No-Fault Case Law

The facts in the case of Alleviation Medical Services, P.C. v Allstate Insurance Company involve a lawsuit by a medical provider seeking to recover assigned first-party no-fault benefits that were denied by the insurance company. The insurance company had denied the claim on the ground of lack of medical necessity. The main issue decided by the court was whether the insurance company's denial of the claim on the grounds of lack of medical necessity precluded the provider from recovering the benefits. The court held that the insurance company's argument that it need not pay the claim because it had paid other claims after denying the instant claim, which subsequent payments exhausted the available coverage, lacked merit. Therefore, the court affirmed the order denying the insurance company's motion for summary judgment dismissing the complaint.

The court considered the plaintiff's claim for first-party no-fault benefits and the defendant's motion for summary judgment. The main issue decided was whether the defendant's proof was sufficient to establish that the amounts charged by the plaintiff for services rendered exceeded the rates set forth in the workers' compensation fee schedule. The court held that the action was not ripe for summary disposition, as the defendant's proof was insufficient to establish this. Additionally, the court found that the plaintiff's bill for services in the amount of $1,495 was timely denied as the 30-day statutory period was tolled by the defendant's timely verification and follow-up requests. Therefore, the court affirmed the order of the Civil Court, denying the defendant's motion for summary judgment.

The relevant facts considered by the court in this case included an automobile accident involving Bujar Kaziu, who began to receive no-fault benefits but failed to appear for an independent medical examination (IME) as requested by the plaintiff, Allstate Insurance Company. The plaintiff rescheduled the IME after Kaziu had surgery on his right shoulder. The insurance regulations required that an IME be scheduled within a 30-day period from the receipt of the claim. The court found that in this case, the delay letter sent by the plaintiff was later than the period allowed to seek verification under the statute, and as a result, the denial of the claim was untimely. However, the defense of excessive fees was not subject to preclusion, and the defendant was entitled to the portion of the claim that was undisputedly pursuant to the fee schedule. The main issues decided by the court were whether the denial of the claim by Allstate Insurance Company was timely, whether the rescheduling of the IME was done with consent, and the reimbursement amount to the defendant, Health East Ambulatory Surgical Center, for the services rendered after the automobile accident. The holding of the court was that plaintiff's motion for summary judgment was denied, and defendant's cross-motion for summary judgment was granted. The defendant was entitled to a total amount of $21,903.93 for the services rendered, taking into consideration the proper fee schedule and the timeliness of the denial of the claim.

The court considered whether an automobile insurance policy had been properly rescinded ab initio according to Florida law, and whether there was coverage available to the plaintiff's assignor. The main issue decided was whether the defendant-insurer's motion for summary judgment should have been granted in the first-party no-fault action. The holding of the case was that the defendant's motion for summary judgment should have been granted, and the complaint was dismissed. The court found that the defendant established, prima facie, that the Florida automobile insurance policy had been properly rescinded according to Florida law, and there was no coverage available to the plaintiff's assignor. Additionally, the court found that the plaintiff failed to raise a triable issue of fact in opposition to the defendant's showing.

The relevant facts considered by the court in this case included the motion for summary judgment filed by the defendant-insurer in a first-party no-fault action. The main issue decided by the court was whether the defendant's motion for summary judgment should have been granted, and if the defendant had submitted competent proof of the assignor's nonappearance at scheduled independent medical examinations (IMEs). The holding of the court was that the defendant's motion for summary judgment should have been denied because it failed to submit competent proof of the assignor's nonappearance at the scheduled IMEs. The court found that the conclusory affirmation of the defendant's IME doctor lacked probative value, as she failed to adequately state the basis of her recollection that the assignor did not appear on the scheduled IME dates. Therefore, the court reversed the order granting the defendant's motion for summary judgment and denied the motion.

This case involves an insurance company's petition to vacate an arbitration award in favor of a physical therapy provider for no-fault compensation. The insurance company had refused to pay for certain physical therapy services on the grounds that it had already reimbursed a different provider for services on the same dates. The arbitration resulted in an award in favor of the physical therapy provider, but the insurance company appealed, arguing that the physical therapy provider did not adequately preserve their defense. The master arbitrator wrongly found that the lower arbitrator had considered the fee schedule defense and determined that the physical therapy provider failed to provide evidence as to the other provider, leading to the reversal of the lower court's decision. The Appellate Division reversed the lower court's decision and remanded the matter to a different arbitrator for arbitration of the fee schedule defense on the merits. Therefore, the holding of the case was in favor of the insurance company, vacating the arbitration award and remanding the case for further arbitration.

The court in this case considered the motion for reargument of the defendant's motion to sever the breach of contract cause of action, or, in the alternative, for a stay of the severance order pending appeal. The main issue was whether the breach of contract cause of action, which contained 198 unrelated no-fault claims, raised common issues of fact or law that justified severing the claims. The court held that the breach of contract cause of action should be severed, as the claims raised no common issues of fact or law. The court also held that the defense of fraudulent incorporation did not present common factual and legal issues, as the defendant had indicated that it did not intend to pursue that defense. Finally, the court held that adjudication of the separate breach of contract claims in Civil Court was not dependent on a determination of the declaratory judgment cause of action.

The court considered the fact that the plaintiff was seeking to recover no-fault benefits for medical services provided to its assignor after a motor vehicle accident on August 22, 2011. The plaintiff had already been awarded judgment in the amount of $3,723.72, which was later modified to $7,784.06 to include interest, costs, and attorney's fees. The main issue the court decided was whether the defendant's insurance policy had been exhausted, as the plaintiff claimed it had not and the defendant argued that it had. The court held that the defendant's motion to modify the judgment and seek a protective order should be denied in its entirety, as the defendant failed to raise and present evidence of the defense of policy exhaustion at trial, despite having had the opportunity to do so. Therefore, the court found in favor of the plaintiff.

The main issue in this appeal addressed the determination of the amount of an additional attorney's fee pursuant to Insurance Department Regulations (11 NYCRR) § 65-4.10 (j) (4). The appellant, AAAMG Leasing Corp., sought an attorney's fee in connection with the court proceedings on the petition to vacate a master arbitrator's award and the cross petition to confirm the award. The Supreme Court denied the appellant's requested relief without stating the basis for that determination, leading to the case being remitted to the Supreme Court, Nassau County, for a determination of the amount of the additional attorney's fee to which the appellant is entitled, stating the evidentiary basis for the award. The Appellate Division found that the Supreme Court erred in denying relief, and concluded that the court must consider the appellant's attorney's additional fee and indicate the evidentiary basis for the award.

The court considered whether the plaintiff, a chiropractic provider, had failed to appear at duly scheduled examinations under oath (EUOs), which is a condition precedent to an insurer's liability on a policy. The main issue decided was whether the defendant had proven the plaintiff's nonappearances at the EUOs. The court held that an appearance at an EUO is a condition precedent to an insurer's liability on a policy and defendant had submitted an affirmation from the attorney responsible for conducting the EUOs, which established that the plaintiff had failed to appear for the scheduled EUOs. Therefore, the court affirmed the order granting defendant's motion for summary judgment dismissing the complaint.