No-Fault Case Law

The main issue in this case was whether the court should reverse the order granting the plaintiff's motion for summary judgment on default and should restore the matter to the motion calendar for a determination of the plaintiff's underlying motion on the merits. The relevant facts considered by the court were that the defendant denied the assignor's claims on the basis of each assignor's failure to appear for a scheduled independent medical examination (IME). However, the court held that an assignor's failure to attend a single requested IME did not afford the insurer a valid basis to deny a no-fault claim where the insurer failed to exhaust the follow-up verification protocols. The court reversed the order and denied the defendant's motion to vacate the order granting the plaintiff's motion for summary judgment, reinstating the judgment in favor of the plaintiff.

The relevant facts included a health care provider's claim for no-fault benefits for services rendered to an assignor. The claim was received by the defendant on October 5, 2001, and was not denied until December 19, 2001. The main issue was whether the defendant's denial of the claim was within the prescribed 30-day period, and whether the alleged injuries were causally related to the accident. The court held that the defendant's denial was ineffective due to being past the 30-day limit, and that there was no proof of an extension by a request for verification. The court also held that the defendant was not precluded from asserting the defense that the injuries were not causally related to the accident, but that the affidavit and "Automotive Engineering Report" submitted by the defendant were insufficient to raise a triable issue of fact. The dissenting judge disagreed, arguing that there was, in fact, an issue of fact as to whether the injuries resulted from the claimed accident, and that the "Automotive Engineering Report" was sufficient to raise a triable issue of fact.

The court was considering an appeal in a case involving plaintiff health care provider's claim for first-party no-fault benefits for medical services rendered to its assignor. The main issue was whether the denial of plaintiff's claim on the ground that plaintiff's assignor failed to appear for examinations under oath (EUOs) was valid. The court held that the plaintiff was entitled to summary judgment, as the defendant failed to establish in the first instance that the insurance policy contained an endorsement authorizing EUOs, and therefore, plaintiff's failure to appear for EUOs cannot be a basis for denial of the claim. The decision was reversed, and the matter was remanded for the calculation of statutory interest and attorney's fees pursuant to Insurance Law § 5106 (a) and the regulations promulgated thereunder.

A chiropractic provider sued to recover first-party no-fault benefits for current perception threshold testing, and both sides moved for summary judgment. The insurer timely denied the claim as medically unnecessary based only on prior arbitration decisions finding such testing invalid. The court held that the insurer bears the burden of proving lack of medical necessity with competent evidence such as an IME or peer review setting out a factual basis and medical rationale. Prior arbitration decisions are not proof, and the insurer offered none. The court granted the provider's motion, denied the cross motion, and directed judgment of $660 plus interest and attorney's fees.

Providers sued to recover assigned first-party no-fault benefits and sought leave to enter a default judgment after the insurer failed to answer, while the insurer cross-moved to open its default. The Appellate Term found the insurer's excuse of inadvertently failing to alert counsel insufficient given months of neglect and delay. It nonetheless held the providers' motion was properly denied because the complaint verified by counsel did not show counsel's personal knowledge and the affidavit by an officer of 'plaintiff' did not establish knowledge for either named plaintiff. The court modified to allow renewal within 30 days and to deny the insurer's cross motion entirely.

A provider brought a special proceeding to vacate a master arbitrator's award that affirmed an arbitrator's denial of its $3,211.42 assigned no-fault claim for lack of medical necessity. The master arbitrator found the arbitrator made a rational determination of no medical necessity. The Appellate Term held the Civil Court correctly found the provider failed to show any CPLR 7511 (b) ground for vacating the award. It affirmed and noted that a special proceeding should end in a judgment rather than an order.

The court considered the defendant's motion to disqualify the plaintiff's law firm, Israel, Israel & Purdy, LLP, from representing the plaintiff on the grounds that the law firm had established a joint business venture with various no-fault medical providers. The defendant argued that the law firm's role in taking over billing functions for the medical providers would require the firm to testify and substantiate, making them an advocate and a witness in the same proceeding. The main issue decided was whether there was a violation of the Code of Professional Responsibility, DR5-102, and if disqualification of the law firm was warranted. The court held that the defendant's motion was without merit as there was no showing that the trial attorney would be called as a necessary witness or that disqualification was necessary. The court also granted the plaintiff's cross-motion for sanctions against the defendant's attorneys in the amount of $500.00 for filing a frivolous motion.

The Court considered that Plaintiff seeks to recover first-party no-fault insurance benefits for medical services rendered to its assignors who were injured in an automobile accident. Plaintiff made a prima facie showing that defendant failed to pay or deny the claims within 30 days after receiving plaintiff's demands and that payment of plaintiff's claims was overdue. The sworn statement of plaintiff's billing manager that the claim forms were mailed to defendant on the date each was signed was uncontradicted on this record. The main issue decided was whether the plaintiff's unopposed motion for summary judgment should have been granted, and the Court held that since Plaintiff made a prima facie showing that defendant failed to pay or deny the claims within 30 days after receiving the demands and that payment of plaintiff's claims was overdue, the Plaintiff's unopposed motion for summary judgment should have been granted.

The case involves a first-party benefits action after a motor vehicle accident in which the plaintiff, Dr. Hellander, provided diagnostic testing to the injured party, Mr. Espinoza. State Farm Insurance Company denied payment for the claim, alleging lack of standing of the plaintiff and lack of medical necessity of the diagnostic testing. At trial, the plaintiff provided evidence of the assignor's signature and the statutory forms of proof of claim and the amount of the loss. State Farm objected to the assignment of benefits based on the lack of authentication of the signature on the form, and also argued that spinal ultrasound testing was not medically necessary. The court held that the plaintiff had established a prima facie case, and that the burden of proof shifted to State Farm on the claim of lack of medical necessity. The court found that State Farm's expert's testimony was equivocal and did not meet the burden of proof necessary to establish that the testing was not medically necessary, and therefore the judgment was rendered for the plaintiff.

The case New York & Presbyt. Hosp. v Allstate Ins. Co. involves an action to recover no-fault medical payments where the plaintiff alleged that the defendant failed to issue a denial of the claim within 30 days of its receipt. The first cause of action was for a claim submitted as the assignee of Adrian Leaf, and the second cause of action was for a claim submitted as the assignee of Noemi Gomez. The plaintiff was granted summary judgment on both causes of action by the Supreme Court, Nassau County. However, the Appellate Division, Second Department reversed the order, with costs, and denied the motion. The court decided that the plaintiff was entitled to judgment on their first cause of action as there were no timely denials of the claims. However, the coverage limits of the policy could be a defense, and there were issues of fact as to whether the coverage limits were exhausted. For the second cause of action, the defendant submitted evidence that the disputed claim was the second of two successive claims for the same services, and the first was properly denied. Therefore, failure to issue a timely denial of the second of these two successive but identical claims would not warrant granting the plaintiff judgment.