No-Fault Case Law

The court considered an order from the Civil Court of the City of New York, Queens County which denied the branches of the plaintiff's motion seeking summary judgment on the first through fourth causes of action and granted the branches of defendant's cross motion seeking summary judgment dismissing those causes of action. The main issue in the case was whether the defendant had properly used the workers' compensation fee schedule to determine the amount which the plaintiff was entitled to receive for the services at issue in the second and third causes of action, and whether the requested verification had been received by the defendant for the fourth cause of action. The holding of the case was that the defendant had demonstrated that it had not received the requested verification for the fourth cause of action, and that the defendant had properly used the workers' compensation fee schedule for the services at issue in the second and third causes of action. The court affirmed the order with costs.

The court considered the denial of claim forms from the defendant and found that they were sufficient to advise the plaintiff that the claims were partially denied because the fees were not in accordance with the workers' compensation fee schedule. The court also found that the defendant's evidence was sufficient to establish that the independent medical examination (IME) scheduling letters had been timely mailed. However, the court decided that the claims in the sums of $290.74 and $210.72 had not been timely denied and that the defendant had not demonstrated that it was not precluded from asserting its defense that the amounts sought to recover were in excess of the workers' compensation fee schedule. As a result, the court held that the branches of the defendant's motion seeking summary judgment dismissing the claims in the sums of $290.74 and $210.72 were denied.

The court considered an appeal from a provider seeking to recover assigned first-party no-fault benefits. The main issue was whether the defendant was entitled to an examination before trial of the plaintiff's owner, as well as the plaintiff's motion for summary judgment pending the completion of discovery. The court held that the defendant was entitled to an examination before trial of the plaintiff's owner, citing relevant statutes and previous cases. The court affirmed the order of the Civil Court, dismissing the portion of the appeal related to the continuation of plaintiff's motion for summary judgment and ordering the plaintiff to pay $25 in costs.

The relevant facts considered by the court were that the defendant had properly used the workers' compensation fee schedule applicable to chiropractors to reimburse the plaintiff for acupuncture services. The main issue was whether the defendant had fully paid the plaintiff for the services at issue in accordance with the workers' compensation fee schedule for acupuncture services performed by chiropractors. The holding of the court was that the defendant had established its entitlement to judgment as a matter of law, and that the order of the Civil Court granting the defendant's motion for summary judgment dismissing the complaint was affirmed. Additionally, the court declined to consider a remaining contention from the plaintiff as it was being raised for the first time on appeal.

The court considered the facts of the case, where the defendant failed to appear at trial and a default judgment was entered against them. The main issue decided was whether the defendant's motion to vacate the default judgment should be granted, based on an excusable default and a meritorious defense to the action. The court held that the defendant failed to demonstrate a meritorious defense, as they had denied the claims on the ground that the plaintiff's assignor had failed to appear for scheduled independent medical examinations, but the denial of claim forms were dated more than one month before the defendant had received the claims. The court also found that the defendant's argument that vacatur was warranted because the judgment awarded plaintiff interest which accrued prior to commencement of the action lacked merit. Therefore, the court affirmed the order denying defendant's motion to vacate the default judgment.

Plaintiff VNP Acupuncture, P.C. filed a lawsuit to recover first-party no-fault benefits for services provided to eight different individuals in connection with three separate motor vehicle accidents. The complaint alleged separate causes of action for each person. Defendant American Commerce Insurance Company moved to sever from the action the causes of action related to two of the accidents, arguing that the defenses involved different questions of fact and law. The denial of the claims at issue in the first, third through fifth, and seventh causes of action was based on lack of medical necessity after independent medical examinations and application of the workers' compensation fee schedule, which raised few issues of fact in common with the claims at issue in the second, sixth, and eighth causes of action. The court reversed the lower court's decision and granted defendant's cross motion to sever those causes of action from the case.

The court considered a case in which the plaintiff, Acupuncture Healthcare Plaza I, P.C., sought to recover first-party no-fault benefits from the defendant, Allstate Ins. Co. The defendant moved for summary judgment, claiming the plaintiff's assignor had failed to appear for scheduled examinations under oath (EUOs). The Civil Court granted the defendant's motion and denied the plaintiff's cross motion for summary judgment. However, the Appellate Term, Second Department reversed the decision and granted the plaintiff's cross motion for summary judgment, as the defendant's follow-up EUO scheduling letter had not been timely mailed, resulting in an untimely denial of claim form from the defendant. Therefore, the defendant was precluded from raising its defense, and the plaintiff was entitled to summary judgment. The case was remitted to the Civil Court for the calculation of statutory interest and an assessment of attorney's fees.

The court considered the facts of a nonjury trial in which the plaintiff, Orlin & Cohen Orthopedic Assoc. sought to recover assigned first-party no-fault benefits, particularly focusing on a claim for $12,862.87 for spinal surgery. Defendant's witness, the orthopedist who prepared the peer review report upon which the defendant relied, testified that the surgery was not medically necessary because it was not causally related to the accident in question. The Civil Court dismissed the complaint insofar as it sought to recover upon the claim for spinal surgery, and awarded the plaintiff the principal sum of $1,376.32 upon an earlier claim. The main issue was whether the plaintiff had met its ultimate burden of proving, by a preponderance of the evidence, that the spinal surgery was medically necessary. The court found that since the defendant sufficiently rebutted the presumption of medical necessity and the plaintiff failed to meet this burden, there was no basis to disturb the Civil Court's finding. The holding of the case was that the judgment of the Civil Court, insofar as appealed from, was affirmed, and the plaintiff was not entitled to recovery for the spinal surgery claim.

The court considered the fact that the plaintiff, Apple Massage Therapy, P.C., had moved for summary judgment to recover assigned first-party no-fault benefits, but the defendant, Adirondack Insurance Exchange, claimed that the plaintiff's assignor had failed to appear at duly scheduled examinations under oath (EUOs). The main issue decided by the court was whether the failure to appear at the EUOs constituted a failure to comply with a condition precedent to coverage. The holding of the case was that the defendant did not demonstrate that there had been a failure to appear at both an initial and a follow-up EUO, and thus, did not establish as a matter of law that the plaintiff had failed to comply with a condition precedent to coverage. The court reversed the decision, denied the branch of the defendant's motion seeking summary judgment dismissing the complaint based upon the assignor's failure to appear at two duly scheduled EUOs, and remitted the matter to the Civil Court for a determination of the remaining branch of the defendant's motion seeking summary judgment.

In the case of American Chiropractic Care, P.C. v GEICO Ins., the main issue decided was whether a no-fault insurer, in this case GEICO Insurance, is obligated to provide good faith reasons for requiring an Examination Under Oath (EUO) of a medical professional provider, in response to timely objections raised by the provider. The relevant facts involved GEICO timely notifying American Chiropractic Care P.C. to appear for an EUO, and American's counsel requesting good faith reasons for the EUO, to which GEICO's counsel declined to provide any reason. The court held that, in accordance with the Comprehensive Motor Vehicle Insurance Reparations Act and the no-fault regulations, the insurer is required to provide some good faith basis for the EUO in response to a timely request from the provider, and failure to do so can result in triable issues as to whether the insurer had any valid reason for the EUO. The court emphasized the importance of balancing the insurer's need to prevent fraud with not unnecessarily disrupting the practice of a medical professional without a good faith basis for doing so. Therefore, the holding was that the burden is on the insurer to respond to a timely request for explanation from the provider and the failure to do so can result in triable issues as to whether the insurer had a good faith basis for seeking the EUO.