No-Fault Case Law

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.

The court considered the fact that the plaintiff, New Way Medical Supply Corp., was appealing an order from the Civil Court of the City of New York that granted the defendant's motion for summary judgment, dismissing the complaint. The main issue decided was whether the action by the provider to recover assigned first-party no-fault benefits was premature, as the defendant had not received requested verification. The holding of the case was that the record demonstrated that the defendant had not received requested verification and, thus, the action was premature. The court affirmed the order granting the defendant's motion for summary judgment dismissing the complaint, with $25 costs.

The main issues considered in this case were whether the defendant properly denied the claims at issue based on the plaintiff's failure to appear for scheduled examinations under oath (EUOs). The court held that the evidence submitted by the defendant did not demonstrate that the claims had been properly denied based on the plaintiff's failure to appear for the EUOs. The court pointed out that the first EUO scheduling letter sent to the plaintiff was mailed more than 30 days after the defendant had received the claims, making it a nullity. Additionally, the defendant had rescheduled each EUO before the date set for each EUO, and was aware that the plaintiff was unable to appear. As a result, the court held that the defendant failed to establish the existence of a triable issue of fact and affirmed the judgment in favor of the plaintiff.

The main issues being decided in this case were whether the defendant timely denied the plaintiff's claims based on a late notice of the accident and whether the plaintiff failed to provide necessary responses for discovery. The court considered the discrepancy in the date when the claims were received and the notice of the claims in relation to the timely denial of the claims. It was also considered whether the plaintiff failed to serve responses to the defendant's demand for interrogatories and appear for an examination before trial, which was necessary for the defendant's defense. The holding of the case was that the branch of the defendant's cross motion seeking summary judgment dismissing the complaint was denied. However, the branch of the defendant's cross motion seeking, in the alternative, to strike the complaint and dismiss the action pursuant to CPLR 3126 was granted to the extent of compelling the plaintiff to provide responses to defendant's demand for interrogatories, demand for discovery and inspection, and demand for expert disclosure within a specific timeframe, and to appear for an examination before trial within a set timeframe. The order was modified in this regard and affirmed as modified.

The court considered the fact that St. Locher Medical, P.C. was seeking to recover first-party no-fault benefits and that IDS Property Casualty Ins. Co. had moved for summary judgment to dismiss the complaint, claiming that the plaintiff and assignor had failed to attend scheduled examinations under oath. The main issue decided was whether defendant had sufficiently established that the first notice for examination under oath had been timely sent and whether the claims had been timely denied. The holding of the court was that the defendant had failed to demonstrate its entitlement to summary judgment based on the plaintiff's alleged failure to comply with a condition precedent to coverage, and as a result, the order was reversed and the defendant's motion for summary judgment was denied.

The court considered the fact that the provider was seeking to recover first-party no-fault benefits that had been assigned to them. The main issue was whether the defendant's motion for summary judgment dismissing the complaint should be granted. The court held that the defendant's evidence did not satisfy the burden of proving the nonappearance of the plaintiff at the examinations under oath. As a result, the defendant failed to establish their entitlement to summary judgment dismissing the complaint, and the court reversed the order and denied the defendant's motion for summary judgment.

The court considered the fact that Compas Medical, P.C. was seeking to recover first-party no-fault benefits and that American Transit Ins. Co. had denied the claim on the basis that Compas Medical had failed to provide requested verification. The main issue decided was whether the action by Compas Medical was premature due to the failure to provide verification. The court held that while American Transit Ins. Co. had demonstrated that it had timely mailed the verification request and had not received the requested verification, there was a triable issue of fact as to whether the action was premature. Therefore, the court modified the order by denying American Transit Ins. Co.'s cross motion for summary judgment dismissing the complaint.

The court considered the fact that the plaintiff, Bay LS Medical Supplies, Inc., had moved for summary judgment to recover assigned first-party no-fault benefits, while the defendant, Allstate Insurance Company, had cross-moved for summary judgment to dismiss the complaint on the basis 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 scheduled examinations under oath warranted the dismissal of the complaint. The holding of the court was that the defendant's cross motion for summary judgment dismissing the complaint was granted and the plaintiff's motion for summary judgment was denied. The court reversed the previous order in favor of the plaintiff and in accordance with the reasons stated in the previous case of Bay LS Med. Supplies, Inc. v Allstate Ins. Co. (50 Misc 3d 147[A], 2016 NY Slip Op 50319[U]), the defendant's motion for summary judgment to dismiss the complaint was granted.