No-Fault Case Law

The court considered a case brought by Maxford, Inc. as the assignee of Reynolds Gregory against Utica Mutual Insurance Company. The main issue decided was whether the defendant's motion for summary judgment dismissing the complaint, which was granted by the Civil Court, was appropriate. The court held that the defendant had demonstrated prima facie that its denial of claim form had been issued within 30 days of receiving the bills at issue, and that the plaintiff had failed to rebut that showing. Additionally, the court found that the plaintiff had failed to appear for scheduled examinations under oath as required, and as the plaintiff raised no other issue on appeal with respect to this defense, the order for summary judgment dismissing the complaint was affirmed.

The relevant facts in this case were that Logic Chiropractic, P.C. was seeking to recover first-party no-fault benefits and moved for summary judgment, while the defendant, Hereford Insurance Co., cross-moved for summary judgment dismissing the complaint. The issues decided were whether plaintiff's assignor had failed to appear for duly scheduled independent medical examinations (IMEs) and whether the claims underlying the causes of action had been timely denied. The holding of the case was that the court modified the order by striking the findings that defendant had properly and timely mailed the IME scheduling letters, and that the sole issue for trial was whether the claimant failed to appear for the scheduled IMEs. The court also found that plaintiff had failed to establish entitlement to summary judgment on the third through sixth causes of action.

The court considered the fact that the plaintiff had failed to appear for scheduled examinations under oath (EUOs) as required for the recovery of assigned first-party no-fault benefits. The main issue decided was whether the affirmation submitted by the defendant's attorney, who was present in her office to conduct the EUOs on the scheduled dates, was sufficient to establish that the plaintiff had failed to appear for the EUOs. The court held that the affirmation submitted by the defendant's attorney was indeed sufficient to establish that the plaintiff had failed to appear for the EUOs, and therefore affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.

The relevant facts the court considered were that the plaintiff was alleging that she became permanently disabled as a result of injuries sustained in an automobile accident, but the defendant's insurance company denied her claims for benefits. The main issues decided by the court were whether the plaintiff adequately stated a claim for General Business Law violations, whether she could seek damages for emotional distress in her breach of contract claim, and whether punitive damages were recoverable for breach of contract. The holding of the case was that the plaintiff did state a claim for violation of General Business Law and that she could seek consequential damages, but not emotional distress or punitive damages, in her breach of contract claim. Therefore, the court modified the order to reverse the dismissal of the General Business Law § 349 cause of action, deny the motion to that extent, and affirmed the decision as modified.

The court considered an action by a provider to recover assigned first-party no-fault benefits for chiropractic manipulation under anesthesia. The main issues remaining for trial were the defenses of medical necessity and whether the plaintiff was properly reimbursed by the defendant pursuant to the fee schedule and calculations applied. The court determined that the defendant did not present sufficient evidence to establish that the manipulation under anesthesia was inconsistent with generally accepted professional practice based on the assignor's medical treatment and condition at the time. Therefore, the evidence was insufficient to carry the defendant's burden of proving that the services were not medically necessary. However, the court found that the defendant had met its burden of showing that the appropriate amount for the invoices at issue was $1,462.47 instead of $3,572.91, and awarded judgment in favor of the plaintiff for that amount.

The court considered the case of Sama Physical Therapy, P.C. v IDS Property Casualty Insurance Company, in which the plaintiff, a provider seeking to recover assigned first-party no-fault benefits, had their claims denied by the defendant based on the plaintiff's failure to appear for duly scheduled examinations under oath (EUOs). The main issue decided by the court was whether the defendant had properly and timely denied the claims based on the plaintiff's failure to comply with a condition precedent to coverage. The court held that the defendant failed to demonstrate that it had properly and timely denied the claims for the first and second causes of action, as the first EUO scheduling letter was not timely with respect to those claims. However, the court also held that the denial of the claim underlying the third cause of action was nevertheless timely, despite the late mailing of the first EUO scheduling letter. Therefore, the court modified the order by denying the branches of the defendant's motion seeking summary judgment dismissing the first and second causes of action.

The relevant facts considered by the court were that a provider was seeking to recover assigned first-party no-fault benefits from an insurance company. The insurance company moved for summary judgment to dismiss the complaint, arguing that the action was premature because the provider had failed to provide requested verification. The main issue decided by the court was whether the action was premature based on the failure to provide requested verification. The holding of the court was that there was a triable issue of fact as to whether the action was premature, as the provider had submitted an affidavit from their owner that gave rise to a presumption that the requested verification had been mailed to and received by the insurance company. As a result, the court reversed the order and denied the insurance company's motion for summary judgment.

The court considered the fact that the defendant had failed to establish that the initial and follow-up independent medical examination (IME) scheduling letters had been timely mailed. As a result, the defendant failed to demonstrate that the IMEs had been properly scheduled. The main issue decided was whether the defendant was entitled to summary judgment dismissing the first and third through sixth causes of action based on the failure of plaintiff's assignor to appear for the scheduled IMEs. The court held that the defendant's cross motion for summary judgment dismissing the complaint was denied due to the failure to properly schedule the IMEs, and that there was a triable issue of fact as to whether the defendant received the claim form underlying the second cause of action. Therefore, the order denying plaintiff's motion for summary judgment and granting defendant's cross motion for summary judgment was modified to provide that defendant's cross motion for summary judgment dismissing the complaint was denied.

The court considered the evidence submitted by the defendant, which showed that the plaintiff had failed to appear for scheduled examinations under oath. The main issue decided was whether the plaintiff's failure to appear for the examinations justified the denial of their claim for first-party no-fault benefits. The court held that the defendant's proof established the plaintiff's failure to appear for the scheduled examinations, and that this justified the denial of their claim. The court also found that the failure to set forth the dates of the scheduled examinations in the denial of claim forms did not render the denials conclusory, vague, or without merit as a matter of law. Therefore, the court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint.

The court considered the denial of the defendant's motion for summary judgment in a case brought by a medical provider to recover assigned first-party no-fault benefits. The main issue decided was whether the services at issue were medically necessary, and the court found that there was a triable issue of fact regarding the medical necessity of the services. The holding of the case was that the denial of the defendant's motion for summary judgment was affirmed, with a determination that there was a triable issue of fact regarding the medical necessity of the services at issue.