No-Fault Case Law

In this case, T&G Medical Supplies, Inc. sued State Farm Mutual Automobile Insurance Co. to recover insurance benefits for nerve stimulating electrodes used in the treatment of an individual injured in a motor vehicle collision. The main issues decided by the court were whether the assignment of coverage for the medical supplies was valid and whether the insurance claim submitted by T&G Medical Supplies, Inc. was complete. The court held that the assignment of benefits to T&G Medical Supplies, Inc. was ineffective, as it did not include essential information and the insured patient did not receive the supplies. Additionally, the court found that T&G Medical Supplies, Inc. lacked standing to sue as the insured patient did not incur any obligation to pay for the supplies, and the assignment did not accomplish the statutory purpose of New York's "No-Fault" Insurance Law. As a result, the court granted State Farm Mutual Automobile Insurance Co.'s motion for summary judgment and dismissed the action.

The relevant facts considered by the court in this case include the motion for summary judgment filed by A.B. Medical Services PLLC, Lvov Acupuncture P.C., and Somun Acupuncture P.C., as well as the lack of opposition papers received from the defendant. The main issue decided by the court was whether the moving plaintiffs were entitled to summary judgment, based on the fact that they submitted statutory proof of claim forms to the defendant, and the payment of no-fault benefits was overdue. The holding of the court was that the order denying the motion for summary judgment was unanimously reversed, and the motion by the plaintiffs for summary judgment was granted. The court also noted that the defendant could seek appropriate relief if it had served and filed opposing papers, but since it did not appear that the court received opposition papers, the motion for summary judgment should have been granted.

The relevant facts in the case included a timely denial of claims submitted by A.B. Medical Services PLLC by American Manufacturers Mutual Insurance Company (American). American's denials were based on a peer review that concluded there was no medical necessity for the procedures performed, due to the reviewer lacking sufficient information to make such a determination. However, the court found that the reviewer's lack of information alone did not demonstrate the existence of a triable issue of fact, as American failed to seek the necessary information through verification procedures. Therefore, the court held that American was precluded from asserting the defense of lack of medical necessity, and granted summary judgment in favor of A.B. Medical Services PLLC. The main issue decided was whether American's defense of lack of medical necessity was valid, and the court held that it was not, granting summary judgment in favor of A.B. Medical Services PLLC.

The court considered an action to recover $8,205.98 in assigned first-party no-fault benefits, in which defendant's denials of plaintiff's claims for $151.28, $67.40, and $180.00 in no-fault benefits were found to be untimely. The main issue was whether the defendant's failure to attend independent medical examinations (IMEs) prior to the submission of statutory claim forms precluded the defendant from defending its denials. The holding of the court was that while the failure of the plaintiff's assignor to attend the IMEs did not afford the insurer a defense to the action, it did rebut the presumption of medical necessity that attaches to the claim forms. The court modified the order to grant the plaintiff partial summary judgment in the sum of $398.68 and remanded the matter for the calculation of statutory interest and attorney's fees thereon.

The court considered the evidence submitted by the plaintiffs, including claim forms and medical reports, in a case to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiffs had established a prima facie entitlement to summary judgment by proving that payment of the benefits was overdue. The court held that in order to establish that payment on the claims was overdue, the plaintiffs had to demonstrate that the 30 calendar days had elapsed from the time the insurer received proof of the claim. Since there was no evidence as to when the claim forms were submitted to the defendant and the defendant's letters did not specify which claims were received, the court found that the plaintiffs were unable to establish whether payments on any of the claims were overdue. Therefore, the plaintiffs' motion for summary judgment was properly denied.

The main issue in A & S Medical P.C. v Allstate Insurance Company was whether a no-fault insurer was able to defend against a claim for services provided after a certain date based on an earlier blanket denial issued to the insured. Plaintiff submitted a claim to defendant for orthopedic services it had provided, and defendant had previously denied all further orthopedic benefits. However, defendant rejected a portion of the claim more than 30 days later. The Court held that the No-Fault Law and regulations required the insurer to respond to the claim within the statutory 30-day time limit, and that it was not sufficient for the insurer to rely silently on an earlier denial issued to the insured. The Appellate Division ultimately affirmed the lower court's decision, granting summary judgment in favor of the plaintiff.

Two providers sued MVAIC to recover first-party no-fault benefits for services to their assignor, and the Civil Court denied summary judgment. The Appellate Term found that the providers made a prima facie showing through proof that claims were submitted and payment was overdue. MVAIC's examiner's affidavit denying receipt of one provider's claims was insufficient to rebut the presumption of receipt arising from proof of mailing. Because MVAIC failed to pay or deny within 30 days, it was precluded from raising most defenses, including untimely submission and lack of medical necessity, and its unsworn peer review was inadmissible in any event. The 30-day period runs from receipt of proof of claim rather than from MVAIC's qualification of the insured, and judgment was granted in specified sums with remand for interest and fees.

The court considered the facts presented in the case of Ocean Diagnostic Imaging, Inc. v Utica Mut. Ins. Co., where the plaintiff sought to recover no-fault benefits for medical services provided to an assignor. The main issue decided was whether the plaintiff was entitled to summary judgment, and whether the defendant's cross motion for summary judgment should be denied. The court held that the plaintiff had established a prima facie entitlement to summary judgment by providing evidence that it mailed the claim forms and that the defendant failed to pay or deny the claims within the prescribed 30-day period. However, the defendant was not precluded from asserting the defense of insurance fraud, despite the untimely denial of the claims. The court ultimately modified the order to deny the plaintiff's motion for summary judgment, and affirmed that the defendant's cross motion for summary judgment was properly denied.

The court in A.B. Medical Services PLLC v Prudential Property & Casualty Insurance Company considered the failure of the insurer to timely pay or deny the claim within the 30-day statutory period, and the sufficiency of proof submitted to rebut a plaintiff's prima facie case for entitlement to no-fault benefits. The main issue decided was whether a timely denial relieves the insurer from the necessity of submitting proof in admissible form to rebut the plaintiff's prima facie case, and the validity of assignments to health care providers of benefits for non-health-related services. The holding of the court was that defendant's failure to seek verification of the assignments or to allege any deficiency in the assignments in its denial of claim forms constituted a waiver of any defenses with respect thereto, and that despite its untimely denial of certain of plaintiff's claims, defendant was not precluded from asserting the defense that the alleged injuries do not arise out of a covered accident. Furthermore, the court held that renewal of plaintiffs' motion for summary judgment would be unwarranted.

The plaintiff supplier sued to recover no-fault benefits for medical supplies furnished to its assignor, and the Civil Court denied its summary judgment motion and conditionally granted the insurer's cross motion to preclude. The Appellate Term held that the plaintiff made a prima facie showing by submitting claims stating the fact and amount of loss and showing that payment was overdue. The insurer's only opposition was an unsworn peer review report, which was inadmissible and insufficient to raise a triable issue. Any lack of authentication of the assignments was not a defect absent a statutory requirement and, in any event, was waived because the insurer did not seek verification or raise it in its denials. The order was reversed, summary judgment was granted to the plaintiff, and the matter was remanded for interest and attorney's fees.