No-Fault Case Law

The relevant facts in this case involved a provider seeking to recover assigned first-party no-fault benefits. The plaintiff moved for summary judgment, and the defendant cross-moved for summary judgment dismissing the complaint. The main issue decided was whether plaintiff had failed to appear for examinations under oath (EUOs) and whether the denial of claim forms had been properly mailed. The court held that the affirmations submitted by defendant's attorneys established that plaintiff had failed to appear for the EUOs, and the proof submitted by defendant gave rise to a presumption that the denial of claim forms had been properly mailed. As a result, the order was affirmed in favor of the defendant.

The court considered the fact that the defendant had fully paid the plaintiff for the services at issue in accordance with the workers' compensation fee schedule. The main issue decided was whether the proof submitted by the defendant in support of its motion was sufficient to give rise to a presumption that the denial of claim form had been properly mailed and to demonstrate that it had properly used the workers' compensation fee schedule to determine the amount the plaintiff was entitled to receive for the services at issue. The holding of the case was that the order granting the defendant's motion for summary judgment dismissing the complaint was affirmed, with the court stating that the proof submitted by the defendant was sufficient to demonstrate that it had properly used the workers' compensation fee schedule to determine the amount the plaintiff was entitled to receive for the services at issue.

The court considered the fact that the plaintiff, Big Apple Ortho Products, Inc., was seeking to recover assigned first-party no-fault benefits, and that the defendant, Allstate Insurance Company, had filed a motion for summary judgment to dismiss the complaint based on the plaintiff's failure to appear for scheduled examinations under oath. The main issue decided in the case was whether the defendant had demonstrated its entitlement to summary judgment by showing that the denial of claim form had been timely mailed, and whether the affidavits submitted by the defendant sufficiently set forth a standard office practice or procedure to ensure this. The holding of the case was that the defendant did not demonstrate its entitlement to summary judgment dismissing the complaint, and as a result, the order granting the defendant's motion for summary judgment was reversed and the motion was denied.

The court considered whether a provider was entitled to recover assigned first-party no-fault benefits, and whether the insurance company had reimbursed the provider properly and in a timely manner. The main issues were whether the insurance company had properly reimbursed the provider for some services according to the workers' compensation fee schedule and whether the denial of reimbursement for other services was justified due to a lack of medical necessity. The court held that there was a triable issue of fact regarding the medical necessity of the denied claims and that the insurance company failed to establish their defense that they had properly paid according to the workers' compensation fee schedule. As a result, the court affirmed the denial of the insurance company's cross motion for summary judgment dismissing the complaint.

In this case, Pro-Align Chiropractic, as assignee of Fatoumata Kouyate, sought reimbursement of assigned first-party no-fault benefits for medical services provided to its assignor after an automobile accident. The defendant, Travelers Property Casualty Insurance Company, sought summary judgment for dismissal of the complaint, arguing that plaintiff's assignor failed to fully comply with defendant's written verification requests. The court denied defendant's motion for summary judgment and granted plaintiff's cross-motion for summary judgment for the relief demanded in the complaint. The court reached this decision based on no-fault regulations and Insurance Law § 5106 (a), stating the insurer must request and receive necessary information to process and verify the applicant's claim, but the scope of the requested materials is not unlimited and must have "good reasons" to demand verification. Additionally, insurers must follow the basic principles of providing prompt and fair payment and must assist an applicant in the processing of a claim, and may not treat the applicant as an adversary.

The court considered the fact that the defendant-insurer failed to establish its entitlement to summary judgment dismissing the underlying first-party no-fault action based upon plaintiff's alleged failure to provide proof of claim. The defendant's claim specialist asserted that they had "no record of receiving" the claim, which was allegedly improperly mailed to a Florida post office box where the defendant "never accepted mail." However, the court found these assertions to be vague and conclusory, and that the defendant failed to make a prima facie showing that the claim was not properly and timely submitted. The main issue decided was whether the defendant had met its burden in proving that the claim was not properly submitted, and the court determined that they had not. The holding of the case was that the defendant's motion for summary judgment was denied, and the complaint was reinstated.

The court considered a case about a medical provider seeking payment under a first-party no-fault benefits assignment. The defendant denied the claim in part because the plaintiff did not bill the services in accordance with the applicable fee schedule. Both parties moved for summary judgment. The main issue decided was whether the "report" in a "By Report" claim is an additional form of documentation or an integral part of the bill or claim form. The court held that the report is a necessary component of the bill for a "By Report" claim, and its absence renders the claim form incomplete, failing to satisfy the prima facie requirements laid out in Viviane Etienne, and therefore failing to trigger the insurer's obligation to timely pay or deny the claim. Therefore, plaintiff's motion to renew and reargue was denied.

The main issues in this case were whether the defendant had a reasonable excuse for its delay in serving an answer and whether the defendant had a meritorious defense to the action. The court found that the defendant had established a reasonable excuse for its failure to serve an answer and had made a prima facie showing of a viable defense based on a lack of medical necessity. As a result, the court reversed the order, denying the plaintiff's motion to enter a default judgment and granting the defendant's cross motion to open its default in answering and to compel the plaintiff to accept a late answer. Therefore, the holding of the case was in favor of the defendant, and the plaintiff's motion was denied while the defendant's cross motion was granted.

The court considered the fact that the defendant had moved for summary judgement to dismiss a complaint by a provider seeking to recover assigned first-party no-fault benefits, on the basis that the plaintiff's assignor had failed to appear for scheduled independent medical examinations (IMEs). The Civil Court had denied the defendant's motion, but made findings that the denial of claim form had been timely and proper, and that the sole issue for trial was whether the plaintiff's assignor had failed to appear for the scheduled IMEs. The main issue decided was whether the plaintiff's assignor had failed to appear for the scheduled IMEs, and the holding of the appellate term was that the defendant's motion for summary judgment was granted, reversing the order of the Civil Court. The court found that the affirmation submitted by the doctor who was to perform the IMEs was sufficient to establish that the plaintiff's assignor had failed to appear for the scheduled IMEs, and as the plaintiff had not challenged the finding that the defendant was otherwise entitled to judgement, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered the appeal from an order of the Civil Court of the City of New York, Queens County, which granted the defendant's motion for summary judgment dismissing the second through seventh causes of action in a case where a provider sought to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff's assignor had failed to appear for duly scheduled examinations under oath. The court affirmed the order, holding that the plaintiff's assignor had indeed failed to appear for the scheduled examinations under oath, and therefore, the defendant's motion for summary judgment was granted. The decision was consistent with a previous case, Greenway Med. Supply Corp., as Assignee of Tellechea Maria v Travelers Ins. Co., which was decided at the same time and provided similar grounds for affirming the lower court's decision.