No-Fault Case Law

The court considered the motion for summary judgment filed by Nationwide General Insurance Company, seeking to dismiss the complaint filed by Ser Sano, Inc. as Assignee of Joy Wiseman, to recover assigned first-party no-fault benefits. Nationwide argued that Ser Sano's assignor had failed to appear for independent medical examinations (IMEs) as scheduled. The Civil Court initially granted Nationwide's motion, finding that they had established the generation of the IME scheduling letters and that Ser Sano's assignor had failed to appear for IMEs. Ser Sano then sought to renew its opposition to the motion based on newly discovered evidence that the name given on the IME scheduling letters to contact in order to reschedule the IMEs was a pseudonym and that there was no actual employee by that name. The Civil Court denied Ser Sano's motion for renewal, and the Appellate Term affirmed the decision. The main issue decided by the court was whether the new evidence presented by Ser Sano warranted a renewal of their opposition to Nationwide's motion for summary judgment. The court ultimately held that the evidence presented did not change the previous determination and affirmed the denial of Ser Sano's motion for renewal.

The relevant facts considered by the court in this case were that the plaintiff, Pierre J. Renelique, M.D., P.C., was seeking to recover assigned first-party no-fault benefits. The court considered the defendant's motion for summary judgment, which sought to dismiss the first and fourth through seventh causes of action. The main issue decided was whether the proof submitted by the defendant was sufficient to give rise to a presumption that the verification requests and denial of claim forms had been properly mailed, and whether the plaintiff had failed to appear for examinations under oath. The holding of the court was that the proof submitted by the defendant was indeed sufficient in both instances, and therefore the order granting the dismissal of the causes of action was affirmed.

The court considered the denial of plaintiff's motion for summary judgment and the granting of defendant's cross motion for summary judgment in this action by a provider to recover assigned first-party no-fault benefits. The main issue decided was whether defendant's cross motion for summary judgment should have been denied. The holding of the court was that all of plaintiff's arguments as to why defendant's cross motion for summary judgment should have been denied are not properly before this court, since they are being raised for the first time on appeal, and therefore the order is affirmed.

The court considered the denial of payment of first-party no-fault benefits by an insurance company to an acupuncture provider. The main issues decided were whether the insurance company sufficiently demonstrated that the denial of claim forms had been timely mailed, and whether the provider had failed to demonstrate its entitlement to summary judgment. The holding of the court was that the insurance company did not sufficiently demonstrate that the denial of claim forms had been timely mailed, and therefore was not entitled to summary judgment dismissing the first three causes of action. The court modified the order to deny the branches of the insurance company's cross-motion seeking summary judgment dismissing the first through third causes of action.

The case involved Adelaida M. Laga, P.T., as the assignee of Mustapha, Jimoh, who was suing GEICO Ins. Co. for first-party no-fault benefits. The Civil Court granted the plaintiff's motion for summary judgment and denied GEICO's cross motion for summary judgment dismissing the complaint, awarding the plaintiff $3,344.87. GEICO appealed, arguing that the court improperly granted plaintiff's motion for summary judgment and citing various cases to support their argument. The Appellate Term, Second Department, held that the plaintiff failed to establish prima facie case for summary judgment, as the proof submitted did not demonstrate that the claim at issue had not been timely denied, or that GEICO had issued a timely denial of claim that was conclusory, vague, or without merit as a matter of law. However, the court also held that GEICO's cross motion for summary judgment was properly denied, as the papers submitted did not establish, as a matter of law, that the fees charged exceeded the amounts set forth in the workers' compensation fee schedule, or that plaintiff's assignor had failed to appear for independent medical examinations. Therefore, the judgment was reversed, and the plaintiff's motion for summary judgment was denied.

The court considered the issues of whether the fees charged for the services exceeded the amounts set forth in the workers' compensation fee schedule, and whether the defendant had used the correct conversion factor in calculating the reimbursement rate and appropriately applied Ground Rule 11. The court held that the defendant failed to establish its defense that the fees charged exceeded the amounts set forth in the workers' compensation fee schedule, and also failed to demonstrate that it had used the correct conversion factor in calculating the reimbursement rate or that it had appropriately applied Ground Rule 11. Therefore, the court denied the branches of the defendant's cross motion seeking summary judgment dismissing the first, second and fourth causes of action.

The relevant facts considered by the court in this case were that the plaintiff, a medical equipment provider, was seeking to recover first-party no-fault benefits on behalf of an injured individual. The defendant, an insurance company, moved for summary judgment dismissing the complaint, alleging that the injured individual was eligible for workers' compensation benefits. The Civil Court held the motion in abeyance pending a determination by the Workers' Compensation Board to decide the parties' rights under the Workers' Compensation Law. The main issue decided in this case was whether the court had jurisdiction to hear the appeal, and the holding of the court was that the appeal was dismissed as the order being appealed from did not decide the defendant's motion, but instead held the motion in abeyance pending a determination by the Workers' Compensation Board. Therefore, the court declined to grant leave to appeal.

The court considered the denial of plaintiff's motion for summary judgment and the granting of the defendant's cross motion for summary judgment dismissing the complaint. The main issue was the failure of the plaintiff's assignor to appear for scheduled examinations under oath. The holding of the case was that, while defendant did not demonstrate entitlement to summary judgment dismissing the complaint, plaintiff also failed to establish that the claims at issue had not been timely denied or that the defendant had issued a timely denial of claim. Therefore, defendant's cross motion for summary judgment dismissing the complaint was denied.

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits. The court found that the defendant had adequately demonstrated payment in accordance with the workers' compensation fee schedule for the claims underlying the first, fourth, and fifth causes of action. It was decided that the defendant did not appropriately reduce the claims in accordance with the workers' compensation Ground Rules for the claims underlying the second, third, and sixth through tenth causes of action. The court held that the branches of the defendant's motion seeking summary judgment dismissing the second, third, and sixth through eighth causes of action were denied, and the findings on the ninth and tenth causes of action were vacated.

The court considered the issues in an action to recover assigned no-fault benefits for treatment rendered to plaintiff's assignor for injuries sustained in a motor vehicle accident. The main issues included lack of medical necessity for the treatment, billing in excess of the applicable fee schedule, and lack of authority to do business in the State of New Jersey. The court granted the defendant's motion for summary judgment, reducing the amount in dispute to $9,160.08 based on the uncontested merits of the fee schedule defense. However, the court denied the motion in all other respects, finding material facts in dispute as to the medical necessity of the treatment provided. The court also concluded that the failure to obtain a certificate of authority to transact business in New Jersey did not warrant claim preclusion, and that the insurer could not rely solely on this to delay or withhold payment. The court determined that the plaintiff had established its prima facie case, and that the defendant had established its timely denial of the assigned no-fault benefits, so there were material facts in dispute to be decided at a trial.