The court considered the plaintiff's motion for summary judgment for recovery of unpaid no-fault benefits and statutory interest and attorney's fees. The plaintiff's assignor was injured in an automobile accident, and the plaintiff submitted the claim to the defendant, who failed to pay within the required 30-day period. The defendant's denial of the claims was found to be untimely, and the defendant failed to provide sufficient evidence to support their defense. As a result, the court granted summary judgment in favor of the plaintiff, awarding the unpaid benefits, interest, attorney's fees, and costs and disbursements. The court held that the defendant breached the contract and was liable for the unpaid no-fault benefits.