No-Fault Case Law

The court considered a case in which a medical professional corporation submitted claims for no-fault benefits to an insurance carrier but failed to appear for scheduled examinations under oath (EUOs). The insurer, Nationwide, sought a declaratory judgment claiming that the failure to appear for the EUOs breached a material condition precedent to coverage. The main issue decided by the court was whether an insurer could be precluded from asserting a defense based on the failure to appear at an EUO if the insurer did not timely deny coverage. The court held that such a defense is subject to preclusion and, since the insurer, Nationwide, failed to establish that it issued timely denials, its motion for summary judgment was denied, and the declarations were vacated. In summary, the court determined that the defense based on nonappearance at an EUO is subject to the preclusion remedy and that the insurer must establish that it issued timely denials. Since the insurer did not meet its burden of proof, the judgment was reversed, and the motion was denied.

The court considered an action by a provider to recover assigned first-party no-fault benefits. The main issue was whether the provider had failed to appear for duly scheduled examinations under oath (EUOs), which would justify the denial of the claim. The court held that the affidavits submitted by the defendant did not sufficiently demonstrate that the denial of the claim form had been timely mailed, and therefore, the defendant was not entitled to summary judgment. However, the affidavit submitted by the plaintiff failed to establish that the claim at issue had not been timely denied or that the denial of claim was conclusory, vague, or without merit as a matter of law. Therefore, the plaintiff's motion for summary judgment was properly denied. Ultimately, the court modified the order by providing that defendant's cross motion for summary judgment dismissing the complaint was denied.

The court considered the facts that the plaintiff, Noel Blackman, M.D., was seeking to recover first-party no-fault benefits as the assignee of Tyshaun Owens. The defendant, State Farm Mutual Automobile Insurance Company, moved for summary judgment to dismiss the complaint on the basis that Owens had failed to appear for scheduled examinations under oath (EUOs). The court found that the defendant had provided sufficient proof of the proper mailing of the EUO scheduling letters and that Owens had indeed failed to appear for the EUOs. As a result, the court affirmed the order to dismiss the complaint, with $25 costs. The main issue decided in this case was whether the defendant had provided sufficient proof of the proper mailing of the EUO scheduling letters and whether Owens had failed to appear for the EUOs. The holding of the case was that the defendant did indeed provide sufficient proof, and as a result, the court affirmed the order to dismiss the complaint.

The main issue decided in this case was whether the defendant was entitled to summary judgment dismissing the complaint and if the plaintiff was entitled to summary judgment in an action to recover assigned first-party no-fault benefits. The court held that the defendant's motion for summary judgment was denied and the plaintiff's cross motion for summary judgment was granted. The defendant's motion for summary judgment was based on an "affidavit" from the claim representative that was not properly sworn to before a notary public, and therefore could not be relied upon to raise an issue of fact as to the timeliness of the defendant's denial of claim forms. The court affirmed the order and concluded that the plaintiff was entitled to summary judgment based on the facts and evidence presented.

The court considered a motion for summary judgment by the plaintiff, who sought to recover assigned first-party no-fault benefits. Additionally, the defendant cross-moved for summary judgment to dismiss the complaint based on lack of medical necessity and the plaintiff not being entitled to be paid for services billed under a specific CPT code pursuant to the workers' compensation fee schedule. The main issue decided was whether the plaintiff was entitled to be paid for services billed under a specific CPT code and whether those services lacked medical necessity. The holding of the case was that the branch of the defendant's cross-motion seeking summary judgment to dismiss the complaint regarding the services billed under the CPT code was denied. The matter was remitted to the Civil Court for a determination of the branch of defendant's cross-motion seeking summary judgment dismissing the complaint for services billed under the CPT code on the ground that those services lacked medical necessity. The plaintiff's motion for summary judgment was properly denied as well.

The court considered the facts that the plaintiff, Pugsley Chiropractic, PLLC, was seeking to recover assigned first-party no-fault benefits from State Farm Mutual Automobile Insurance Co. The main issue decided was whether plaintiff had failed to appear for two scheduled examinations under oath (EUOs). The holding of the case was that defendant had sufficiently established plaintiff's failure to appear for the EUOs, and therefore the court granted defendant's motion for summary judgment dismissing the complaint and denied plaintiff's cross motion for summary judgment. The order was affirmed, and the court declined to review the defendant's argument that the appeal was untimely based on dehors-the-record allegations.

The court considered a case in which a provider was seeking to recover assigned first-party no-fault benefits. The main issue was whether the amounts the provider sought to recover for services rendered after April 1, 2013 exceeded the workers' compensation fee schedule. The court decided that since 11 NYCRR 65-3.8 (g) (1) (ii), effective April 1, 2013, provides that no payment shall be due for services that exceed the charges permissible under Insurance Law sections 5108 (a) and (b) and the regulations promulgated thereunder, the provider's claim was without merit. Therefore, the court affirmed the order that granted the defendant's motion for summary judgment dismissing the complaint and denied the plaintiff's cross motion for summary judgment.

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits, and that the defendant had motioned for summary judgment, claiming that the plaintiff's assignor had failed to appear for independent medical examinations (IMEs). The plaintiff argued that the defendant did not mail the IME scheduling letters to the correct address, but the defendant demonstrated that the letters had been sent to the attorney representing the plaintiff's assignor. Additionally, the defendant provided proof that the assignor had indeed failed to appear for the IMEs. The main issue decided was whether the defendant had properly sent the IME scheduling letters and whether the plaintiff's assignor had failed to appear for the IMEs. The holding of the court was that the order granting the defendant's motion for summary judgment and dismissing the complaint, while denying the plaintiff's cross motion for summary judgment, was affirmed.

The main issue in the case was whether the action by a medical supply corporation to recover assigned first-party no-fault benefits was premature because the plaintiff failed to provide requested verification. The defendant argued that the action was premature because the plaintiff had not provided the requested verification, and the Civil Court granted the defendant's motion for summary judgment dismissing the complaint. However, in opposition to the motion, the plaintiff submitted an affidavit from the owner, which gave rise to a presumption that the requested verification had been mailed to and received by the defendant. The court held that there was a triable issue of fact as to whether the action was premature, and therefore the order was reversed, and the defendant's motion for summary judgment dismissing the complaint was denied.

The court considered whether a provider could recover first-party no-fault benefits when the assignor failed to appear for scheduled independent medical examinations (IMEs). The main issue was whether the defendant's proof sufficiently established the proper mailing of the IME scheduling letters and whether the assignor failed to appear for the scheduled IMEs. The court held that the defendant's proof did establish the proper mailing of the IME scheduling letters and the assignor's failure to appear for the scheduled IMEs. Therefore, the court affirmed the order, denying the plaintiff's motion for summary judgment and granting the defendant's cross-motion for summary judgment to dismiss the complaint.