No-Fault Case Law

The main issue in the case was whether the plaintiff was entitled to recover assigned first-party no-fault benefits from the defendant, IDS Property Casualty Insurance Company. The defendant appealed from an order of the Civil Court that denied the branches of the defendant's motion seeking summary judgment dismissing the complaint. This was because the plaintiff had failed to appear for duly scheduled examinations under oath (EUOs). The defendant established that the plaintiff had failed to appear for the scheduled EUOs and that the claims had been timely denied on that ground. As the plaintiff failed to raise a triable issue of fact in opposition, the defendant was entitled to summary judgment dismissing the claims. The holding of the case was that the order denying the defendant's motion was reversed, and the defendant's motion seeking summary judgment to dismiss the claims was granted.

The court considered the circumstances of a lawsuit brought by T & S Medical Supply Corp. against New York Central Mutual Fire Insurance Company to recover assigned first-party no-fault benefits. The main issue decided was whether the action was premature due to the plaintiff's alleged failure to provide requested verification. The court held that there was a triable issue of fact as to whether the action was premature, as the plaintiff's affidavit in opposition to the defendant's motion was sufficient to create a presumption that the requested verification had been mailed to and received by the defendant. The court ultimately reversed the order granting the defendant's motion for summary judgment and denied the motion to dismiss the complaint.

The court considered an action by a provider to recover first-party no-fault benefits, where the defendant had denied the plaintiff's claim for services billed under a specific CPT code. The main issue in this case was whether the provider was required to furnish additional documentation for the services billed and if the insurer properly requested additional verification before denying the claim. The court held that the insurer's denial of the claim was without merit as a matter of law because the insurer did not request the necessary documentation from the provider. As a result, the court reversed the lower court's decision, denied the insurer's motion for summary judgment, granted the provider's cross motion for summary judgment, and remitted the matter back to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees.

The court considered the fact that the defendant's cross motion for summary judgment was based on the plaintiff's assignor's failure to appear for scheduled independent medical examinations and on the ground that the amounts sought by the plaintiff exceeded the workers' compensation fee schedule. The main issue decided was whether the defendant's motion for summary judgment should be granted or denied, and whether the plaintiff's motion for summary judgment should be granted or denied. The holding of the case was that the order was modified by providing that the defendant's cross motion for summary judgment dismissing the complaint was denied, meaning that the defendant did not demonstrate its entitlement to summary judgment dismissing the complaint, and that the plaintiff's motion for summary judgment was properly denied.

The court considered an action by a provider to recover assigned first-party no-fault benefits, as defendant moved for summary judgment dismissing the complaint on the ground that they had paid the plaintiff for the services at issue in accordance with the workers' compensation fee schedule. The main issue decided was whether the defendant's motion for leave to reargue should have been granted, as the Civil Court had denied their previous motion for summary judgment. The holding of the court was that the defendant's motion for leave to reargue should have been denied, as they did not provide any new matters of fact or law that were overlooked or misapprehended by the court in determining their previous motion. As a result, the court reversed the previous decision and reinstated the order denying defendant's motion for summary judgment dismissing the complaint.

The court considered the issue of whether the plaintiff, a provider seeking to recover assigned first-party no-fault benefits, had a reasonable excuse for failing to timely submit written opposition to the defendant's motion for summary judgment. The main issue was whether the plaintiff had an excusable default for their late submission, as required by CPLR 5015 (a) (1). The court held that the plaintiff failed to demonstrate a reasonable excuse for its default, as the excuse offered by the plaintiff's attorney was deemed mere neglect based on a heavy workload, which is not accepted as an excusable default. Therefore, the court affirmed the order entered on March 6, 2012, which denied the plaintiff's motion to vacate the prior order granting the defendant's motion for summary judgment.

The court considered the plaintiff's motion for summary judgment and the defendant's cross motion for summary judgment to dismiss the complaint in an action to recover first-party no-fault benefits. The main issue decided was whether the plaintiff's failure to appear for scheduled examinations under oath (EUOs) justified the dismissal of certain causes of action. The court held that the defendant's affirmation was sufficient to establish the plaintiff's failure to appear for the EUOs, and therefore granted the defendant's cross motion for summary judgment and denied the plaintiff's motion for summary judgment on the second, third, fourth, eighth, and ninth causes of action. The court did not consider the plaintiff's argument regarding the first cause of action as it remained pending and undecided. The decision of the Civil Court was affirmed.

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.