No-Fault Case Law

The relevant facts of the case involved an action to recover first-party no-fault benefits for medical equipment provided to the plaintiff's assignors. The plaintiff filed a cross motion for summary judgment after the defendant moved for summary judgment as well. The court denied both motions, stating that the supporting affidavit submitted by the plaintiff was defective because it contained legal arguments even though the affiant was not an attorney. The main issue was whether the plaintiff's cross motion for summary judgment should have been granted, and the holding was that the plaintiff's cross motion sufficed to establish a prima facie cause of action, shifting the burden to the defendant to demonstrate the existence of a material issue of fact. As such, the court granted the plaintiff's cross motion for summary judgment and remanded the case for a calculation of statutory interest and an assessment of attorney's fees.

The court considered the fact that the plaintiff had submitted a completed claim to the defendant for first-party no-fault benefits and had not received payment or denial within the required 30 days. The main issue was whether the defendant had timely sent a verification request to the plaintiff, which would have tolled the 30-day period for denial or payment. The holding of the court was that the plaintiff established its entitlement to summary judgment by showing that the claim was submitted and acknowledged by the defendant, and the burden then shifted to the defendant to show a triable issue of fact, which it failed to do. Therefore, the plaintiff's motion for summary judgment was granted in the principal sum of $517, and the matter was remanded for the calculation of statutory interest and attorney's fees.

The court considered the fact that the plaintiff, Amaze Medical Supply Inc., had filed a motion for summary judgment, which was denied by the Civil Court. The main issue decided was whether the plaintiff had provided proper proof of claim for the recovery of no-fault benefits and if the additional documents submitted by the plaintiff raised a triable factual issue. The holding of the case was that the denial of the plaintiff's motion for summary judgment was affirmed, as the inclusion of additional documents for the first time raised a triable factual issue as to whether certain of the no-fault benefits sought were for equipment that was not part of the prescribed course of treatment or for equipment other than what the patient actually received.

Hospital plaintiffs sued the New York City Transit Authority for two separate no-fault medical payments, and the Supreme Court denied summary judgment on the second cause of action and granted the defendant's cross motion dismissing it. The Appellate Division found that the defendant failed to deny the hospital's claim within the 30-day period under Insurance Law 5106(a) and 11 NYCRR 65-3.8(c). Because the denial was untimely, the defendant was precluded from disclaiming coverage. The court reversed, granted the plaintiffs' motion on the second cause of action, and denied the cross motion.

This case involved the timeliness of a lawsuit between an insurance company and a driver who had caused an accident that led to an insurance payout. The relevant facts are that the injured party in the accident had an insurance policy that provided extended economic loss coverage, for which the insurance company paid an extended economic loss beyond the mandatory no-fault coverage. The lawsuit was contested based on when the statute of limitations should be considered and whether it began from the date of the accident or the date when the APIP benefits were first paid. The court held that the statute of limitations runs from the date of the accident, not the date when the first APIP benefits were paid, and therefore, the insurer's action was deemed time-barred.

The relevant facts considered by the court were that a medical supply house filed a lawsuit to recover no-fault benefits for medical supplies provided to its assignor. The main issue decided was whether the defendant failed to pay or deny the claim within 30 days of receipt of the proof of claim, in violation of Insurance Law § 5106 (a) and 11 NYCRR 65.15 (g) (3) (now 11 NYCRR 65-3.8 [c]). The court held that the plaintiff was entitled to summary judgment because the defendant failed to show the existence of a triable issue of fact in opposing the motion. The court determined that as the defendant interposed no proper defense to the claim, summary judgment should have been granted, and the matter was remanded for a calculation of the statutory interest and an assessment of attorney's fees.

The court considered a case where A.B. Medical Services PLLC and G.A. Physical Therapy P.C. (plaintiffs) were seeking recovery of motor vehicle no-fault benefits for medical expenses they claimed were incurred by their assignor, Smolyanskiy. The record showed that A.B. Medical Services was entitled to summary judgment on their claim for neurological testing administered to Smolyanskiy on April 24, 2000 because the insurance company, CNA Insurance, did not deny the claim within 30 days of receipt. However, summary judgment was not warranted for the remaining no-fault claims. The peer review reports relied upon by CNA Insurance in denying the remaining claims were considered a proper defense of lack of medical necessity, and set forth sufficient facts to raise a triable issue. Therefore, the court modified the order to grant plaintiff's motion for summary judgment on one claim, but denied summary judgment on the remaining claims.

The relevant facts considered by the court in this case were that three patients, Marina Shaulov, Dwayne Dowdell, and Maria Arevalo, received medical treatment from the plaintiff, Behavioral Diagnostics, after being involved in motor vehicle accidents and had assigned their insurance benefits to the plaintiff. Allstate, the defendant, paid for some services but denied payment for others, stating that they were not "medically necessary" as required by regulations. The main issue decided in this case was whether the services rendered were medically necessary, and the court held that the burden rests on the defendant to prove that the services rendered were not medically necessary. The court considered expert testimony from doctors regarding the medical necessity of services, and the court ruled that some of the services billed by the plaintiff were not medically necessary, while others were deemed to be necessary. As a result, the court entered judgment in favor of the plaintiff for the amount of $67.24, along with interest and attorneys' fees.

A psychological services provider sued for $1,181.63 in first-party no-fault benefits for psychological evaluation, testing and psychotherapy. The parties stipulated to proper proof of claim and a timely denial, so the only issue at trial was medical necessity, on which the insurer bore the burden. The insurer's psychologist testified that the records failed to establish medical necessity, while the plaintiff's psychologist testified that the testing instruments were commonly used, but neither addressed generally accepted practice directly. The court held that an insurer must at least show that the services were inconsistent with generally accepted medical or professional practice, and that an expert's opinion alone is not enough. The insurer failed to carry its burden, and judgment was awarded to the plaintiff with interest, attorney's fees and costs.

The court considered the fact that the plaintiffs in this case had filed a motion for summary judgment in an action to recover first-party no-fault benefits for medical treatment provided to their assignor. Defendant opposed the motion and submitted nurses' unsworn reviews of the files, concluding that the treatments were medically unnecessary. The main issues decided were whether the nurses' reviews created a triable issue of medical necessity, and whether the benefits sought exceeded those permitted by Workers' Compensation schedules. The holding of the case was that the medical reviews failed to create a triable issue of material fact as to the treatment's medical necessity, and that the benefits sought did not exceed those permitted by Workers' Compensation schedules. The court granted partial summary judgment in favor of the plaintiffs in the sum of $2,559.39, and remanded the case for further proceedings on the remaining portion of the claim.