No-Fault Case Law

The court considered the fact that the plaintiff was seeking to recover assigned first-party no-fault benefits and that the only issue for trial was whether the services rendered to the plaintiff's assignor were medically necessary. The defendant's peer review doctor testified that the services provided by the plaintiff were not medically necessary because there was no indication of a "diagnostic dilemma" that would warrant such testing, and the assignor was not neurologically deteriorating and was responding to chiropractic treatment. The court found the testimony of the peer review doctor to be credible and that there was no medical necessity for the services at issue, and the plaintiff did not present any evidence to rebut the defendant's evidence. The main issue decided was whether the services provided by the plaintiff were medically necessary. The holding of the case was that the judgment in favor of the plaintiff was reversed, and a judgment was directed in favor of the defendant dismissing the complaint.

The court considered the refusal of Dr. Alexandre Scheer, principal of Gotham Medical, P.C., to answer questions at an examination under oath (EUO) regarding his compliance with a consent agreement and order entered into with the Office of Professional Medical Conduct (OPMC). The main issue decided was whether the questions about Scheer's compliance with the OPMC order were proper and whether any determination of noncompliance would render him "unlicensed" to practice medicine. The holding of this case was that Scheer's refusal to answer the questions at the EUO constituted a failure to comply with the request for the EUO, a condition precedent to coverage under the insurance policy. Additionally, the consent agreement and order entered into by Scheer were determined to be public documents, and any violation of the terms of the order would constitute the unauthorized practice of medicine, rendering him ineligible to receive no-fault reimbursement. Finally, the court found that the defendant waived the defenses of res judicata and award and arbitration, as there was no indication that they moved to assert those defenses in their answer to the action.

The court considered a case in which a medical supply corporation was seeking to recover first-party no-fault benefits from an insurance company. The insurance company had filed a motion for summary judgment to dismiss the complaint on the grounds that the action was premature because the medical supply corporation had failed to provide requested verification. The main issue decided was whether the requested verification had been mailed to and received by the insurance company, giving rise to a presumption. The holding of the court was that the affidavit submitted by the medical supply corporation was sufficient to give rise to a presumption that the requested verification had been mailed to and received by the insurance company, creating a triable issue of fact as to whether the action was premature. The court reversed the order granting summary judgment to the insurance company and denied the motion for summary judgment, allowing the case to proceed.

The court considered a petition to vacate part of the award of a Master Arbitrator, which vacated the lower arbitrator's award of $4,329.19 and remanded the matter back to arbitration to consider the respondent's Mallela defense of fraudulent incorporation. The main issue was whether the lower arbitrator's decision addressed respondent's Mallela defense of fraudulent incorporation, and whether the matter should be remanded back to arbitration to consider this defense. The court granted the petition to vacate part of the award of the Master Arbitrator and confirm the remaining part of the award, and held that the lower arbitration decision had already precluded respondent's fee schedule defense due to the failure of a timely denial of the claim, and that all other issues were moot, including the Mallela contentions.

The relevant facts of the case were that Irina Acupuncture, P.C. was seeking to recover assigned first-party no-fault benefits from USAA Casualty Insurance Company. USAA moved to strike the action from the trial calendar and vacate the notice of trial, or, in the alternative, to dismiss the complaint. The Civil Court granted the branches of USAA's motion seeking to strike the action from the trial calendar and vacate the notice of trial, and denied the branch seeking to dismiss the complaint. The court also, on its own accord, awarded defense counsel costs and imposed sanctions upon plaintiff's counsel. The main issue in the appeal was whether the court provided a reasonable opportunity to be heard before making the sua sponte award of costs and imposition of sanctions. The holding of the case was that the court failed to provide such an opportunity and as a result, the order awarding costs and imposing sanctions was reversed and vacated.

The case involved a dispute between Jamhil Medical, P.C. and One Beacon Ins. Co. regarding an order to compel Jamhil Medical to respond to discovery demands including an examination before trial. The Civil Court initially granted One Beacon's motion to dismiss or compel disclosure, but denied the request to compel Jamhil Medical to appear for an examination before trial. One Beacon then sought reargument and the Civil Court vacated its previous decision, directing Jamhil Medical to resubmit responses to the discovery demands within 45 days and to appear for an examination before trial. On appeal, Jamhil Medical argued about the notice to produce, which was not addressed in the order, but did not make specific arguments regarding the examination before trial or the interrogatories. The Appellate Term affirmed the order, with the costs of $25.

The court considered the fact that NYS Acupuncture, P.C. was seeking to recover first-party no-fault benefits from New York Central Mutual Fire Insurance Company, but the defendant had denied the claims on the ground that the plaintiff's assignor had failed to appear for scheduled independent medical examinations. The main issue was whether the defendant was entitled to summary judgment dismissing the complaint based on the assignor's failure to appear for the examinations. The court held that the defendant was entitled to summary judgment because they had established that the letters scheduling the examinations had been timely mailed, the assignor had failed to appear for the examinations, and the claims had been timely denied on that ground. As the plaintiff failed to raise a triable issue of fact in opposition to the defendant's motion, the court granted summary judgment in favor of the defendant.

The court considered the fact that in an action by a provider to recover assigned first-party no-fault benefits, the defendant had moved for summary judgment dismissing the complaint based upon the assignor's failure to appear for independent medical examinations. The main issue decided was whether the defendant's motion for summary judgment should be granted. The holding of the case was that the proof submitted by the defendant in support of its motion was sufficient to establish that the defendant had timely denied the claims at issue. As the plaintiff did not challenge the finding that the defendant was otherwise entitled to judgment, the defendant's motion for summary judgment dismissing the complaint was granted.

The court considered an appeal from an order of the Civil Court of the City of New York in which the defendant's motion for summary judgment dismissing the complaint was granted. The main issue in the case was whether the action to recover assigned first-party no-fault benefits was premature due to the plaintiff's failure to provide requested verification. The court held that while the defendant had demonstrated prima facie evidence that it had properly mailed the initial and follow-up verification requests and had not received the requested verification, the affidavit submitted by the plaintiff in opposition to the motion was sufficient to give rise to a presumption that the requested verification had been mailed to and received by the defendant. As a result, the court found that there was a triable issue of fact as to whether the action was premature and reversed the order, denying the defendant's motion for summary judgment dismissing the complaint.

The main issue in this case was whether the provider had failed to appear for scheduled examinations under oath (EUOs) and if this constituted a valid reason to deny the claims for assigned first-party no-fault benefits. The court considered the affirmation submitted by the defendant and found it was sufficient to establish the plaintiff's failure to appear for the EUOs. As a result, the court denied the branches of the plaintiff's motion seeking summary judgment on the second through fourth causes of action and granted the branches of the defendant's cross motion seeking summary judgment dismissing those causes of action. The holding of the case was that the order, insofar as appealed from, was affirmed, with costs.