No-Fault Case Law

The court considered a case in which a provider was seeking to recover assigned first-party no-fault benefits. The main issue decided was whether the plaintiff had failed to appear for examinations under oath, leading to the granting of the defendant's cross motion for summary judgment dismissing several causes of action. The holding of the case was that the order, insofar as appealed from, was affirmed, with the court referring to a similar case for the reasons behind their decision.

The main issue in this case was whether the plaintiff, a provider seeking to recover assigned first-party no-fault benefits, had failed to appear for examinations under oath. The court considered the fact that the defendant had cross-moved for summary judgment dismissing the complaint, and the plaintiff had appealed from the order granting the defendant's cross motion. The holding of the court was that the order, insofar as appealed from, was affirmed, with the plaintiff being required to pay $25 in costs. This decision was based on the fact that the plaintiff had failed to appear for examinations under oath, as determined in a related case.

The court considered the facts of a case in which a provider was seeking to recover assigned first-party no-fault benefits. The plaintiff had moved for summary judgment, while the defendant cross-moved for summary judgment dismissing the complaint on the basis that the plaintiff had failed to appear for examinations under oath. The main issue decided was whether the defendant's cross motion for summary judgment was valid based on the plaintiff's failure to appear for examinations under oath. The holding of the case was that the order granting the defendant's cross motion for summary judgment was affirmed. The court's decision was based on the plaintiff's failure to appear for the required examinations under oath, as established in the previous case of Masigla, as Assignee of Brumaire, Shimaine v Travelers Ins. Co.

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.