No-Fault Case Law

The court considered an appeal from a provider seeking to recover first-party no-fault benefits assigned to them, in which the defendant insurance company sought summary judgment to dismiss claims for services billed under specific CPT codes. The main issue decided was whether the amounts sought to be recovered for services rendered prior to April 1, 2013, were in excess of the workers' compensation fee schedule. The holding of the court was that the branches of the defendant's cross-motion seeking summary judgment to dismiss the claims for services billed under the specific CPT codes were granted, reversing the order of the Civil Court. Therefore, the defendant insurance company was successful in their appeal and were not required to pay for the services billed under those specific CPT codes.

The case involved Island Life Chiropractic, P.C. seeking to recover assigned first-party no-fault benefits from Erie Insurance Company of New York. The insurance company had denied the claim due to the provider's failure to submit the claim within 45 days of the services being rendered. The Civil Court denied the insurance company's motion for summary judgment, finding that the sole issue for trial was whether the claim had been timely submitted. The insurance company appealed, arguing that the provider had failed to comply with the regulation requiring submission of claims within 45 days. The appellate court affirmed the lower court's decision, finding that the affidavit of the provider's owner was sufficient to demonstrate a triable issue of fact regarding the timeliness of the claim submission. Therefore, the insurance company did not establish, as a matter of law, that the provider had failed to comply with the regulation, and the lower court's decision was affirmed.

The court considered an appeal from an order of the Civil Court of the City of New York, Kings County, which denied the branches of defendant's cross motion seeking summary judgment dismissing claims for services billed under CPT codes 97810 and 97811. The main issue decided was whether the amounts plaintiff sought to recover, for services rendered prior to April 1, 2013, were in excess of the workers' compensation fee schedule. The court held that the proof submitted by the defendant in support of its cross motion was sufficient to give rise to a presumption that the denial of claim forms at issue had been timely mailed and that the defendant had fully paid the plaintiff for the services billed under CPT codes 97810 and 97811 in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. Therefore, the court reversed the order and granted the branches of the defendant's cross motion seeking summary judgment dismissing claims for services billed under CPT codes 97810 and 97811.

The court considered the fact that Right Aid Medical Supply Corp., as Assignee of Mery M. Quezada, was seeking to recover assigned first-party no-fault benefits from Hereford Insurance Co. The main issue was whether the action was premature because plaintiff had failed to provide requested verification. Defendant argued that the action was premature because the requested verification had not been received, but plaintiff's affidavit was deemed sufficient to give rise to a presumption that the verification had been mailed to and received by the defendant. As a triable issue of fact existed as to whether the action was premature, the Civil Court denied defendant's motion for summary judgment, and the order was affirmed. Therefore, the holding of the case was that the denial of the defendant's motion for summary judgment was proper due to the existence of a triable issue of fact.

The court considered the facts of a provider seeking to recover first-party no-fault benefits, where the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs). The main issue decided was whether defendant's proof sufficiently established the proper mailing of the IME scheduling letters and that the plaintiff's assignor had failed to appear for the scheduled IMEs. The court held that contrary to plaintiff's arguments, defendant's proof did establish proper mailing and the assignor's failure to appear for the IMEs, leading to the denial of plaintiff's motion for summary judgment and the granting of defendant's cross motion for summary judgment dismissing the complaint.

The main issue in this case was whether the plaintiff had failed to appear for duly scheduled examinations under oath, which would result in the dismissal of the complaint. The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits and had failed to appear for the scheduled examinations. The court ultimately held that the order granting the defendant's motion for summary judgment dismissing the complaint was affirmed, with the plaintiff being required to pay $25 in costs. The court's decision was based on the plaintiff's failure to comply with the requirement to appear for the examinations under oath, as stated in an earlier case, Pavlova, as Assignee of Scurry, Kevin v State Farm Mut. Auto. Ins. Co. The appellate court judges unanimously concurred with the decision.

The court considered a provider's attempt to recover assigned first-party no-fault benefits from an automobile insurance company. The main issue decided in this case was whether the plaintiff failed to appear for duly scheduled examinations under oath, which resulted in the defendant's motion for summary judgment dismissing the complaint being granted by the Civil Court of the City of New York, Kings County. The holding of this case was that the order granting the defendant's motion for summary judgment dismissing the complaint was affirmed, with $25 costs. This decision was based on the plaintiff's failure to appear for examinations under oath, as discussed in a related case, Pavlova, as Assignee of Scurry, Kevin v State Farm Mut. Auto. Ins. Co.

The court considered the fact that the plaintiff, a provider seeking first-party no-fault benefits, failed to appear for scheduled examinations under oath (EUOs) as requested by the defendant, an insurance company. The main issue was whether the defendant had provided sufficient proof that the plaintiff had failed to appear for the EUOs, and whether the defendant was required to provide objective reasons for requesting the EUOs in order to establish entitlement to summary judgment. The court held that the proof submitted by the defendant was sufficient to demonstrate that the plaintiff had failed to appear for the EUOs, and that the defendant was not required to set forth objective reasons for requesting the EUOs in order to establish entitlement to summary judgment. Therefore, the court affirmed the order of the Civil Court granting the defendant's motion for summary judgment dismissing the complaint.

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.